Durable Medical Equipment Claims Paid by National Heritage Insurance Company, Inc., Did Not Always Meet the Requirements of the Local Coverage Determination for Lower Limb Prostheses

National Heritage Insurance Company, Inc. (NHIC), paid $450,000 for 651 lines of service for lower limb prostheses from January 1, 2009, through September 30, 2012, that did not meet local coverage determination (LCD) requirements. At the time that NHIC paid these lines of service, it did not have edits in place to evaluate whether they met all the LCD requirements.

We recommended that NHIC (1) recover $450,000 in identified overpayments for lines of service for lower limb prostheses that did not meet LCD requirements and (2) monitor the edits it developed and updated to ensure that the edits are functioning correctly. NHIC concurred with our recommendations and described corrective actions that it had taken or planned to take.