Recommendations Tracker

We recommend that the Centers for Medicare & Medicaid Services direct the DME MACs to recover from suppliers up to $22,671,778 in identified improper payments for our audit period that are within the 4-year reopening period in accordance with CMS's policies and procedures.

We recommend that the Centers for Medicare & Medicaid Services instruct the DME MACs to notify, as CMS deems appropriate, suppliers that received an overpayment or overpayments to consider conducting one or more internal audits or investigations based on the risks identified by this audit to identify any similar overpayments the supplier might have received and return any identified overpayments to the Medicare program.

We recommend that the Centers for Medicare & Medicaid Services review system edits to determine whether any refinements are necessary to prevent improper payments to suppliers for DMEPOS items provided to enrollees during inpatient stays.

We recommend that the Centers for Medicare & Medicaid Services determine why claims that did not have the required modifiers were paid for replacement OTS braces, and take steps to prevent payments for such claims.

We recommend that the Centers for Medicare & Medicaid Services analyze supplier billing patterns and use that information to determine whether to conduct additional prepayment or postpayment reviews of suppliers or impose a temporary moratorium on enrolling new suppliers of OTS braces if CMS determines that there is significant potential for fraud, waste, or abuse.

We recommend that the Centers for Medicare & Medicaid Services educate suppliers and enrollees on telemarketing practices for OTS braces, specifically on not using direct solicitation of enrollees, and consider revoking billing privileges of suppliers that engage in prohibited solicitation practices.

We recommend that the Centers for Medicare & Medicaid Services take the following actions for supplier claims for DMEPOS items provided to hospice beneficiaries, which could have saved Medicare an estimated $116.9 million in improper payments and could have saved beneficiaries an estimated $29.8 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during the audit period.

We recommend that the Centers for Medicare & Medicaid Services implement a postpayment edit process to detect claims submitted by suppliers processed before a beneficiary's notice of election of hospice care is processed in the CWF, and instruct the DME Medicare contractors to deny DMEPOS claims identified by the edit process if they do no have the GW modifier.

We recommend that the Centers for Medicare & Medicaid Services study the feasibility of including palliative items and services not related to a beneficiary's terminal illness and related conditions within the hospice per diem. Such a requirement would eliminate the need for Medicare to make additional payments for these services consistent with CMS's longstanding position that payments for services unrelated to a beneficiary's terminal illness and related conditions should be exceptional, unusual, and rare given the comprehensive nature of the services covered under the Medicare hospice benefit. In analyzing the feasibility of such a change, CMS could consider: (1) beneficiary access to care, (2) administrative costs, (3) appropriate adjustments to the per diem rates to reflect the higher costs associated with providing hospice services, and (4) possible improvement of coordination of care.

We recommend that Visionquest Industries, Inc. refund to the DME MACs the portion of the $2,504,829 in estimated overpayments for claims that are within the 4-year reopening period.

We recommend that Visionquest Industries, Inc. obtain as much information from beneficiary medical records as it determines necessary to assure itself that claims for orthotic braces meet Medicare requirements for medical necessity.

We recommend that Desoto Home Health Care, Inc. refund to the DME MACs $2,878,544 in estimated overpayments for orthotic braces.

We recommend that Desoto Home Health Care, Inc. obtain as much information from beneficiary medical records as it determines necessary to assure itself that claims for orthotic braces meet Medicare requirements for medical necessity.

We recommend that Freedom Orthotics, Inc. refund to the DME MACs $6,987,413 in estimated overpayments for orthotic braces.

We recommend that Freedom Orthotics Inc. obtain as much information from beneficiary medical records as it determines necessary to assure itself that claims for orthotic braces meet Medicare requirements for medical necessity

We recommend that the Centers for Medicare & Medicaid Services review Medicare allowable amounts for 161 orthotic device HCPCS codes for which Medicare and beneficiaries paid an estimated $337,547,542 more than select non-Medicare payers and adjust the allowable amounts, as appropriate, using regulations promulgated under existing legislative authority, or if the allowable amounts cannot be adjusted using regulations promulgated under existing legislative authority, seek legislative authority to align Medicare allowable amounts for these items with payments made by select non-Medicare payers.

We recommend that Kelley Medical refund to the DME MACs $4,079,308 in estimated overpayments for orthotic braces (of which $76,964 was overpayments identified in our sample).

We recommend that Kelley Medical obtain as much information from beneficiary medical records as it determines necessary to assure itself that claims for orthotic braces meet Medicare requirements.

We recommend that Pacific Medical refund to the DME MACs $247,493 in estimated overpayments for orthotic braces (of which $4,777 was overpayments identified in our sample).

We recommend that Pacific Medical obtain as much information from beneficiary medical records as it determines necessary to assure itself that claims for orthotic braces meet Medicare requirements.

Direct the Medicare contractors to recover the $34,014,796 in identified improper payments to suppliers in accordance with CMS's policies and procedures and recommend that the suppliers refund to beneficiaries up to $8,702,539 in deductible and coinsurance amounts that may have been incorrectly collected from them or from someone on their behalf

We recommend that CMS take all necessary actions, including seeking legislative authority, to require suppliers to refund to beneficiaries incorrectly collected Medicare Part B deductible and coinsurance amounts for items and services reimbursable under Medicare Part A.

If the CWF edits had been designed properly since CY 2008, Medicare could have saved $223.1 million, and beneficiaries could have saved $56.3 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf.

CMS should promulgate regulations to implement the BIPA payment requirements.