OPTUM NP'S

Good Morning!!  HHS OIG has released Mid-Year update.  I wanted to share a couple points.

here is the link to the entire report…

https://oig.hhs.gov/reports-and-publications/archives/workplan/2015/PartI-MedicarePartA-B-WPUpdate2015.pdf

 

 

1. Competitive Bid DMEPOS.  “Equipment and Supplies—Quality of Care and Safety NEW Access to durable medical equipment in competitive bidding areas We will determine the effects of the competitive bidding program on Medicare beneficiaries’ access to certain types of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) subject to competitive bidding. In an effort to reduce waste, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) updated Medicare’s payment system for certain DMEPOS from a fee schedule to a competitive bidding program. Under this program, DMEPOS suppliers compete on price to supply to particular geographic areas. Anecdotal reports allege that competitive bidding has led to reduced access to DME and, in turn, compromised the quality of care beneficiaries receive. (OEI; 01-15-00040; expected issue date: FY 2016)”  Does this mean competitive bidding may be scrapped?  WHO KNOWS…..!!!!

2. Billing RUG Ultras in SNF’s.  There better be really good documentation to support the high level of service given.   “Medicare Part A billing by skilled nursing facilities We will describe changes in SNF billing practices from FYs 2011 to 2013. Prior OIG work found that SNFs increasingly billed for the highest level of therapy even though beneficiary characteristics remained largely unchanged. OIG also found that SNFs billed one-quarter of all 2009 claims in error; this erroneous billing resulted in $1.5 billion in inappropriate Medicare payments. CMS has made substantial changes to how SNFs bill for services for Medicare Part A stays. (OEI; 02-13-00610; various reviews; expected issue date: FY 2015)”.

3. Independent Therapy Practices. “Physical therapists—High use of outpatient physical therapy services We will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. Prior OIG work found that claims for therapy services provided by independent physical therapists were not reasonable or were not properly documented or that the therapy services were not medically necessary. Our focus is on independent therapists who have a high utilization rate for outpatient physical therapy services. Medicare will not pay for items or services that are not “reasonable and necessary.” (Social Security Act, § 1862(a)(1)(A).) Documentation requirements for therapy services are in CMS’s Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 15, § 220.3. (OAS; W-00-11- 35220; W-00-12-35220; W-00-13-35220; W-00-14-35220; W-00-15-35220; various reviews; expected issue date: FY 2015)”.  Watch out guys,  you cant just bill, bill, bill!!!!!