Home Health & Hospice Week

Inherent reasonableness cuts might not be far behind OIG studies.  The OIG might not have set out a separate category for power wheelchairs in its latest Work Plan, but suppliers can expect heavy investigative action in that area nonetheless. The HHS Office of Inspector General designates only three DME-specific areas in its fiscal year 2004 Work Plan, as opposed to five areas last year. But the reduction in DME items doesn't mean there will be a corresponding reduction in OIG scrutiny of the industry, warns attorney Robert Falk with the Washington, DC office of Powell Goldstein Frazer & Murphy. "I do not see the 'numbers' as any indication of OIG's level of concern at all," Falk tells Eli. The work plan areas "are very focused, indicating that OIG expects to find problems." The OIG uses the studies in the Work Plan as a "platform for future attacks," either via policy or enforcement, Falk reminds suppliers. In the plan, the OIG fails to set out a separate category for power wheelchairs, which have been so conspicuously targeted in Operation Wheeler Dealer headed up by the Centers for Medicare & Medicaid Services (see Eli's HCW, Vol. XII, No. 32, p. 251). But suppliers can expect the OIG to find plenty of ways to incorporate scrutiny of power wheelchairs into its 2004 tasks, experts say. The work plan sets out these project areas: CMNs. Appropriate certificates of medical necessity are an ongoing issue in the Medicare program, and this year is no exception. The OIG plans to determine if suppliers correctly used and maintained CMNs and whether ordered items were reasonable and necessary. "An improperly completed CMN can really trip up a supplier in an HME audit," cautions attorney Jeff Baird with Brown & Fortunato in Amarillo, TX. Suppliers with sloppy CMN practices can expect recoupment at best and False Claims Act charges at worst, he says. Medical Necessity. The OIG singles out power wheelchairs and therapeutic footwear for scrutiny in this area, in which it will assess whether suppliers' documentation supports the claim, whether the item was medically necessary and whether the beneficiary actually received the item. The OIG and CMS suspect many beneficiaries receiving power wheelchairs don't really need them, says Gabe Imperato with Broad and Cassell in Ft. Lauderdale, FL. Beneficiaries "don't need Cadillacs when a Chevrolet will do," he quips. Proving an item's medical necessity can be a resource-intensive process, Baird points out. First suppliers must produce key pieces of documentation: a physician order, CMN, delivery ticket or other proof of delivery, assignment of benefit (AOB) form, and, if necessary, an advance beneficiary notice (ABN). After jumping through those hoops, suppliers must produce documentation supporting the actual medical necessity, [...]