Medicare Compliance & Reimbursement

Plus: Michigan clinic manager pleads guilty to defrauding Medicare of $6.5 million.

Suppliers' costs keep wheelchairs from being a cash crop. Industry insiders have taken exception to the Office of the Inspector General's August report that claimed Medicare and its beneficiaries paid up to four times more than the average amount paid by suppliers for wheelchairs.

The report used "flawed methodology and incomplete data" to draw conclusions, claimed Eric Sokol, director of the Power Mobility Coalition (PMC), a nationwide association of manufacturers and suppliers of motorized wheelchairs and power operated vehicles.

These "inaccuracies" could affect more than just suppliers' reputations. "If readers incorrectly draw conclusions that low acquisition costs equates to high profit margins,then the PMC questions the completeness of the study and its usefulness to policymakers," Sokol pointed out.

Mistakes: The OIG didn't calculate costs of the services provided, as well as overhead expenses such as salaries, fuel, transportation, rents, beneficiary assistance in billing Medicare, and other defining factors. Also, "increased Medicare standards and documentation confusion" like the accreditation and surety process has "raised the cost to providers of partnering with the Medicare program," Sokol said.

Reality: Medicare reimbursement for power wheelchairs has decreased in the past few years, Sokol noted.

The Centers for Medicare & Medicaid Services and Congress have slashed Medicare reimbursement by more than 37 percent and further cuts are expected. Sokol and the PMC hope CMS will rethink its position and statements so that beneficiaries and others don't assume that wheelchair providers are benefiting unfairly.

• The Department of Justice has laid down the law on another infusion clinic employee. On Sept. 2, the DOJ announced that a Detroit clinic manager pleaded guilty to defrauding Medicare and now faces a maximum of 10 years in prison and a $250,000 fine.

The clinic manager admitted that the clinic "routinely billed the Medicare program for services that were medically unnecessary or were never provided," the DOJ press release stated. She also "admitted that patients were prescribed medications at the clinic based not on medical need, but on what medications were likely to generate Medicare reimbursements."

The clinic submitted over $6.5 million in false and fraudulent claims over a six month period, resulting in almost $5 million in payments from Medicare. The indictment was led by the Medicare Fraud Strike Force and the U.S. Attorney's Office for the Eastern District of Michigan.

To read more about the case, go online to the DOJ Web site at: www.usdoj.gov/opa/pr/2009/September/09-crm-910.html.

Good idea: Currently, routinely evaluating beneficiaries for their risk of falls isn't covered by Medicare -- but regional home health intermediary Palmetto GBA wants to change that.

The RHHI has included V15.88 (History of fall) in the final Part A rule to help agencies better pinpoint when a patient would benefit from physical or occupational therapy to cut down on falls.

Payment: Claims containing V15.88 will still need another covered ICD-9-CM code to specify the type of impairment or limitation causing the increased risk of falls. However, tacking on that V15.88 will help communicate what coverage is available and ensure your patients get the help they need.

• The research on negative pressure wound therapy (NPWT) has just been completed by CMS and the Agency of Healthcare Research and Quality, and NPWT proponents may not like the findings. "The available evidence does not support significant therapeutic distinction of a NPWT system or component of a system,"

CMS said. In other words, no one NPWT system or part deserves its own HCPCS code.

NPWT applies a localized vacuum to draw the edges of the wound together while providing a moist environment to promote rapid wound healing. NPWT is based on two theories: (1) the removal of excess interstitial fluid decreases edema and concentrations of inhibitory factors and increases local blood flow; and (2) stretching and deformation of the tissue by the negative pressure can disturb the extracellular matrix and introduce biochemical responses that promote wound healing.

The study backing up CMS' decision can be accessed online at www.ahrq.gov/clinic/ta/negpresswtd/npwtd01.htm.

• Home health agencies are more satisfied with Medicare than almost every other provider type, according to the 2009 Medicare Contractor Provider Satisfaction Survey (MCPSS). MCPSS also found that 81 percent of respondents would like more training and education material focused on claims processing and 77 percent want more resources focused on the appeals and payment policy business functions. Across providers, 81 percent of survey respondents ranked their overall satisfaction as between a 4 and 6 on a 6-point scale.

Published Sept. 16, the MCPSS allows CMS to gauge provider satisfaction with key services performed by Medicare's Fee-for-Service contractors. The survey was sent to more than 32,000 randomly selected providers across the industry. Access the survey results at www.cms.hhs.gov/MCPSS or www.mcpsstudy.org.

• More funds from the $500 million allotted to the Health Resources and Services Administration to address workforce shortages under the American Recovery and Reinvestment Act (ARRA) have been released by the Department of Health and Human Services. HHS Secretary Kathleen Sebelius announced, in a press release, the awarding of a total of $33 million to expand the training of health care professionals. The grants announced are distributed through six HRSA programs. Health Professions Awards by can be accessed at www.hhs.gov/recovery/programs/hrsa/healthprofessions awardees.html and www.hhs.gov/recovery/programs/hrsa/healthprofessionsawardeesbystate.html