February 20, 2012

Knee Orthoses Part of Fraud Scheme, RAC Issue

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DCS, the Region A recovery auditor, will recoup payments for additions to knee orthoses because they are included in reimbursement for specific base knee orthoses.

The new issue, posted Feb. 13, applies to 11 states. Maryland was not included in the post.

Knee orthoses also were part of two Medicare schemes in Puerto Rico that led to indictments of 10 people announced in January.

Both cases involved submission of false claims for durable medical equipment (DME) including knee orthoses and power wheelchairs, according to the Office of Inspector General (OIG).

In the 39-count indictment, the government alleges that one company submitted more than 1,500 false claims for medically unnecessary DME totaling almost $3 million. Medicare paid $1.4 million but put the company on prepayment review. At that point, two defendants bought a second company and submitted at least 359 fraudulent claims. When that company was put on prepayment review, defendants bought another company and submitted more than 100 more false claims, OIG stated. Medicare paid a total of more than $1.9 million on those claims.

The government seeks forfeiture of more than $1.9 million including two bank accounts, an investment account and a condominium, OIG stated. In a 60-count indictment, defendants submitted 95 fraudulent claims for DME for which Medicare paid almost $108,000.

RACs Post DME, Physician, Hospital Issues

Along with DCS's knee orthoses issue, Region C RAC Connolly posted a DME issue about therapeutic footwear use. RACs also posted two physician issues and two inpatient hospital issues.

Durable medical equipment

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Therapeutic footwear utilization

2/15/12

RAC Region C

The LCD and policy article for therapeutic shoes for diabetes limit the use of shoes and inserts. For patients meeting these criteria, coverage is limited to one of the following within one calendar year (January through December): One pair of custom-molded shoes (A5501), which includes inserts provided with those shoes, and two additional pairs of inserts; or one pair of depth shoes (A5500) and three pairs of inserts.

CMS Pub. 100-02 chapter 15

Knee orthosis bundling

2/13/12

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Payments for knee orthoses additions, as specified in NHIC's LCD for knee orthoses (L27263), are bundled into the payment for specific base knee orthoses and should be recouped if paid separately.

LCD for knee orthoses (L27263); article for knee orthoses - policy article (A46762) DME MAC jurisdiction A

 


 

Physician

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Rituximab - non-covered/non-allowed service under Part B

2/13/12

RAC Region C

An overpayment exists when a provider bills for a services of J9310/Rituximab with an ICD-9 code that is not included in the list of covered ICD-9 codes for J9310/Rituximab with the applicable local coverage determination (LCD) documents.

CMS Pub. 100-02 chapter 15; First Coast Service Options LCD L29271; Pinnacle local coverage article A45248; TrailBlazer superseded LCD L26746; Palmetto retired LCD L26147

E/M billed without modifier 25 on same day as dialysis

2/10/12

RAC Region D

Except when reported with modifier 25, payment for certain evaluation and management services is bundled into the payment for dialysis services 90935, 90937, 90945 and 90947.

CMS Pub. 100-04 chapter 8

 

Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Acute care hospitalization - hepatobiliary procedures (DRGs 420, 421, 422, 424 and 425)

2/10/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

Acute care hospitalization - bowel and rectal procedures (DRGs 329, 330, 332, 333, 334, 344, 345 and 346)

2/10/12

RAC Region D

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6

 

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

To comment on this article please go to editor@racmonitor.com

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