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Medical Services & Equipment

Health Hippo: Medical Services, Supplies & Equipment

Health Hippo: Medical Services, Supplies & Equipment

US CODE || CFR || CASES || REPORTS || CONGRESSIONAL RECORD || BILLS || FEDERAL REGISTER


Of several remedies, the physician should choose the least sensational.

To determine coverage, co-pays and deductibles for medical services, equipment and supplies under the Medicare program it’s really important to understand whether you are in a Part A stay or not. Part A covers inpatient hospital stays (not outpatient or observation), care in a nursing facility after a three day hospital stay and if skilled nursing or rehabilitation services are required, hospice care, and intermittent home health care, if skilled care is required. Things like wheelchairs, oxygen, bandages, insulin supplies and the like are covered when you are in a Part A stay, because all of the things necessary for your care are included or “bundled” into the Part A payment. If you are not in a Part A stay, then most of these things, including doctor’s visits and outpatient procedures, may be covered under Part B.

U.S. Code

  • Affordable Care Act: Part B Provisions.
    • Sec. 3103. Extension of exceptions process for Medicare therapy caps.
    • Sec. 3104. Extension of payment for technical component of certain physician pathology services.
    • Sec. 3105. Extension of ambulance add-ons.
    • Sec. 3110. Part B special enrollment period for disabled TRICARE beneficiaries.
    • Sec. 3111. Payment for bone density tests.
    • Sec. 3112. Revision to the Medicare Improvement Fund.
    • Sec. 3113. Treatment of certain complex diagnostic laboratory tests.
    • Sec. 10311. Revisions to extension of ambulance add-ons.
    • Sec. 10336. GAO study and report on Medicare beneficiary access to high-quality dialysis services.
  • Balanced Budget Act Equipment & Services Provisions.
    • Sec. 4531 Payments for ambulance services.
    • Sec. 4532 Demonstration of coverage of ambulance services under medicare
      through contracts with units of local government.

    • Sec. 4541 Prospective payment for outpatient rehabilitation services.
    • Sec. 4551 Payments for durable medical equipment.
    • Sec. 4552 Oxygen and oxygen equipment.
    • Sec. 4553 Reduction in updates to payment amounts for clinical diagnostic
      laboratory tests; study on laboratory tests.

    • Sec. 4554 Improvements in administration of laboratory tests benefit.
    • Sec. 4555 Updates for ambulatory surgical services.
    • Sec. 4556 Reimbursement for drugs and biologicals.
    • Sec. 4557 Coverage of oral anti-nausea drugs under chemotherapeutic
      regimen.

    • Sec. 4558 Renal dialysis-related services.
    • Sec. 4559 Temporary coverage restoration for portable electrocardiogram
      transportation.

    • Sec. 4571 Part B premium.
    • Sec. 4581 Protections under the medicare program for disabled workers who
      lose benefits under a group health plan.

    • Sec. 4582 Governmental entities eligible to elect to pay part B premiums
      for eligible individuals.
  • 42 U.S. Code Part B Supplementary Medical Insurance Benefits for Aged and Disabled
    • Sec.1395j Establishment of supplementary medical insurance program for aged and disabled
    • Sec.1395k Scope of benefits; definitions
    • Sec.1395l Payment of benefits
    • Sec.1395m Special payment rules for particular items and services
    • Sec.1395m-1 Improving policies for clinical diagnostic laboratory tests
    • Sec.1395n Procedure for payment of claims of providers of services
    • Sec.1395o Eligible individuals
    • Sec.1395p Enrollment periods
    • Sec.1395q Coverage period
    • Sec.1395r Amount of premiums for individuals enrolled under this part
    • Sec.1395s Payment of premiums
    • Sec.1395t Federal Supplementary Medical Insurance Trust Fund
    • Sec. 1395t-1, 1395t-2. Repealed.
    • Sec.1395u Provisions relating to the administration of part B
    • Sec.1395v Agreements with States
    • Sec.1395w Appropriations to cover Government contributions and contingency reserve
    • Sec.1395w-1 Repealed.
    • Sec.1395w-2 Intermediate sanctions for providers or suppliers of clinical diagnostic laboratory tests
    • Sec.1395w-3 Competitive acquisition of certain items and services
    • Sec.1395w-3a Use of average sales price payment methodology
    • Sec.1395w-3b Competitive acquisition of outpatient drugs and biologicals
    • Sec.1395w-4 Payment for physicians services
    • Sec.1395w-5 Public reporting of performance information

Code of Federal
Regulations

  • 42 CFR Part 405, Subpart H Appeals Under the Medicare Part B Program
    • Sec. 405.800 Appeals of CMS or a CMS contractor.
    • Sec. 405.803 Appeals rights.
    • Sec. 405.806 Impact of reversal of contractor determinations on claims processing.
    • Sec. 405.809 Reinstatement of provider or supplier billing privileges following corrective action.
    • Sec. 405.812 Effective date for DMEPOS supplier’s billing privileges.
    • Sec. 405.815 Submission of claims.
    • Sec. 405.818 Deadline for processing provider enrollment initial determinations.
  • 42 CFR Part 414 PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES
    • SUBPART A General Provisions (414.1 – 414.4)
    • SUBPART B Physicians and Other Practitioners (414.20 – 414.92)
      • Sec. 414.20 Formula for computing fee schedule amounts.
      • Sec. 414.21 Medicare payment basis.
      • Sec. 414.22 Relative value units (RVUs).
      • Sec. 414.24 Review, revision, and addition of RVUs for physician services.
      • Sec. 414.26 Determining the GAF.
      • Sec. 414.28 Conversion factors.
      • Sec. 414.30 Conversion factor update.
      • Sec. 414.34 Payment for services and supplies incident to a physician’s service.
      • Sec. 414.36 Payment for drugs incident to a physician’s service.
      • Sec. 414.39 Special rules for payment of care plan oversight.
      • Sec. 414.40 Coding and ancillary policies.
      • Sec. 414.42 Adjustment for first 4 years of practice.
      • Sec. 414.44 Transition rules.
      • Sec. 414.46 Additional rules for payment of anesthesia services.
      • Sec. 414.48 Limits on actual charges of nonparticipating suppliers.
      • Sec. 414.50 Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier.
      • Sec. 414.52 Payment for physician assistants’ services.
      • Sec. 414.54 Payment for certified nurse-midwives’ services.
      • Sec. 414.56 Payment for nurse practitioners’ and clinical nurse specialists’ services.
      • Sec. 414.58 Payment of charges for physician services to patients in providers.
      • Sec. 414.60 Payment for the services of CRNAs.
      • Sec. 414.61 Payment for anesthesia services furnished by a teaching CRNA.
      • Sec. 414.62 Fee schedule for clinical psychologist services.
      • Sec. 414.63 Payment for outpatient diabetes self-management training.
      • Sec. 414.64 Payment for medical nutrition therapy.
      • Sec. 414.65 Payment for telehealth services.
      • Sec. 414.66 Incentive payments for physician scarcity areas.
      • Sec. 414.67 Incentive payments for services furnished in Health Professional Shortage Areas.
      • Sec. 414.68 Imaging accreditation.
      • Sec. 414.80 Incentive payment for primary care services.
      • Sec. 414.90 Physician Quality Reporting System.
      • Sec. 414.92 Electronic Prescribing Incentive Program.
    • SUBPART C Fee Schedules for Parenteral and Enteral Nutrition (PEN) Nutrients, Equipment and Supplies (414.100 – 414.104)
    • SUBPART D Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices (414.200 – 414.232)
    • SUBPART E Determination of Reasonable Charges Under the ESRD Program (414.300 – 414.335)
    • SUBPART F Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) (414.400 – 414.426)
    • SUBPART G Payment for New Clinical Diagnostic Laboratory Tests (414.500 – 414.510)
    • SUBPART H Fee Schedule for Ambulance Services (414.601 – 414.625)
    • SUBPART I Payment for Drugs and Biologicals (414.701 – 414.707)
    • SUBPART J Submission of Manufacturer’s Average Sales Price Data (414.800 – 414.806)
    • SUBPART K Payment for Drugs and Biologicals Under Part B (414.900 – 414.930)
    • SUBPART L Supplying and Dispensing Fees (414.1000 – 414.1001)
    • SUBPART M Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) Services (414.1100 – 414.1105)

Cases

  • Billing Privileges
    • Joy Medical Supply (2014)(revocation of Medicare billing privileges upheld because office was inaccessible and unstaffed during posted hours of operation on two occasions)
    • Karthik Ramaswamy(2014)(enrollment process culminates in “the granting of billing privileges or denial or rejection of the application” for purposes of determining enrollment date in case involving multiple applications)
    • Lorrie Laurel (2013)(physical therapist’s guilty plea to grand theft was a conviction that allowed revocation of Medicare billing)
    • EI Jardin Pharmacy (2012)(CMS authorized to revoke supplier number and billing privileges for failure to provide change of address)
  • Ambulance
    • In the Case of North Country Ambulance (June 15, 2012)(Documentation supports the conclusion that the medical condition of the beneficiary required ambulance transport)
    • In the Case Midwest Lifeteam (March 18, 2011) (The beneficiary, rather than the supplier, is responsible payment when the services do not meet the criteria under the origin and destination coverage requirements of the regulations).
    • In the Case of Eagle Air Med (March 18, 2011) (A finding that a beneficiary required ground ambulance services versus air ambulance transport is an adverse level of care determination and it is appropriate to consider whether the beneficiary and the appellant are entitled to limitation on liability protection).
    • In the Case of Estate of G.B.R.(December 3, 2010) (The ambulance service furnished to the beneficiary from one trauma center to another met Medicare coverage guidelines because specialized neurological/neurosurgical critical care was unavailable at the hospital to which the beneficiary was originally taken).
    • In the Case of Air Evac EMS, Inc. (October 14, 2009) (two or more facilities may meet the local “destination” requirement for coverage).
    • In the Case of Gold Cross Ambulance (September 29, 2009) (the record contains medical documentation from the beneficiary’s physician, in addition to a Physician Certification Statement, that shows the ambulance transportation was medically required).
    • In the Case of D.C. (November 17, 2009) (the evidence fails to show the ambulance services were medically required and when the criteria for coverage are not met, limitation on liability provisions do not apply).
  • Dental
    • In the Case of A.F. (November 12, 2009) (payment for an oral appliance, as an item of durable medical equipment, will not be made for a replacement furnished within five years of the previous covered oral appliance).
    • In the Case of the Estate of W.D.(April 10, 2009) (the evidence shows the hospital services received in connection with a dental surgery are excluded from coverage as the beneficiary was admitted and received treatment for extraction of teeth in a hospital setting as an outpatient).
    • In the Case of A.K. (May 24, 2009) (the record indicates the beneficiary’s dental surgery was performed on an outpatient basis in a hospital operating room and the anesthesiology fee is therefore not a Part A inpatient hospital expense).
    • In the Case of A.B. (August 13, 2009) (Medicare coverage for medical services, as opposed to coverage for the dental services, is based on when the hospitalization is required because of the individual’s underlying condition and medical status).
  • Durable Medical Equipment
    • Maximum Comfort Inc. v. Secretary Of Health And Human Services (2007) (Secretary was not precluded from requiring documentation, in addition to a certificate of medical need (CMN), to substantiate supplier’s claims for Medicare reimbursement, and supplier was not entitled to waiver for Medicare reimbursement overpayments for power wheelchairs).
    • In the Case of AeroCare Holdings (Aug 3, 2012) (The Council reversed the ALJs decision and found that Medicare would cover the formoterol fumarate inhalation solution refill).
    • In the Case of Cornerstone Prosthetics and Orthotics (June 19, 2012) (The Council concluded that the appellant provided no basis for entitlement to additional reimbursement for the articulating prosthetic fingers and thumb user unit provided to the beneficiary).
    • In the Case of R.C. (June 13, 2012) (The medical records do not demonstrate that the beneficiary requires mobility assistive equipment for MRADLs within his home).
    • In the Case of The Scooter Store (May 18, 2012) (The Council found that the medical documentation is insufficient to substantiate the medical necessity for the power wheelchair and accessories, and further stated that the treating physician rule does not apply in the matter before it).
    • In the Case of Chair & Equipment Rentals and Sales (April 13, 2012) (finding the non-covered items payable under section 1879 where the record did not support a finding that the supplier could have been expected to know that the items were excluded from coverage).
    • In the Case of Loyalsock Mobility (April 12, 2012) (the appellant met the documentation requirements along with all other requirements for coverage of the power wheelchair and accessories).
    • In the Case of Home Medi Service, Inc.(September 29, 2011) (The beneficiary may receive a new power wheelchair, without regard to the existence of the previous wheelchair furnished more than five years previously, provided she satisfies the requirements for coverage anew).
    • In the Case of National Seating & Mobility (September 20, 2011) (The power seat elevation system and electrical connecting components at issue and do not meet the definition of durable medical equipment for Medicare coverage).
    • In the Case of Gordian Medical, Inc. d/b/a American Medical Technologies (September 16, 2011) (Contrary to the appellants assertions, it is reasonable to assume that long-term care facilities would maintain clinical records detailing wound evaluations and care performed by physicians, nurses, and other treating health care professionals to substantiate the need for the type and quantity of items ordered, as well as for the frequency of use or replacement).
    • In the Case of Advanced Medical Concepts, Inc.(September 13, 2011) (The evidence of record fails to document the beneficiarys weight gain and is insufficient to demonstrate that the power wheelchair was medically necessary).
    • In the Case of Allied Home Medical, Inc.(July 29, 2011) (The documentation of record does not establish that the beneficiary was unable to self-propel a manual wheelchair and the power wheelchair at issue is not covered by Medicare).
    • In the Case of S.C.S. (January 20, 2011) (The evidence of record fails to show the power standing system device at issue primarily and customarily serves a medical purpose and therefore, regardless of its benefit to the beneficiary, is not a durable medical equipment).
    • In the Case of D.B.C. (November 22, 2010) (The supplier received Medicare payment in error for a power wheelchair and accessories which resulted in an overpayment as the record shows that the beneficiary took physical possession of the wheelchair, at the insistence of the supplier, more than 120 days after the face-to-face physician consult).
    • In the Case of International Rehabilitative Sciences, Inc. (September 22, 2010) (reviewing coverage claims for a durable medical device that is the subject of multiple district court decisions, the Council finds the Maryland district court’s decision persuasive in this case and that the Washington district court decision is limited to the facts of those particular cases).
    • In the case of OJ Medtech, Inc. (February 19, 2010) (clinical documentation satisfied the coverage criteria set forth in both the applicable NCD and LCD, and the device furnished to the beneficiary was reasonable and necessary for the treatment of her medical condition).
    • In the case of Affordable Home Care (June 22, 2010) (documentation requirements of LCD for power wheelchairs and accessories do not apply to equipment that is replacement equipment for damaged or destroyed items and that have been determined medically necessary for the Medicare beneficiary).
    • In the case of Extreme Mobility, Inc. (June 22, 2010) (descriptive phase “power-mobility device” was sufficient description of the medical equipment needed based upon beneficiary’s health records to satisfy the relevant LCD).
    • In the case of J. D. K. (August 20, 2010) (incorrect billing coding not detrimental to DME claim when the unassigned claim was filed by the beneficiary and the contractor assigned the incorrect billing code).
    • In the Case of Maximum Comfort, Inc. (June 11, 2003) (the certificate of medical necessity (CMN) submitted by the supplier is insufficient to document the criteria for Medicare coverage and the supplier is required to maintain medical documentation in addition to the CMN).
    • In the Case of Kinetic Concepts Inc. (October 28, 2008) (the checklist forms created by the supplier sufficiently establish medical necessity for continuing coverage during the first four months of treatment in the absence of underlying clinical records as the forms require certifying physicians to provide clinical data in support of the certifications and the forms contain the information required by the local coverage determination to establish medical necessity).
    • In the Case of Kinetic Concepts Inc. (June 5, 2009) (the local coverage determination requires documentation in addition to the supplier created checklist to establish medical necessity beyond four months and must be from an independent provider, case specific, contemporaneous with the beginning of the fifth month, explain the special circumstances necessitating the extended time, and justify the expense to the Medicare program based on the therapeutic benefits to the individual beneficiary).
    • In the Case of BioniCare Medical Technologies, Inc. (July 13, 2009) (coverage by Medicare for a durable medical device, and related supplies, depends on the device being safe and effective and not experimental; devices categorized by the Food and Drug Administration (FDA) as non-experimental/investigational are eligible for consideration of Medicare coverage but the FDA classification does not qualify the device for automatic coverage; assignment of a HCPCS code does not automatically imply coverage).
    • In the Case of Keeler’s Medical Supply (September 21, 2009) (medical evidence documenting the beneficiary’s weight gain over a three year period is sufficient to show the beneficiary met the criteria for a heavy duty wheelchair as she exceeded the weight limit for her previously supplied standard wheelchair).
    • In the Case of Hudson Home Health Care (August 12, 2009) (the medical documents, signed by both the beneficiary’s physician and physical therapist, is sufficient evidence of the criteria for Medicare coverage of a new lightweight wheelchair).
    • In the Case of Webb Medical Systems (October 27, 2009) (the documents submitted showing the treating physician conducted a full face-to-face examination for the purpose of evaluating the beneficiary’s need for a power mobility device contain sufficient evidence of the criteria for Medicare coverage of a wheelchair accessory kit).
    • In the Case of Allied Home Medical, Inc. (Oct. 27, 2009) (supplier may not dispense a power mobility device to a beneficiary until the supplier has received both the prescription and the supporting documentation to substantiate the medical necessity for the item from the physician).
    • In the Case of C.H. (October 28, 2009) (the adjustable bed and mattress do not meet the definition of durable medical equipment which is equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to an individual in the absence of an illness or injury, and is appropriate for home use).
  • Professional Services
    • In the Case of Michael Schill, DC. (June 21, 2012) (The record did not demonstrate that the subluxations at issue were chronic in nature and that there was a reasonable expectation of functional improvement in the beneficiarys condition).
    • In the Case of Art Ankle & Foot Care Specialist (June 28, 2012) (On remand, the Council instructed the ALJ to make a determination based on the record evidence as it pertains to each beneficiary and to issue a new decision which explains the basis for the decision consistent with applicable regulations and other relevant coverage authorities).
    • In the Case of Sunrise Family Foot Center (June 18, 2012) (The Council affirmed the ALJs ultimate conclusion that Medicare will not cover the services at issue, but supplemented the ALJs decision to set forth the applicable Medicare coverage criteria).
    • In the Case of Med Health Services (June 14, 2012) (The Council found that the CPT codes 93320 and 93325 were component codes of 93306 during the dates of service at issue and that they are not separately reimbursable).
    • In the Case of Radiation Oncology Healthcare, P.A. (June 11, 2012) (Finding that the NCCI edits in effect for the dates of service at issue indicate that the use of a modifier is not appropriate to override the payment restriction).
    • In the Case of Shawn Lee, D.C. (August 29, 2011) (the SOAP/plans of care submitted by the appellant do not, alone, consititute proper documentation of chiropractic manipulation).
    • In the Case of K.E.D. (June 22, 2012) (Medicare did not cover the pap smear and related service because the appellant did not satisfy the criteria set forth in the applicable statutory provisions and NCD).
    • In the Case of LaPorte Chiropractic (October 30, 2009) (the submitted evidence lacks the specific information about the onset and duration of the beneficiary’s symptoms or past health history and is insufficient to support Medicare coverage for chiropractic services).
    • In the Case of Harlan Appalachian Regional Hospital (June 13, 2012) (The Council determined that the appellant did not furnish sufficient documentation to establish that the service at issue was medically reasonable and necessary).
    • In the Case of Klaes Chiropractic Clinic, Inc. (November 18, 2009) (chiropractic services must be furnished within a reasonable period of time to qualify for Medicare coverage).
    • In the Case of Comprehab Wellness Group (May 17, 2012) (The supplier did not meet its burden based on binding regulations and interpretative manual sections pertinent to CORF services).
    • In the Case of Caris MPI, Inc. (April 24, 2012) (finding that the ALJ erred when it failed to: 1) review the Qualified Independent Contractors dismissals of the requests for reconsideration; 2) afford substantial deference to the applicable LCD or provide reasons for not doing so; and 3) make a determination as to whether the services not specified in the LCDs coverage requirements are reasonable and necessary, and not experimental and investigational, as set forth in the MPIM).
    • In the Case of Steven B. Cagen, M.D., P.C. (April 12, 2012) (applicable authorities provide that Medicare Part B payment may not be made for the technical component of the services in question when the services are furnished to hospital inpatients).
    • In the Case of Junichiro Sageshima, M.D. (June 27, 2011) (the use of an inappropriate modifier resulted in more than a minor clerical error and therefore the claim is subject to the appeals process).
    • In the Case of North Alabama Neurological, P.A. (November 22, 2010) (The ALJ erred by focusing on the issue of the amount of payment instead of the issue of whether the surgical procedure on the date of service was reasonable and necessary).
    • In the Case of Health Spring, Inc. (November 16, 2010) (The MOA is not bound to cover the non-emergency oncology and laboratory services provided by an out-of-network physician where there was no evidence that the enrollee sought a referral or authorization from the MOA to see an out-of-network physician).
    • In the Case of Robert E. Rothfield, M.D. (December 16, 2009) (the record indicates the beneficiary’s breast implant surgery was not cosmetic in nature but was a medically required revision of a previous reconstruction after a bilateral mastectomy due to breast cancer).
    • In the Case of Rocky Mountain Anaplastology, Inc. (December 8, 2009) (the billed facial template utilized by a surgeon during a surgical implant procedure does not fall within the definitions of services or supplies “incident to a physician’s service” or the definition of a prosthetic device).
    • In the Case of Starosta Medical PC (September 23, 2009) (an appellant has the burden to provide sufficient documentation, evidence and testimony that indicates the services provided are covered by Medicare).
    • In the Case of Advanced Diabetes Treatment Centers(August 26, 2009) (the billed services do not qualify for Medicare coverage as the services do not fall within the definition of “monitoring” a subject of a clinical trail for Medicare coverage of routine costs because the tests were a critical component of the clinical trials for Pulsatile Intravenous Insulin Therapy).
  • Supplier Services
    • In the Case of Amigo Home Health Hospice Agency (April 24, 2012) (contrary to the ALJ’s findings, none of the blood glucose tests were covered under Part B because in order for glucose monitoring service to qualify for separate payment the service must be performed in accordance with laboratory coverage criteria, which includes prompt notification of each and every test result).
    • In the Case of Gordian Medical, Inc., d/b/a American Medical Technologies (August 8, 2011) (neither the ALJ or the Council has the authority to review HCPCS definitions).
    • MP Totalcare/CCS Medical (June 22, 2011) (the evidence produced by the appellant must contain sufficient documentation of the beneficiary’s medical condition to substantiate the necessity for the type and quanitity of the items ordered).
    • In the Case of R.J. (December 31, 2010) (The beneficiary’s blood glucose testing logs, with the additional documentation of record, satisfies the coverage criteria set forth in the applicable LCD).
    • In the Case of Dynamic Rehabilitation Services (October 21, 2010) (LCD L5017 precludes a supplier or an individual with a financial relationship with the supplier from completing the medical necessity forms).
    • In the Case of Jacksonville Hearing & Balance Institute (August 2, 2010) (the applicable LCD does not provide billing or payment guidance and the record does not support the use of the -59 modifier to bypass the MUE (Medically Unlikely Edit) in effect during the period of service at issue).
    • In the Case of Ridgefield Surgical Center (February 18, 2010) (an ambulatory surgical center is not entitled to Medicare payment of a facility fee for a procedure billed used an unlisted procedure code).
    • In the Case of CourierMed, Inc. (November 24, 2009) (the supplied dressings are covered under the ESRD composite rate and therefore are not separately billable).
    • In the Case of Kohll’s Pharmacy & Homecare, Inc. (September 30, 2009) (the surgical dressings are not covered by Medicare as the medical evidence shows the dressings were not used for a surgical or debrided wound).
    • In the Case of Texas Oncology (October 21, 2009) (the ALJ erred in basing his decision solely on unidentified provisions of a local coverage determination without considering whether there is supportive clinical evidence for the off-label use of a prescribed drug).

Reports

  • Additional Time to Establish Protocols for Newly Required Face-to-Face Encounters for Durable Medical Equipment (DME) (CMS 2014) The law requires that a physician must document that a physician, nurse practitioner, physician assistant or clinical nurse specialist has had a face-to-face encounter with the patient. The encounter must occur within the 6 months before the order is written for the DME.
  • Manual Medical Review of Therapy Claims Above the $3,700 Threshold (CMS 2014) Exceptions to the therapy cap are allowed for reasonable and necessary therapy services. Per beneficiary, services above $3,700 for PT and SLP services combined and/or $3,700 for OT services are subject to manual medical review. CMS is not precluded from reviewing therapy services below these thresholds.
  • Therapy Caps and Advance Beneficiary Notice of Noncoverage Fact Sheet (CMS 2014) Provider/supplier must issue a valid, mandatory ABN to the beneficiary before providing services above the cap when the therapy coverage exceptions process isn’t applicable.
  • Prior Authorization of Power Mobility Devices (PMDs) Demonstration (CMS 2014) This demonstration will help ensure that a beneficiary’s medical condition warrants their medical equipment under existing coverage guidelines. Moreover, the program will assist in preserving a Medicare beneficiary’s ability to receive quality products from accredited suppliers.
    • PMD Documentation Requirements (CMS 2014) In addition to the prescription for the PMD, the physician or treating practitioner must provide the supplier with supporting documentation consisting of portions of the medical record essential for supporting the medical necessity for the PMD in the beneficiary’s home.
    • PMDs Demonstration: Status Update Since implementation, the Centers for Medicare & Medicaid Services (CMS) observed a decrease in expenditures for power mobility devices in the demonstration states and non- demonstration states.
  • Physical Therapy: Self-Referring Providers Generally Referred More Beneficiaries but Fewer Services per Beneficiary (GAO 2014) Non-self-referred physical therapy (PT) services increased at a faster rate than self-referred PT services. The growth rate in expenditures associated with non-self-referred PT services was also higher than for self-referred services.
  • National Telecommunications and Information Administration Recent Federal Register documents related to first responders.
  • MedPac: Outpatient Therapy Services Physical and Occupational Therapy Services restore and maintain physical function and treat and prevent illness and injury. Physical therapy includes therapeutic exercises and activities while Occupational therapy focus on improving a patient’s ability to perform activities of daily life independently. These services are subject to therapy caps, which limit the amount of coverage Medicare will provide without additional justification.
  • MedPac: Durable Medical Equipment Payment System Medical equipment needed at home to treat a beneficiarys illness or injury is covered under the durable medical equipment (DME) benefit. Medicare spent about $8.4 billion on DME in calendar year 2012. Oxygen and related supplies has been the largest category of DME, representing about a quarter of DME spending in recent years. Wheelchairs and respirators are typical of the equipment Medicare pays for under this benefit. To be covered, the equipment must: withstand repeated use, primarily serve a medical purpose, and generally not be useful to a person without an illness or injury.
  • MedPac: Ambulance Service Payment System Ambulance services include both emergency and nonemergency transport from the point of patient pick-up to an appropriate medical facility. Medicare Part B covers ambulance services in cases where other transportation could endanger the life of the beneficiary.
  • MedPac: Outpatient Dailysis Services Individuals with end-stage renal disease (ESRD)irreversible loss of kidney functionrequire either dialysis or kidney transplantation to survive. In 1972, the Social Security Act extended all Medicare Part A and Part B benefits to individuals with ESRD who are entitled to receive Social Security benefits. More than 90 percent of all dialysis patients undergo hemodialysis three times per week in dialysis facilities.
  • MedPac: Outpatient Hospital Services Medicare beneficiaries receive a wide range of services in hospital outpatient departments, from injections to complex procedures that require anesthesia. Medicare originally based payments for outpatient care on hospitals costs, but the Centers for Medicare & Medicaid Services (CMS) began using the outpatient prospective payment system (OPPS). When CMS began using the OPPS, the new payment system had the potential to substantially reduce hospital payments below the amounts under the cost-based system. In response, the Congress partially protected hospitals that experienced financial losses by providing transitional corridor and hold harmless provisions.
  • Outpatient Therapy: Implementation of the 2012 Manual Medical Review Process (GAO 2013) This report describes (1) CMS’s implementation of the 2012 MMR process, and (2) the number of individuals and claims subject to MMRs and the outcomes of these reviews. GAO reviewed relevant statutes, CMS policies and guidance, and CMS data on these reviews. GAO also interviewed CMS staff and officials from three MACs that accounted for almost 50 percent of the MMR workload and that processed claims for states previously determined to be at a higher risk for outpatient therapy improper payments.
  • Physicians May Be Liable for False Claims Submitted by Entities Receiving Reassigned Medicare Payments (OIG 2012) Physicians who reassign their right to bill the Medicare program and receive Medicare payments by executing the CMS-855R application may be liable for false claims submitted by entities to which they reassigned their Medicare benefits.
  • Telemarketing by Durable Medical Equipment Suppliers (OIG 2010) Section 1834(a)(17)(B) specifically prohibits payment to a supplier that knowingly submits a claim generated pursuant to a prohibited telephone solicitation. Accordingly, such claims for payment are false and violators are potentially subject to criminal, civil, and administrative penalties, including exclusion from Federal health care programs.
  • Retoractive Beneficiary Cost Sharing Liability (OIG 2010) OIG statement to assure providers, practitioners, and suppliers affected by retroactive increases in payment rates resulting from the operation of new Federal statutes or regulations that they will not be subject to Office of Inspector General (OIG) administrative sanctions if they waive Retroactive Beneficiary Liability.
  • Air Ambulance: Effects of Industry Changes on Services Are Unclear (GAO 2010). Changes in the air ambulance industry’s size and structure have led to differences of opinion about the implications for air ambulance use, safety, and services. Some industry stakeholders believe that greater state regulation would be good for consumers
  • Potential Strategies to Address Air Ambulance Safety Concerns (GAO 2009) GAO has identified several potential strategies for improving air ambulance safety, including the following: (1) Obtain complete and accurate data on air ambulance operations. (2) Increase the use of safety technologies. (3) Sustain recent efforts to improve air ambulance safety. (4) Fully address NTSB’s recommendations. (5) Adopt safety management systems within the air ambulance industry. (6) Clarify the role of states in overseeing air medical services. (7) Determine the appropriate use of air ambulance services.
  • State Medicaid Program Efforts to Control Costs for Disposable Incontinence Supplies (OIG 2007) In 2012, fee-for-service State Medicaid programs reported spending $266 million on nine specific types of disposable incontinence supplies (e.g., diapers).
  • Accuracy of Unique Physician/Practitioner Identification Number Registry Data (OIG 2003) As part of the Medicare enrollment process, CMS began assigning Unique Physician/Practitioner Identification Numbers (UPINs) to all physicians who bill or perform services for Medicare payment. The use of UPINs was later expanded to include non-physician practitioners and medical group practices. Information on all UPINs is stored in a national database called the Unique Physician/Practitioner Identification Number System, also known as the UPIN Registry.
  • Oversight of Ambulatory Surgery Centers: A System in Neglect (OIG 2002) Quality oversight of ASCs revolves around Medicare’s minimum health and safety standards, called the Conditions of Coverage. CMS requires ASCs to become Medicare-certified or privately accredited to show that they meet the Conditions. Certification is carried out by State agencies and accreditation by CMS-approved accreditors.
  • Quality Oversight of Ambulatory Surgical Centers: The Role of Certification and Accreditation (OIG 2002) CMS does little to hold State agencies and accreditors accountable to the Medicare program. It does little to monitor their performance. CMS does not use electronic data reporting to track basic metrics of performance. It rarely conducts Federal oversight surveys to monitor review done by State agency and accreditation surveyors. Its formal evaluations of State agencies and accreditors provide little insight on performance. It provides almost no feedback on their performance. With little performance monitoring, CMS has little on which to base meaningful feedback to State agencies and accreditors. Routine, operational feedback to State agencies and accreditors is problematic, since policy emerges from one of several units within CMS.
  • Durable Medical Equipment Ordered with Surrogate Physician Identification Numbers (OIG 2002) For 61 percent of services, ordering physicians had permanent UPINs at the time the service was provided. Physicians for more than one-third of these services had individual UPINs for at least 5 years prior to the dates on the claims. Physicians for 17 percent of these services had individual UPINs at least 10 years before the dates of service.
  • Quality Oversight of Ambulatory Surgical Centers: Holding State Agencies and Accreditors Accountable (OIG 2002) CMS does little to hold State agencies and accreditors accountable to the public Survey results are not readily accessible. CMS does not publish the results of State agency surveys on the Medicare web site, the Medicare telephone hotline, or on-site at ASCs. State agency certification and accreditation provide few meaningful insights for comparing ASCs. State agency survey reports lack comparative information on ASCs’ performance relative to their past or their peers. Complaint processes have limited accessibility. CMS does not provide prominent, clear instructions for complaining about poor care received in certified ASCs. CMS makes no information available on the performance of State agencies and accreditors.
  • Medical Equipment and Supply Claims with Invalid or Inactive Physician Numbers (OIG 2001) Medicare regulations require suppliers to provide the unique physician identification number (UPIN) of the physician who ordered the equipment and/or supplies when submitting a claim. Because Medicare payment for medical equipment and supplies is only authorized when items are ordered by a physician, claims with incorrect UPIN information should not be paid. Nevertheless, Medicare paid $32 million for medical equipment and supply claims with invalid UPINs in 1999.
  • Chiropractic Care: Comparison of Medicare Managed Care and Fee-For-Service (OIG 2000) Most Medicare beneficiaries can choose between the Medicare managed care program and the fee-for-service program. Medicare fee-for-service coverage of chiropractic services is limited to manual manipulation of the spine to correct a subluxation. Managed care plans offer that service, and can offer other chiropractic services.
  • Use of Universal Product Numbers for Medical Equipment and Supplies (OIG 1999) Most industry members agree that UPNs would allow for a number of advantages to both Medicare and the industry as a whole by allowing Medicare to specifically identify the product being claimed and provide more efficient edits. They would also aid in fraud and abuse detection.
  • Physician Liability for Certifications in the Provision of Medical Equipment and Supplies and Home Health Services (OIG 1999) While the OIG believes that the actual incidence of physicians’ intentionally submitting false or misleading certifications of medical necessity for durable medical equipment or home health care is relatively infrequent, physician laxity in reviewing and completing these certifications contributes to fraudulent and abusive practices by unscrupulous suppliers and home health providers.
  • Accuracy of Unique Physician Identification Number Data (OIG 1999) We have found a number of UPIN and PIN issues that need attention: 1) Deactivate UPINs and PINs for Inactive Providers and Practice Locations; 2) Improve Data Entry Instructions for Specific Data Fields; 3) Establish a Priority to Review Individuals with Numerous PINs, and; 4) Reconcile Identical Fields in UPIN and PIN Records Before Implementing National Provider Identifier.
  • Chiropractic Services Covered by Medicare Managed Care Organizations (OIG 1999) This report describes policies and practices for providing chiropractic services to Medicare enrollees in seven managed care organizations (MCOs).
  • Medicare Payments for Therapeutic Shoes (OIG 1998) The Medicare Part B benefit covers therapeutic footwear for beneficiaries with diabetes and one or more of six qualifying conditions. According to documentation guidelines specified by Medicare, a doctor of medicine or a doctor of osteopathy who is treating the beneficiary’s systemic diabetic condition under a comprehensive plan of care must certify the need for therapeutic footwear. This physician must also attest that the beneficiary suffers from one or more of the qualifying conditions.
  • Are Medicare Allowances for Albuterol Sulfate Reasonable? (OIG 1998) This report provides: (1) information from previously published Office of Inspector General (OIG) reports pertaining to albuterol sulfate, and (2) new updated information on the appropriateness of Medicare allowances for albuterol sulfate.
  • Medicare Part B Allowances for Wound Care Supplies (OIG 1998) Allowances for wound care supplies decreased dramatically after CMS and its contractors changed procedures to prevent inappropriate payments.
  • Medicare Allowances for Lymphedema Pumps (OIG 1998) Medicare allowed charges for the most expensive type lymphedema pump (E0652) increased from $18.5 million in 1991 to $106.7 million in 1995–almost a 500 percent increase in 4 years.
  • Home Oxygen Program
    Warrants Continued HCFA Attention.     (OIG 1997) Reviews the appropriateness of Medicare’s reimbursement rates for home oxygen.

  • Medicare Allowances for Incontinence Supplies (OIG 1997) We focused on questionable practices concerning two facets of billing: 1) accessories that can only be billed with prosthetic devices and 2) frequency parameters for female external urinary collection devices.
  • FDA’s Urgent Notices (OIG 1996) Assessing the effectiveness of the Food and Drug Administration’s (FDA) Urgent Notice on recalled blood glucose test strips.
  • Medicaid Payments for Incontinence Supplies (OIG 1995)
    We recently reviewed Medicare payments for incontinence supplies. We found that questionable billing practices may have accounted for almost $100 million or half of incontinence allowances in 1993. We also found that suppliers engage in questionable marketing practices to nursing homes and that Medicare beneficiaries may be receiving unnecessary or noncovered supplies.

  • Questionable Medicare Payments for Wound Care Supplies (OIG 1995) Four supplies, hydrogel wound filler, tape, a hydrogel dressing wound cover, and a foam dressing wound cover, account for almost half of the excessive utilization. We found excessive utilization in all groups of wound care products.
  • Marketing of Wound Care Supplies (OIG 1995) This report describes supplier and nursing home practices that can lead to inappropriate payments for wound care supplies, and examines issues concerning Medicare beneficiaries’ use of these supplies.
  • Wound Care Supplies: ORT Data (OIG 1995) This report identifies questionable billing practices and describes supplier and nursing home practices that can lead to questionable payments under the Medicare Part B wound care benefit.
  • Medicare: Excessive
    Payments for Medical Supplies Continue Despite Improvements     (GAO 1995) In fiscal year 1994 alone, Medicare was billed over $6.8 billion for medical supplies.

  • Durable Medical
    Equipment: Regional Carriers’ Coverage Criteria Are Consistent with Medicare Law     (GAO 1995) In November 1993, the Health Care Financing Administration began consolidating the work of processing and paying claims for durable medical equipment, prostheses, orthoses, and supplies at four regional carriers. Claims for such items had previously been processed and paid by local Medicare carriers.

  • Medicare: Excessive Payments for Medical Supplies Continue Despite Improvements (GAO 1995) GAO discussed Medicare payments for medical supplies.
  • Medicare Part B:
    Regional Variation in Denial Rates for Medical Necessity     (GAO 1994) To determine whether Medicare carriers in various parts of the country differed significantly in denying coverage for medical treatment they consider unnecessary, GAO analyzed Medicare Part B data on claims processed by six Medicare carriers for 74 services that were either expensive or heavily used.

  • Medicare:
    Beneficiary Liability for Certain Paramedic Services May Be Substantial     (GAO 1994) Volunteer ambulance companies often transport Medicare patients to hospitals.

  • Marketing of Incontinence Supplies (OIG 1994) This report describes supplier and nursing home practices that can lead to inappropriate payments for incontinence supplies, and examines issues concerning Medicare beneficiaries’ use of incontinence supplies.
  • Questionable Medicare Payments for Incontinence Supplies (OIG 1994) Incontinence allowances rose from $S8 million in 1990 to $230 million in 1993, an increase of $142 million. During the same period, the number of beneficiaries receiving incontinence supplies fell from 312,200 to 292,700. Allowances per beneficiary increased from $282 to $786.
  • Medicare Tests of Lower Extremity Arteries (OIG 1993) Medicare Part B allowed amounts virtually doubled for these tests in all settings and specialties from 1987 to 1990. In 1991, total allowed dollars exceeded $71 million. In terms of total Part B billings, the leading specialties include general surgeons, thoracic surgeons, and internal medicine specialists. These 3 groups accounted for more than 410,000 services totaling some $34 million in allowances.
  • Medicare Carriers’ Policies for Transcranial Dopplers: A New Technology (OIG 1993) Transcranial doppler (TCD) is a noninvasive ultrasound technique that measures blood flow velocities in the major arteries in the skull. The TCD technology was introduced in 1982.
  • Oxygen Concentrator Reimbursement: Medicare and the Department of Veterans Affairs (OIG 1991) VA reimburses considerably less for oxygen concentrators than Medicare.

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