Yesterday, the Centers for Medicare and Medicaid Services’ (CMS) Office of Inspector General (OIG) released a report entitled “Medicare Remains Vulnerable to Fraud, Waste, and Abuse Related to Off-the-Shelf Orthotic Braces, Which May Result in Improper Payments and Impact the Health of Enrollees”. (link to OIG announcement) This report continues to highlight fraud and abuse vulnerabilities that exist through the provision of off-the-shelf (OTS) orthosis by unscrupulous providers. The report is one that AOPA has been expecting for a while and does not identify any new or surprising issues regarding the provision of OTS orthoses. AOPA has long been on record regarding the need to eliminate fraud and abuse by unqualified providers and bad actors and continues to support efforts by the OIG and CMS to take appropriate action to eliminate fraud and abuse in all its forms.
The report looked at Medicare claims for OTS orthoses for FY 2018 through 2020 representing $1.9 billion in Medicare reimbursement and $484.6 million in beneficiary co-Insurance. The OIG report identified six areas of vulnerability to continued fraud and abuse and made the following recommendations for actions CMS should take to address each area.
- Determine why claims that did not have the required modifiers were paid for replacement OTS braces, and take steps to prevent payments for such claims;
- Identify providers who ordered OTS braces for enrollees with whom they had no treating relationships and use that information to determine whether to provide additional education to—or take administrative or legal action against—the ordering providers or associated suppliers;
- Analyze supplier billing patterns and use that information to determine whether to: conduct additional prepayment or post-payment reviews of suppliers or impose a temporary moratorium on enrolling new suppliers of OTS braces if CMS determines that there is significant potential for fraud, waste, or abuse;
- Review Medicare allowable amounts for OTS braces that are not currently in the DMEPOS Competitive Bidding Program to ensure that Medicare payments for OTS braces are reasonably comparable with payments made by non-Medicare payers, and determine whether to include any of those procedure codes for braces in future rounds of competitive bidding;
- Educate suppliers and enrollees on telemarketing practices for OTS braces, specifically on not using direct solicitation of enrollees, and consider revoking billing privileges of suppliers that engage in prohibited solicitation practices; and
- Use predictive data analysis and information from other Federal agencies and from State agencies to identify emerging fraud schemes related to OTS braces, and use CMS’s authority to prevent further losses to the Medicare program.
Based on CMS’ response to an earlier draft of the report, the OIG indicated that CMS has already addressed or is currently addressing its first, fourth, and fifth recommendations but should take further action to implement the remaining three recommendations.
If you have any questions contact Joe McTernan at jmcternan@aopanet.org or Devon Bernard at dbernard@aopanet.org.