The Office of Inspector General (OIG) has added noninvasive home ventilators to their active work plan items. Recently announced on the 'Active Work Plan Items' list, the audit details are as follows:
The Office of Inspector General (OIG) has added noninvasive home ventilators to their active work plan items. Recently announced on the 'Active Work Plan Items' list, the audit details are as follows:
For items such as noninvasive home ventilators (NHVs) and respiratory assist devices (RADs) to be covered by Medicare, they must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Depending on the severity of the beneficiary's condition, an NHV or RAD may be reasonable and necessary. NHVs can operate in several modes, i.e., traditional ventilator mode, RAD mode, and basic continuous positive airway pressure (CPAP) mode. The higher cost of the NHVs' combination of noninvasive interface and multimodal capability creates a greater risk that a beneficiary will be provided an NHV when a less expensive device such as a RAD or CPAP device is warranted for the patient's medical condition. Prior OIG work identified significant growth in Medicare billing for NHVs in the years since they reached the market. We will determine whether claims for NHVs were medically necessary for the treatment of beneficiaries' diagnosed illnesses and whether the claims complied with Medicare payment and documentation requirements.
This isn't the first time the OIG has conducted investigations of noninvasive ventilators. In fact, after publishing their September 2016 report, Escalating Medicare Billing for Ventilators Raises Concerns, suppliers of ventilators and PAP devices received letters from Noridian and CGS, advising them to investigate and self-report claims identified by the OIG that were potentially overpaid.
While we at The van Halem Group cannot predict the future, what I can see by gazing into my crystal ball is that the ramifications from this second OIG audit of noninvasive ventilators won't be as merciful. To begin, the OIG intends to make on-site visits with suppliers that provide noninvasive ventilators to Medicare beneficiaries. Investigators will come prepared with a list of beneficiairies and request to see documentation to support the claims billed.
The OIG isn't the only contender in the NIV audit game. Performant Recovery, the national DMEPOS, Home Health and Hospice RAC, announced in January that they would be reviewing ventilator claims with dates of service on or after January 1, 2016. In March, Performant then added ventilator claims with dates of service prior to January 1, 2016 to their approved issues list.
Want to feel confident that the ventilators you are providing meet coverage criteria? Sign up for our ventilator prescreen program.
Before you put out the equipment, let our clinical staff review your documentation to ensure the ventilator meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.
Have a patient that has been on a ventilator for some time? Our clinical team can review your documentation and determine if it would stand up to an OIG or RAC audit. Let our expert clinicians review your files and provide helpful feedback for you and your referral sources.
Contact us for more information!