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By Sandra Gauron, Appeals Coordinator

Part of the Office of Inspector General's (OIG) objectives are to promote economy and efficiency and to detect and prevent fraud, waste and abuse.  In order to do this, they develop and continually update their work plan.  Last week, the OIG announced in their work plan that they will begin conducting reviews on CPAP supplies. According to the work plan, the OIG intends to review claims for frequently replaced PAP device supplies to determine whether documentation requirements for medical necessity, frequency of replacement and other Medicare requirements are met. 

DMEPOS suppliers may recall in 2018 when the OIG conducted audits of (CYs) 2014 and 2015 claims for PAP Supplies.  Specifically, the OIG reviewed supporting documentation for replacement PAP device supplies to determine if the documentation complied with Medicare requirements. Previous OIG work found that Medicare allowed replacement of PAP device supplies more frequently than what was reasonable and necessary.  In the audit, for those claims deemed overpaid, the supplier was notified of the denied claim(s) and were subsequently required to conduct an audit of 100% of their replacement PAP supplies or pull a statistically valid random sample of replacement PAP supplies within six years of the date the overpayment was received. 

What you need to know: 

  • Expected time frame of these audits are at the end of 2019.  We are expecting an issue date of their results in 2020.
  • Review your claims and perform internal reviews to prepare for this audit.  Get ahead of it now.
  • If you receive a request letter, read and understand exactly what is being requested and provide what they are asking.  You may only get once chance at this.
  • Only one claim deemed overpaid by the OIG may require a 100% claim review of six-years of claims.

Do you provide PAP equipment and supplies?

Look-back reviews can be burdensome and require an expert statistician. The van Halem Group will work in conjunction with your legal counsel and our doctorate level statisticians to provide an accurate and thorough audit response. In addition to statistical analysis, our clinical experts will conduct a review of the identified claims to determine coverage and documentation requirements are met. 

For more information on how we can help with these audits, or anything else, contact us today!