Furthermore, CMS will be taking additional steps to fight fraud and abuse in home health agencies in Florida and suppliers of durable medical equipment, prosthetics and orthotics (DMEPOS) in Florida, California, Texas, Illinois, Michigan, North Carolina and New York. Those additional steps include the following, many of which affect physicians:
conducting more stringent reviews of new DMEPOS suppliers applications including background checks to ensure that a principal, owner or managing owner has not been suspended by Medicare;
making unannounced site visits to double check that suppliers and home health agencies are actually in business;
implementing extensive pre- and post-payment review of claims submitted by suppliers, home health agencies and ordering or referring physicians;
validating claims submitted by physicians who order a high number of certain items or services by sending follow-up letters to these physicians;
verifying the relationship between physicians who order a large volume of DMEPOS equipment or supplies or home health visits and the beneficiaries for whom they ordered these services; and
identifying and visiting high risk beneficiaries to ensure they are appropriately receiving the items and services for which Medicare is being billed.
The additional reviews that will be focused on DMEPOS equipment and supplies with high expenditures and high growth rates expect to identify items such as oxygen supplies and equipment, power mobility devices or power wheelchairs, and diabetic test strips.
For those claims not reviewed before payment is made, CMS is implementing further medical review of submitted DMEPOS claims by one of the new recovery audit contractors (RACs). The RACs review paid claims for all Medicare Part A and B providers to ensure their claims meet Medicare statutory, regulatory and policy requirements and regulations. If the RACs find that any Medicare claim was paid improperly it will then request repayment from the provider if an overpayment was found or request that the provider is repaid if the claim was underpaid. Here are the new national RACs:
Diversified Collection Services of Livermore, Calif., in Region A, initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York.
CGI Technologies and Solutions of Fairfax, Va., in Region B, initially working in Michigan, Indiana and Minnesota.
Connolly Consulting Associates of Wilton, Conn., in Region C, initially working in South Carolina, Florida, Colorado and New Mexico.
HealthDataInsights, Inc. of Las Vegas, in Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona.
The new RACs were selected under a full and open competition and will begin to educate and inform providers later in October and November about the program. The RACs will be paid on a contingency-fee basis on both the overpayments and underpayments they find. The selection of these new contractors was based on a best value determination that included a sound technical approach for the level and quality of claim analysis and detail to exceptional customer service, conflict of interest reviews and lowest contingency fee. Additional states will be added to each RAC region in 2009. The three -year RAC demonstration program in California, Florida, New York, Massachusetts, South Carolina and Arizona collected hundreds of millions in overpayments.
Finally, CMS is consolidating the work of Medicares program safeguard contractors (PSCs), and the Medicare Drug Integrity Contractors (MEDICs) with new Zone Program Integrity Contractors (ZPICs). The new contractors will eventually be responsible for ensuring the integrity of all Medicare-related claims under Parts A and B (hospital, skilled nursing, home health, provider and durable medical equipment claims), Part C (Medicare Advantage health plans), Part D (prescription drug plans) and coordination of Medicare-Medicaid data matches (Medi-Medi). The first two ZPIC contracts were awarded to Health Integrity (Zone 4) and SafeGuard (Zone 7).
Learn more about the RAC program.
