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Durable Medical Equipment Community Supports Tough Anti-Fraud Measures, Corrects Persistent Myths
Date:9/22/2010

This is incorrect as Congress and CMS have adjusted DME pricing multiple times over the past decade so that current Medicare payments are sometimes 50 percent less than they were a decade ago.

Improper Payments Should Not Be Confused with Fraud

There have been a number of audit samples of specific HME items such as oxygen therapy, power wheelchairs and continuous positive airway pressure (CPAP) devices that indicate a high improper payment rate.  As the OIG correctly points out, the increase in the Medicare error rate in the home medical equipment sector is "not necessarily due to more fraud in the program. In fact, the error rate is not a measure of fraud." In 2009, the OIG implemented a strict adherence to policy documentation requirements, retro application of rules, signature legibility requirements, and lack of physician documentation and the removal of claims history as a valid source for review information.  In this latter example, in previous years, auditors could use clinical inference to determine if a claim was reasonable and necessary.  Now, they cannot use their education and training to determine if a claim is appropriate.

However, when there is an error rate of 78 percent as was the case in a recent oxygen probe audit, this points to a larger problem with the overall system—not with HME providers.  We maintain that CMS is not doing an adequate job of educating physicians and homecare providers and the policies have become so complex that the vast majority of HME providers are not able to reasonably comply. In this example and others, federal bureaucrats are overturning physician decision making and judgment in more than 3 out of every 4 cases. Upon appeal at the Administrative Law Judge (ALJ) level, the ALJs are reversing CMS' decisions 3 out of 4 times suggesting that there is an institutional disconnect that is hurting legitimate providers of HME.

Homecare providers and the Medicare benef
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SOURCE American Association for Homecare
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