OIG: Medicare vulnerable to fraud and abuse over off-the-shelf orthotic braces
A new report by the Office of Inspector General (OIG) examines orthotic braces, which are among the top 20 durable medical equipment with the highest improper payment rates. From calendar years 2014 through 2020, Medicare paid $5.3 billion for orthotic braces provided to enrollees.
The review found several problems that led to fraud and abuse: providers ordered braces for enrollees even though they didn’t have a history of treating them; new suppliers were in geographic areas with known Medicare fraud; Medicare paid more than private payers for off-the-shelf braces; and suppliers used prohibited solicitation to contact enrollees.
These issues put Medicare and its enrollees at risk and show the need for CMS to strengthen its oversight related to supplier billing requirements, ordering provider requirements, supplier enrollment and monitoring, Medicare allowable amounts for OTS braces, telemarketing to Medicare enrollees, and fraud related to OTS braces. If CMS doesn’t address these issues, it could result in improper payments, potential enrollee harm, and Medicare paying more than non-Medicare payers, such as private insurance companies, for the braces.
OIG recommends CMS take the following actions:
· Take steps to prevent payments for claims for replacement braces billed without required modifiers
· Identify providers who ordered 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 to determine whether to conduct additional prepayment or post payment reviews of suppliers
· Ensure that Medicare allowable amounts are reasonably comparable with payments made by non-Medicare payers
· Educate suppliers and enrollees on telemarketing practices for off-the-shelf braces
· Use predictive data analysis and information from other federal agencies and from state agencies to identify emerging fraud schemes related to the braces
· Use its authority to prevent further losses to the Medicare program
Senators seek answers from Multiplan on sky-rocketing medical bills
Senate Finance Committee Chair Ron Wyden, D-Ore., and Senate Health, Education, Labor and Pensions (HELP) Committee Chair Bernie Sanders, I-Vt., have asked data analytics company MultiPlan to meet with the committees and explain the company’s role in negotiating out-of-network payments on behalf of employer-sponsored health plans, which reportedly often result in higher costs for patients.
“While this practice is advertised as a way to constrain health care costs, recent reporting reveals that this practice often dramatically reduces plan payments for out-of-network services and leaves patients with sky-high medical bills that they are on the hook for paying,” Wyden and Sanders wrote in a recent letter to MultiPlan President and CEO Travis Dalton. “We are concerned that your company’s Data iSight product improperly drives up patient health care costs and, further, that the financial incentives built into the fee for the use of the Data iSight product result in an improper conflict of interest between determining a plan’s liability for out-of-network claims and the plan’s duty to provide promised benefits pursuant to ERISA.”
The letter outlines how MultiPlan reportedly works to negotiate rates paid by insurance companies to health providers for out-of-network services and takes a fee that is a percentage of any savings to the insurance company. This fee structure provides an incentive to iMultiPlan to negotiate the lowest possible payout by the insurance company, which in turn shifts costs onto patients.
NY reps introduce legislation to address MA wage index
Congresswoman Elise Stefanik (R-N.Y.) and Congresswoman Claudia Tenney (R-N.Y.) have introduced a bill to address what they describe as the significant under projection of Medicare Advantage (MA) local growth due to wage index reclassification.
The Centers for Medicare & Medicaid Services (CMS) uses the Medicare Wage Index to help determine how much the federal government should reimburse hospitals that provide care for patients with original Medicare. The wage index adjusts a hospital’s payments based on labor costs for a specific geographic area. Health plans often use the same payment rates for hospitals caring for their MA members.
The FY24 Inpatient Prospective Payment System (IPPS) Rule updating the wage index and reclassified many hospitals as “rural.” Stefanik and Tenney said the federal government did not give higher reimbursements to MA insurers. As a result, regional plans that solely service Upstate New York are being negatively impacted. Without a fix from CMS, they said the wage index increase could significantly raise out-of-pocket costs and premiums for the 119,183 MA beneficiaries living in NY-21.
”By adjusting the benchmark rates to reflect the increased costs faced by our regional plans, we can protect our seniors from losing essential coverage and experiencing higher premiums,” said Tenney in the announcement. “This bill will ensure that Medicare Advantage plans continue to provide the robust benefits that so many members of our community rely on.”