Abuses still exist, warns OIG report
Restrictions on the Medicare reimbursement of pressure-reducing support surfaces have curtailed some misuse of that money, but abuses still exist, according to a report from the federal Office of Inspector General (OIG).
The report examined the aftermath of the January 1996 implementation in of new guidelines for support services for patients with pressure sores. Among the most prominent aspects of the new guidelines was the decision to stop reimbursement for these mattresses if used for preventive treatment, which had been covered previously. (Durable equipment manufacturers are still fighting to have preventive reimbursement reinstated.) The guidelines also dropped a requirement for certificates of medical necessity for support surface equipment, with the exception of air-fluidized beds.
One result of the changes has been a drop in Medicare reimbursement for alternating pressure mattresses from $183.4 million in 1995 to $148.9 million in 1996, the report says.
Unnecessary use dropping
In 1996, 29% of the beneficiaries who were sampled used support surfaces that were medically unnecessary, compared to 47% of beneficiaries who used a medically unnecessary support surface in 1995. Also, 12% of beneficiaries in 1996 reported receiving upcoded equipment or no equipment at all, or had duplicate support surface billings - down from 22% in 1995. Because of a small sample size, the authors of the study said they could not demonstrate statistical significance for their findings.
The report says the problems regarding unnecessary use of support surfaces were due to a lack of adherence to existing Durable Medical Equipment Regional Carrier (DMERC) guidelines and were not affected in any way by the establishment of the 1996 guidelines. These problems include:
· the use of group 2 equipment before a trial of less expensive and less complex group 1 equipment;
· the continued use of support surface equipment after sores had healed completely;
· an apparent lack of physician involvement in and documentation for beneficiary use of support surfaces;
· improper use of support surfaces by beneficiaries who do not plug in their electrical equipment.
The OIG noted that while the 1996 DMERC guidelines appear to be having a positive impact on controlling Medicare costs for support surfaces, inappropriate payments are still being made and other problems continue to adversely affect Medicare reimbursement for the equipment.
The report recommends additional ways to reduce inappropriate support surface payments, including a suggestion that the Health Care Financing Administration require mandatory periodic review and renewal of the medical necessity for beneficiaries' use of group 2 support surface equipment. The report estimated that $12 million or more could be saved each year.
"We recognize that establishing such a requirement may be cumbersome to both the DMERCs in processing claims and to the suppliers in obtaining the necessary information," the report says. "However, we believe that this requirement should help to eliminate problems identified in this report. . . . Periodic recertifications could be done every three months and completed by a health care practitioner."