OIG dumps compliance role in laps of DME suppliers

The Office of the Inspector General has released its harshest model plan yet, saddling durable medical equipment suppliers with greatly increased responsibility for ensuring that claims are properly filed.

"This is much more onerous than the guidance they gave to other industries," says Mark Hobratschk, assistant government affairs director for the Health Information Distributors Association in Washington, D.C. In particular, he points to the OIG’s recommendations on cover letters for Certificates of Medical Necessity. The OIG plan warns that while cover letters should not include diagnostic information, they should address HCFA or DMERC policies, changes in patient regimen and descriptions of the items provided. Hobratschk replies that this contradicts earlier HCFA guidance that a cover letter just needs to confirm a verbal conversation with a doctor. It also preempts a HCFA guidance on cover letters that should be coming out soon.

The OIG plan, which is open for public comment until March 1, contains a long list of do’s and don’ts that should be specifically addressed in the compliance plan that every DME firm would be wise to have. Many of the don’ts focus on the ways that some suppliers have boosted their reimbursement, or at least skirted the law to help physicians with their paperwork. OIG says:

- Don’t sign the Certificate of Medical Necessity for the treating physician.

- Don’t urge doctors to order more equipment than is necessary.

- Don’t deliver anything that requires pre-authorization without first getting a CMN and physician order.

- Don’t submit a claim until the CMN is completed by the physician.

- Do keep the original CMNs in your files.

- Do complete sections A and C of the CMN before sending it to the physician.

OIG also lists a slew of risk areas that DME suppliers better address. If they don’t, federal investigators will take the position that the model plan gives suppliers ample warning of what auditors will be looking for. The risk areas include the following: ordering unnecessary equipment; upcoding claims for more expensive items; billing for new equipment even though old items were supplied; billing for rental equipment that’s no longer medically necessary; refusing to file a claim on behalf of a beneficiary; providing excessive amounts of supplies; and completing portions of the CMN that should be filled out by the physician.

In line with a special fraud alert that warned doctors against dishonest DME suppliers, the OIG plan admonishes suppliers not to violate the anti-kickback statute by paying physicians to sign CMNs, bribing referral sources such as hospitals, or paying patients for ordering services. Many cases against suppliers "have involved the DMEPOS supplier giving the beneficiary free gifts such as angora underwear, microwaves and air conditioners in return for providing and billing for unnecessary items," OIG notes.

As with the model plan for billing companies, OIG expects DME companies to educate doctors on complying with regulations and paperwork. And echoing complaints from the billing industry, Hobratschk says that will put suppliers in an awkward position where lecturing to doctors could mean losing their clientele.

In other respects, the DME plan resembles earlier OIG model plans for other health care industries. For example, suppliers should have a compliance officer, even if it just an existing employee who wears an extra hat. For the vital question of when a supplier has to report a violation to the government, OIG says the time limit is 60 days after the company first discovers credible evidence of a problem.