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Wednesday, August 28, 2013

Questionable Billing May Have Cost Medicare $425 Million in 2011

by James Swann

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A weakened claims-processing system combined with limited oversight may have cost Medicare $425 million in inappropriate claims payments in 2011 to diabetes-test strip (DTS) suppliers, according to a recent OIG report. The DTS claims associated with the $425 million in payments exceeded the threshold for at least one out of six questionable billing patterns, which indicate an unusually high level of DTS billing. While the claims might be legitimate, "suppliers that bill for extremely high amounts warrant further scrutiny," OIG said.

OIG also uncovered roughly $6 million in DTS claims payments in 2011 that either were lacking a diagnosis code for diabetes, inappropriately overlapped with a beneficiary's hospital stay, or inappropriately overlapped with a beneficiary's short-term nursing facilities stay. Under Medicare coverage policies, the claims should not have been paid.

The report recommended that CMS strengthen claims-processing edits for DTS claims and improve oversight of DTS suppliers. In addition, OIG said CMS should investigate and take appropriate action toward the $6 million in inappropriate payments identified in the report.

 
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