The DMEPOS supplier industry has been singled by the Inspector General of the Department of Health and Human Services,Daniel Levinson, as an area of heightened fraud related concern. He noted during congressional testimony that, over the last three decades, HHS-OIG has detected “significant levels” of fraud and abuse related to durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). In addition, many DMEPOS suppliers are highly dependent on federal healthcare programs for revenue and CMS believes that a number of these types of providers enter business without any substantial clinical or business experience which in turn leads to a high level of non-fraud related errors and omissions. To help reduce these problems new, more stringent rules regrading DMEPOS provider enrollment and recertification have been enacted. The new rules went into effect on March 25, 2011.
As part of the new regulatory environment risk assessment categories of “limited”, “moderate” and “high” have been created. (More information here about the new classifications). Under the new rule currently enrolled DMEPOS suppliers will be automatically assigned to the “Moderate Risk” category while any new suppliers or those adding a new location will be assigned to the “High Risk” Category.
The practical applications of these category assignments are a significant, increasing the time and paperwork involved in newly enrolling entity’s credentialing process. The new procedures include extensive data base searches, including “The List of Excluded Individuals or Entities” and “ The Exclude Parties List” system of the GSA. On-site inspections will likely increase with Medicare contractors, The National Supplier Clearinghouse (authorized for both pre and post enrollment visits) as well as any national accreditation organization and state agencies with jurisdiction having the right and/or obligation to pay the supplier’s offices a visit. Criminal background checks of owners as well as fingerprinting of of all owners and managing employees are authorized.
For revalidating entities who are automatically assigned to the “Moderate Risk” category the process of making sure all the regulatory and licensing issues are current and up to date, while not quite as difficult, will likely be more through and time consuming. They too will be subject to on going data base checks and unannounced site visits.
In addition, if any existing DME supplier is subject to any of the issues detailed below they will be reassigned to the “High Risk” category and subject to the same provider enrollment restrictions.
- CMS imposed a payment suspension on the supplier in the last 10 years;
- The supplier has been excluded from Medicare by HHS-OIG;
- The supplier is precluded from billing Medicaid;
- The supplier has been subject to any “final adverse action” in the last 10 years;
- The supplier has been excluded from any federal healthcare program; or
- CMS has lifted a temporary moratorium for a particular supplier type and a supplier that was prevented from enrolling due to the moratorium applies for enrollment within 6 months from the date the moratorium was lifted.
In addition to all of the above, the certification standards have also be tightened
- All DMEPOS suppliers must obtain oxygen for state-licensed suppliers, where required
- All DMEPOS suppliers must maintain ordering and referring documentation for 7 years of the date of service
- All DMEPOS suppliers are prohibited for sharing a practice location with any other medicare suppler or provider except in the the case of Medicare Part A providers or where a medical provider furnished the items to his or her own patients.
- All DMEPOS suppliers must be open at least 30 hours per week.
All of these restrictions and new provider enrollment procedures are designed to stop what is seen to be the egregious level of abuse encountered within the industry. While these problems do surely exist, the net result will be a substantial increase in the complexity associated with future Medicare authorization for both the good and the bad. These complexities will add significant time and cost to the process. DMEPOS suppliers and those responsible for their enrollment activities should take note and plan accordingly.