Deeper Than the Headlines: Positive Airway Pressure

Wake up and stop snoring! Well, at least from a compliance perspective, some of us need to wake up according to the latest OIG report on the types of devices that treat, among other things, sleep apnea and the accompanying snoring for some patients. The OIG concluded most Medicare claims for replacement Positive Airway Pressure (PAP) device supplies did not comply with Medicare requirements. The report was posted on their website in June 2018. According to their report, previous OIG reviews found that Medicare allows replacement of positive airway pressure (PAP) device supplies more frequently than what is reasonable and necessary and that durable medical equipment (DME) suppliers often do not have the documentation required to support the need for replacement supplies. So, the OIG set about to determine whether Medicare claims that DME suppliers submitted for replacement PAP device supplies complied with Medicare requirements.

The OIG selected a statistical sample of 110 claims for replacement PAP device supplies that Medicare paid in 2014 and 2015. Then they reviewed supporting documentation from the supplier to determine whether that documentation complied with Medicare requirements. They found that most Medicare claims that DME suppliers submitted for replacement PAP device supplies did not comply with Medicare requirements. Of the 110 claims in the sample, only 24 complied with Medicare requirements. 86 claims with payments totaling $13,414 did not comply. Based on the sample results, OIG estimated that Medicare made overpayments of almost $631.3 million for replacement PAP device supply claims that did not meet Medicare requirements.

Payments for PAP devices have been on the rise of late. Medicare payments for PAP device supplies increased 271 percent from approximately $194 million in 2007 to $526 million in 2015. The number of beneficiaries receiving PAP device supplies also increased 196 percent from approximately 774,000 in 2007 to 1.52 million in 2015.

The errors that created the non-compliance were varied:

The OIG concluded that the overpayments occurred because CMS oversight of replacement PAP device supplies was not sufficient to ensure that suppliers complied with Medicare requirements or to prevent payment of claims that did not meet those requirements. They said that although Medicare contractors reviewed claims for PAP devices, they did not conduct periodic reviews of claims for replacement PAP device supplies.

The largest error type included Physicians’ orders not being in accordance with Local Coverage Determination (LCD) Requirements. The LCDs for PAP devices state that an order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Suppliers may dispense supplies based on a verbal or written dispensing order, but the supplier must obtain a detailed written order before submitting a claim. The detailed written order must contain several elements, such as the beneficiary’s and physicians’ names, the date of the order, a detailed description of the items to be dispensed, the quantity to be dispensed, the frequency of use, and the number of refills. The supplier must obtain a new order when there is a change in supplier, supplies, frequency or quantity of use, or length of need.

For 53 claims in the OIG sample, the physician's orders were not in accordance with the LCDs because (1) the written order did not contain at least one of the required elements, (2) the supplier did not obtain a detailed written order before billing Medicare, (3) the order did not contain at least one of the supplies on the claim, or (4) the supplier did not obtain a new order after a change of supplier.

These orders often contained multiple supplies that were contradictory, such as more than one type of mask; did not indicate which specific supplies the physician was ordering; or were missing the frequency or duration of use.

One of the OIG recommendations was for CMS to work with Medicare contractors to establish periodic reviews of claims for replacement PAP device supplies and take remedial action for suppliers that the contractors find consistently bill claims that do not meet Medicare requirements. CMS concurred with this recommendation and stated they would work with local contractors to conduct these periodic reviews for replacement PAP devices.

If your organization provides these services and devices, it might be wise to review the OIG report in full and perform some self-reviews within your organization.