Officer of Inspector General – 2016 Work Plan

NEW Orthotic braces–reasonableness of Medicare payments compared to amounts paid by other payers

We will determine the reasonableness of Medicare fee schedule amounts for orthotic braces. We will compare Medicare payments made for orthotic braces to amounts paid by non-Medicare payers, such as private insurance companies, to identify potentially wasteful spending. We will estimate the financial impact on Medicare and on beneficiaries of aligning the fee schedule for orthotic braces with those of non-Medicare payers. (OAS; W-00-15-35756; expected issue date: FY 2016).

NEW Orthotic braces–supplier compliance with payment requirements

We will review Medicare Part B payments for orthotic braces to determine whether durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers’ claims were medically necessary and were supported in accordance with Medicare requirements. Prior OIG work indicated that some DMEPOS suppliers were billing for services that were medically unnecessary (e.g. beneficiaries receiving multiple braces and referring physician did not see the beneficiary) or were not documented in accordance with Medicare requirements. Medicare requires that such items be “reasonable and necessary.” (Social Security Act § 1862(a)(1)(A).) Further, LCDs issued by the four Medicare contractors that process DMEPOS claims include utilization guidelines and documentation requirements for orthotic braces. (OAS; W-00-15-35749; expected issue date: FY 2016).

For the entire 2016 Work Plan please click here:  2016 OIG Work Plan

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Categories: DME Information

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