As Goes Florida

Every year, the Office of Inspector General releases its Work Plan for the upcoming fiscal year, identifying areas of concern it intends to investigate for possible enforcement activity or regulatory reform.

The OIG mentions several times in the 2008 Work Plan its recent investigation of South Florida DME suppliers to ferret out sham businesses that failed to comply with the supplier standards and, for the most part, did not really exist except for fraudulent purposes.

The OIG touted its investigation as a huge success, noting: “In a recent review of DME suppliers in three South Florida counties, we found that 31 percent of suppliers did not meet selected Medicare supplier standards requiring suppliers to maintain a physical facility and to be open and staffed during reasonable business hours.”

The OIG's comments reveal important indicators of upcoming activity. For example, the OIG intends to continue its focus on South Florida suppliers to “determine whether DME claims paid under Medicare to suppliers in South Florida were allowable.” The Work Plan does not state that the OIG will review claims submitted only by that 31 percent of suppliers who were found to violate the supplier standards. Rather, it indicates that South Florida suppliers in general will have their claims scrutinized.

As a practical matter, this means that “perfection” in claims submission may well be the de facto standard for South Florida home care companies for a while. I expect this will also include a review of supporting medical documentation, such as items for power mobility devices. Smart Florida suppliers should take care to ensure that their claims are as pristine and free from omissions and errors as is possible.

If the DME MACs' behavior during the 2007 investigation is predictive of the claims review project in 2008, suppliers who wish to challenge alleged overpayments or deficient claims, etc., may find little willingness by CMS or the MAC to compromise, or even to be reasonable in negotiation. Rather, suppliers may find that an appeals process is their only outlet for fair treatment.

Further, if 2007 activities are predictive of 2008, the hearing officers may very well be under very narrow parameters in their discretion at the hearing. They may be pressured to find against the supplier in the event of any uncorrected imperfections. Again, hyper-vigilance is key.