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David McGill Blogger

OIG Issues New Report on O&P Facility

Posted by David McGill | February 23, 2015


​​The OIG released its 6th report since May 2011 analyzing lower limb prosthetic claims from an individual O&P facility. Prosthetic Science (TX) had 167 claims worth $1.79M reviewed. The OIG concluded that Prosthetic Science should return just over $25,000 in claims for which it should not have received payment.

What does this mean for you?

While it's tempting to create a narrative from this report and/or from a review of all 6 OIG audits of O&P facilities, we think it's dangerous to do so. However, we do want to offer 3 take​aways.

First, the OIG seems to be increasing its focus on high-dollar-value claims. Of the 6 audits, the two with the highest average value per claim are the two most recent, with average claim values of approximately $13,000 (Aug. 2014) and $10,783 (Feb. 2015). The first audit, in comparison, had an average claim value of only $609 per claim. 

Second, the OIG has steered away from reviewing the medical necessity of the services provided. All of the 6 individual facility audits have focused on the O&P's compliance with Medicare's documentation requirements. So the OIG has and continues to focus on exactly the same kinds of issues as the Recovery Auditors and the DME MACs. Assuming that OIG continues to audit in this manner, if you are successfully navigating the recovery auditor/prepayment claim review processes, then it's likely you would similarly fare well in an OIG audit.

Finally, most of the findings have not yielded significant recoveries for the OIG. In one audit, the OIG determined that all claims had been correctly paid. Four of the remaining five audits resulted in findings that anywhere from .1% ($1,929) to 2.9% ($67,000) of the value of the billed claims had been paid inappropriately. Only one audit produced worrisome results: a demanded $284,000 repayment from the OIG that represented 9.6% of the total amount billed by that O&P.

It all comes back to the same message we have repeated time and time again in these e-pages: (1) understand Medicare's coverage requirements (​read the LCD and accompanying Policy Article!); (2) implement processes that ensure you do not file claims until you have all appropriate documentation, both in your file and the physician's; and (3) if you struggle with this, consider utilizing resources like Ossur's strategic partner, The Audit Team.


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