Medicare Updates
  • Recovery Audit Contractor (RAC) Program
  • Fraud Alert / Telemarketing
  • DME For Diabetic Patients / Elements Needed in Medical Record
  • Overpayment Letters
  • 26 Supplier Standards

RAC Program - RACs detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments. As a Medicare fee-for-service program biller, your claims will be subject to review by the RACs. MMA Section 306 required implementation of a RAC program no later than 2010 and gave CMS the authority to pay RAC contractors on a contingency basis. RACs will not be able to review claims paid prior to October 1, 2007. Additional information is also available in the attached RAC document and on the RAC website at www.cms.hhs.gov/RAC.

Fraud Alert / Telemarketing - The Office of Inspector General (OIG) has received credible information that some DME suppliers continue to use independent marketing firms to make unsolicited telephone calls to Medicare beneficiaries to market DME, notwithstanding clear statutory prohibition issued in March 2003. In January, an updated Special Fraud Alert was released to further clarify details that suppliers of durable medical equipment (DME) are prohibited from making unsolicited telephone calls to Medicare beneficiaries regarding the furnishing of a covered item, except in three specific situations: (i) the beneficiary has given written permission to the supplier to make contact by telephone; (ii) the contact is regarding a covered item that the supplier has already furnished the beneficiary; or (iii) the supplier has furnished at least one covered item to the beneficiary during the preceding 15 months. Additional details are provided in an attached telemarketing document.

DME for Diabetic Patients - Elements Needed in Medical Record - A physician’s documentation is critical for the payment of a patient’s diabetic supplies, Physicians should be reminded of the requirements that they must provide a copy of their patient’s medical records when requested for a supplier of diabetic supplies (for CERT or other Medicare audits) or their patient may not receive Medicare coverage for these items. Additional information is available at https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/glucose_monitors.htm.

For a patient’s diabetic supplies to be covered under Medicare, the physician’s record must document five elements:

  1. The frequency of diabetic testing and for how long
  2. If testing > 3 times/day when using insulin (> once/day if not using insulin), the reason for the increased testing frequency
  3. Evidence that the physician & patient have reviewed and are using the results (the diabetic "log")
  4. Any diet, medication or other changes
  5. Most recent Hgb A1c

CERT (Comprehensive Error Rate Testing) - The DME MAC CERT Education Task Force, a collaboration of all four DME MAC contractors held a conference call last week to educate suppliers and improve knowledge and performance related to the CERT program. The Cert Documentation Contractor (CERT DC), Lifecare Management Partners, initiates the CERT process by requesting medical records/documentation for a random sample of claims. The Cert Review Contractor (CRC), AdvanceMed, reviews the received documents, determines if paid correctly or in error and calculates the error rates. Documentation requests, with official CMS logo, will contain a pull-list that identifies the beneficiary and requested medical records/claims attachments. Suppliers are responsible for obtaining records from external entities necessary to comply with CERT requests and putting a process is in place to guarantee they can respond within the specified timeframe. Suppliers should ensure all medical records are accessible for a minimum of 7 years. For additional details or to update your contact information, visit www.certprovider.org.

Medicare 26 Supplier Standards - As a reminder, Medicare publishes Supplier Standards that all Medicare DMEPOS suppliers must meet in order to obtain and retain billing privileges. Full and abbreviated versions of the current DMEPOS Supplier Standards are available at: click here.

Recovery Audit Contractor (RAC) Slide Presentation
Fraud Alert Telemarketing
Supplier Standards Abbreviated Final

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