CMS Proposes 10-Year Claims Review

Proposed rule would implement aggressive enforcement of Affordable Care Act provision that could pose problematic to providers.

The Centers for Medicare and Medicaid Services proposed a rule in the Federal Register on Feb. 16 that would call for a 10-year review period for various claims, including those for home medical equipment.

The proposed rule, which is published in detail at, is a response to part of the Patient Protection and Affordable Care Act, which calls for stronger policing of overpayments. So the CMS rule proposes a far-ranging, 10-year "lookback" window to hunt for overpayments that would be recouped.

"We selected 10 years because this is the outer limit of the False Claims Act statute of limitations," the proposed rule's text reads. "We believe that the proposed 10-year lookback period is appropriate for several reasons. First, we believe that providers and suppliers should have certainty after a reasonable period that they can close their books and not have ongoing liability associated with an overpayment. We also believe that the length of the lookback period is long enough to sufficiently further our interest in ensuring that overpayments are timely returned to the Medicare Trust Funds."

However, the length of the window, and other aspects of the propsed rule could prove problematic for providers. HME Business sat down with Wayne Stanfield, president and CEO of the National Association of Independent Medical Equipment Suppliers, to clarify the proposed rule's implications:

Q: What do you expect will be the implication for providers?
A: Having to maintain records for 10 years is a big problem. Currently seven years is the standard. With rules changing and software evolving, a 10-year look back will cause suppliers to refund legitimate payments without evidence to prove them right.

Q: Looking at section one under Definitions (called “overpayments”) the definition appears very broad. What is your take?
A: "Overpayments," by the CMS definition, covers a lot of territory, thus adding to the risk of suppliers being seen a committing fraud, waste and abuse.

Q: What should providers being saying in their public comments regarding this proposed rule?
A: I think comments should follow those of other providers caught in this, like hospitals and physicians. Looking back beyond four years is unreasonable, and places an unnecessary administrative burden on everyone.

Q: What else should providers be doing in regard to this proposed rule (i.e., should they be contacting lawmakers, or anything else)?
A: I absolutely think this should be a topic raised with lawmakers. CMS has 10 years under the False Claims Act, so this goes too far and will penalize suppliers.

Providers can leave comments on the rule. The deadline for public comments 5 p.m. Eastern Time, April 16, and providers can submit their questions via:

  • Visiting and following the ‘‘Submit a comment’’ instructions.
  • Mailing written comments to Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–6037–P, P.O. Box 8013, Baltimore, MD 21244–8013.
  • By express or overnight mail at Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–6037–P, Mail Stop C4–26–05, 7500 Security Boulevard, Baltimore, MD 21244–1850.
  • By hand courier, the details for which are published in the proposed rule.


About the Author

David Kopf is the Editor of HME Business.


Sun, Mar 11, 2012 SHAHZAD KHAN

I am really surprised to hear this new 10 year review. CMS should realize that companies being in business for 10+ must have reputation and must be loyal to their patients. After all these years of hard work and investment and excellent care of beneficiaries, providers and still under the threat of loosing money just beacuse of the reason that docotr did not write the Rx correctly or did not provide the code. I beleive CMS should start fast and speedy proir authorization process ASAP to control the fraud and abuse now and future, instead of going back farhter and digging graves to find the reasons for denial. I believe CMS has technology to process the electronic claim and except all the required documentation and issue prior authorization in timely manner.

Fri, Mar 9, 2012 Celeste California

After 23 yrs in the business, I keep saying I'm amazed at what CMS throws at us DME Suppliers. It's a wonder how any of us small independant companies have stayed in business this long. Ive always said hold the Doctors accountable for their chart notes and take their money away from them and you'll see the AMA in a heart beat respond, and CMS may sing to a different tune. Unless everything goes prior auth (like previous stated) we are in a no win situation. In one of my wheelchair audits, I had 57 pages of notes from 3 different PT's and numerous doctor's and still denied. I think every 103 year old with 57 pages of chart notes should be allowed a manual wheelchair. All these audits are taking my time away from what we ARE REALLY HERE FOR, taking care of patients and their DME needs. Yet again all the illegal companies have ruined our livelihood! The towel is very close to being thrown in. The nationals can have it!!!!!

Fri, Mar 9, 2012 Editor

Sorry gang, there was a version control problem and bad copy sneaked into the published product. Apologies. Color me red. Edited copy should now be live. — Ed.

Fri, Mar 9, 2012 Spell "Check" USA

Only in America can we have a republican run for office that doesn't work for a living but makes 250 million a year....face off with a democrat who symbol is a "jack***"....Now the smart ones in Washington want to prevent fraud, abuse and overcharging by what.....going back ten years?! Only thing funnier is the poorly written article followed by a typo in a comment by the reader "Check".....I wake up every morning and chuck my e-male on the intranet....and give thanks to Mr. Goore. :-)

Fri, Mar 9, 2012 MJ Cookeville Tn

I feel the 10 year look back is just another way for Medicare to rob Providors from product that they have paid for and placed because a physician ordered it. Now we are responsible for Doctors chart notes and blamed for denials that had nothing to do with what we did wrong only that the Doctor didn't do the charts right. What kind of school does a providor go to that makes him the gatekeeper for what a Doctor doesn't do right. We need more parameters for Doctors to do their job right then it would not matter that they audit for 10 years and yes they also pull dead people files so how could you possible ever win. So look out this is just another unreasonable way to take advantage of the providors that are always going to lose. What protection is there for providors even when we get the chart notes and feel they are good in review or cert they say not good enough. They are questioning the doctors but the doctors don't get recouped we do this is a very on fair arrangement. If they want to be fair why doesn't everything require a prepayment review then they would save alot of money and not have hire all these new auditors it would be right from the beginning and give us all a sense of closure when we give someone a product we know that we are going to get paid and not wait 10 years, 7 years or 3 years to require charts. This is crazy.

Fri, Mar 9, 2012 Chuck

"What should providers being saying..." & "Looking back beyond 4 years is unreasonably and..." What kind of grammer is that? Did you write the article from your I-Phone?

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