Some States See Post-Pay Audits on Parenteral Nutrition, Ventilators

With high denial rates in Jurisdiction A, it is likely the audits will expand.

Jurisdiction A’s recovery audit contractor (RAC), Performant Recovery, is conducting post-pay claims audits on parenteral nutrition and ventilators, according to the American Association for Homecare.

The affected states include Connecticut, Delaware, Massachusetts, Maryland, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont, as well as District of Columbia.

“The review for both items will be complex, which means the RAC will be asking for medical records on randomly selected claims,” a statement from the association reads. “Any claims that have a ‘claim paid date’ over three years prior to the ADR date are not subject to this review.”

Where ventilators are concerned, the RAC’s website stated the audit risk arose because, “potential incorrect billing occurred when claims for ventilators were billed without an indication supporting the coverage and/or medical necessity guidelines outlined in the Medicare National Coverage Determinations Manual (NCD), §280.1, and the ‘Correct Coding and Coverage of Ventilators’ Joint DME MAC Publication, including when ventilator codes are incorrectly billed for CPAP- or bi-level PAP-only use.”

It is likely that the audits will spread to other states, according to Wayne van Halem, president of audit consulting firm The van Halem Group, a division of VGM Group Inc.

“I think with the results being published in Jurisdiction A showing a 91 percent denial rate, we can expect this to expand — especially when the national RAC begins their work,” he said. “Since they are paid on a contingency and these products have such a high reimbursement, there’s quite an incentive there.”

Providers impacted by the audits must educate themselves on the proper patients that should be receiving ventilation, van Halem said. 

“The product categorization limits coverage for only the most severe patients,” he explained. “It all rests on a clear discussion in the medical record that, one, the underlying condition and, two, whatever evidence is appropriate for the condition to show that without ventilator support the patient is a real risk of death.”

About the Author

David Kopf is the Publisher and Executive Editor of HME Business and DME Pharmacy magazines. Follow him on Twitter at @postacutenews.

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