Inappropriate Medicare Payments for Pressure Reducing Support Surfaces

Title: oei-02-07-00420.pdf (1.96 MB)

Inappropriate Medicare Payments for Pressure Reducing Support Surfaces

Inappropriate Medicare Payments for Pressure Reducing Support Surfaces

Inappropriate Medicare Payments for Pressure Reducing Support …

Link:
http://oig.hhs.gov/oei/reports/oei-02-07-00420.pdf (1.96 MB)
Format: pdf
Publication Year: August 2009
Language: English
Audiences: Older Americans , Caregivers , Family Caregivers , Families of Alzheimer’s Patients …
Source: Office of Inspector General

http://oig.hhs.gov

Abstract:

BACKGROUND
Pressure reducing support surfaces (support surfaces) are used for the
care or prevention of pressure ulcers. A pressure ulcer, also known as a
bedsore or decubitus ulcer, is an area of skin that breaks down when a
person stays in one position for too long without shifting his or her
weight. Pressure ulcers commonly occur among the elderly and among
individuals with spinal cord injuries.
The Centers for Medicare & Medicaid Services (CMS) categorizes
support surfaces into three groups based on the complexity of their
features. This report focuses on group 2 support surfaces, which is the
largest group. In 2007, Medicare payments for group 2 support surfaces
totaled $109 million, which accountedfor 80 percent of all support
surface payments. Medicare covers support surfaces under its durable
medical equipment (DME) benefit.
To assess the appropriateness of Medicare payments for group 2 support
surfaces, we used a contractor to conduct a medical record review of a
stratified random sample of 363 claims. We also conducted a separate
review of the documentation that suppliers are required to keep on file
for each claim. Lastly, we conducted structured telephone interviews
with CMS contractor staff who process, review, and analyze DME
claims.

Major Descriptor(s):

Medicare 02 Criteria

Inappropriate Medicare Payments for Pressure Reducing Support …
$33 million in inappropriate payments during that time. We considered a claim as not meeting Medicare coverage criteria if it either (1) did not. OEI-02-07-00420.

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Inappropriate Medicare Payments for Pressure Reducing Support …
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Medicare’s Oversight of Managed Care: Monitoring Plan

Title: oei-01-96-00190.pdf (2.39 MB)

Medicare's Oversight of Managed Care: Monitoring Plan

Medicare’s Oversight of Managed Care: Monitoring Plan

 

Medicare’s Oversight of Managed Care: Monitoring Plan – Office of …

Link:
http://oig.hhs.gov/oei/reports/oei-01-96-00190.pdf (2.39 MB)
Format: pdf
Publication Year: 1998
Language: English
Audiences: Older Americans , Caregivers , Family Caregivers , Families of Alzheimer’s Patients …

Major Descriptor(s):

Medicare Tracking Software

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The Sanction Referral Authority of Peer Review Organizations

Title:  oei-01-92-00250.pdf (4.32 MB)

The Sanction Referral Authority of Peer Review Organizations

The Sanction Referral Authority of Peer Review Organizations

The Sanction Referral Authority of Peer Review Organizations (OEI …

Link:
http://oig.hhs.gov/oei/reports/oei-01-92-00250.pdf (4.32 MB)
Format: pdf
Publication Year: 1993
Language: English
Audiences: Older Americans , Caregivers , Family Caregivers , Families of Alzheimer’s Patients …

Abstract:

BACKGROUND
Since their establishment in 1982, the Peer Review Organizations (PROS) have
reviewed millions of inpatient medical records to confirm the necessity, quality, and
appropriateness of care rendered to Medicare beneficiaries. One controversial aspect
of the PROS’ responsibilities has been their sanction referral authority, which requires
them to recommend that the Office of Inspector General (OIG) sanction physicians
and hospitals responsible for violating their Medicare obligations, as specified in
section 1156(a) of the Social Security Act. If the OIG accepts a PRO’s
recommendation, it can sanction physicians and hospitals by excluding them from
participating in Medicare and all State health care programs or by imposing a
monetary penalty.
In this report, we provide an update on the extent to which the PROS have been using
that authority and the difficulties they experience with it. We offer three options for
policymakers to consider. We reviewed the PRO sanction referral data for FYs 1986
through 1992 and intemiewed representatives of 10 pROs. Among those 10 were
PROS that, during Fiscal Years 1990 and 1991, had made at least 1 referral leading to
a sanction, PROS that had made referrals that were rejected by the OIG, and PROS
that had made no referrals.
.

Major Descriptor(s):

Medicare Sanctioned Physicians

The Sanction Referral Authority of Peer Review Organizations (OEI …
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