Pacific Medical target of audit for braces

Friday, January 4, 2019

TRACY, Calif. – Pacific Medical did not always comply with Medicare requirements when billing for selected orthotic braces, according to an audit by the Office of Inspector General. For 89 of the 100 sampled claims, the company complied with requirements, but for the remaining 11 claims, it did not. Specifically, Pacific Medical billed for orthotic braces that were not medically necessary for nine claims and could not provide medical records for two claims, the OIG says. “The deficiencies occurred because the company did not always obtain sufficient information from the medical records of beneficiaries to assure itself that the claims for orthotic braces met Medicare requirements,” the audit reads. On the basis of sample results, the OIG estimates that Pacific Medical received at least $247,483 in unallowable payments. The agency recommends that Pacific Medical refund the DME MACs $247,493; exercise reasonable diligence to identify and return any additional similar overpayments outside of the audit period, in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation; and obtain as much information from medical records as necessary to assure itself that claims meet requirements. Pacific Medical did not concur with the first recommendation, but concurred with the second and third recommendations.