Vents: RACs join the party

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Friday, January 26, 2018

WASHINGTON – The national recovery audit contractor for HME has set its sights on ventilators, but that’s no big surprise, industry stakeholders say.

The Medicare Administrative Contractors are already auditing vents, and the Office of Inspector General has included the product category in past work plans.

“I think it’s a no-brainer for the RACs to say, ‘Hey let’s audit this, too,’” said Kim Brummett, vice president of regulatory affairs for AAHomecare.

Performant Recovery announced in January that it would perform widespread complex reviews for E0465 (invasive) and E0466 (non-invasive) for claims on or after Jan. 1, 2016. It will be looking to see if coverage criteria and/or medical necessity requirements were met.

With no local coverage determinations for vents—only a broad national coverage determination—it will be interesting to see what, exactly, auditors are looking for.

“I don’t know if they are simply going through detailed written orders and making sure that there are things such as a start date, or if they are looking deeper into coverage criteria such as whether a BiPAP was ruled out,” said Kelly Grahovac, a senior consultant with The van Halem Group. “They don’t have any black-and-white requirements (to follow).”

As long as providers follow the NCD, they should be OK, Brummett said.

“I think most people are fairly comfortable with where we are on vents today,” she said.

Still, there are movements to effect change to the product category. Several respiratory groups, including the American Association of Respiratory Care and the National Association for Medical Direction of Respiratory Care, have submitted a request seeking a reconsideration of the current NCD for home ventilators, including BiPAPs.

Additionally, in November 2017, Sens. Bill Cassidy, R-La., Charles Grassley, R-Iowa, and Joe Manchin, D-W.Va., introduced S. 2175, which would also pave the way for providers to receive a possible increase in reimbursement for non-invasive vents, pending any decreases in utilization.

So far, CMS has declined to make any changes, says Brummett.

“CMS said it just didn’t fit in their scope of work,” she said. “We’re a teeny part of the pie, and when you look at vents in terms of total spend for Medicare, we are really not in the spotlight.”

In case they do get selected for an audit, it’s a good time for providers to be prepared, Grahovac says.

“Do some documentation checks, review those fields and make sure it is all there,” she said.