Market changes likely to drive increase in audit activity 

YARMOUTH, Maine – The end of Medicare’s competitive bidding program for knee and back braces on Dec. 31 could open the door to increased audit activity for orthotics in 2024, industry consultants predict. 

“We’ve already seen the Supplemental Medical Review Contractor (SMRC) add braces back onto their project list and the Recovery Audit Contractor (RAC) still has them on their approved list,” said Kelly Grahovac, general manager of the van Halem Group. “But I think we’ll probably see them more on the Target Probe and Educate (TPE) side by the DME MACs because that’s pre-pay and that keeps the money in-house. It’s less pay and chase.” 

Audits of knee and back braces reached a crescendo in 2019 during the Department of Justice’s “Operation Brace Yourself,” which resulted in charges against 24 individuals responsible for more than $1.2 billion in losses.  

Now consultants say the end of the bid program could give contractors potentially fresh material to work with. 

“With bidding wrapping up, there might be more suppliers entering the off-the-shelf brace market and (contractors) might drill down into any big spikes they see,” said Andrea Stark, a Medicare consultant and reimbursement specialist for MiraVista. 

Another product category that will likely see increased audit activity: continuous glucose monitoring systems. CGMs, consultants point out, have not only seen increased utilization but also changing policies. For example, a public health emergency-related moratorium on requiring patients to see their physician every six months expired this year and CMS recently published a change request directing the DME MACs to allow 90- vs. 30-day billing for CGM supplies. 

“There are a lot of details that could trip a supplier up,” Stark said. 

Consultants also have their eyes on lymphedema and complex rehab – two product categories where CMS has recently expanded coverage for compression garments and power seat elevation systems, respectively. 

“Anytime CMS says, ‘We’ll cover this now,’ you usually see increased oversight to cover their tracks,” Grahovac said.