The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released a report on rising Medicare billing for noninvasive pressure support ventilators. The OIG recognized this ventilator as particularly vulnerable to inappropriate billing due to (1) its ability to operate in several modes; and (2) Medicare policies favoring reimbursement for ventilators. Medicare pays for home ventilators as durable medical equipment as long as the ventilator meets medical necessity and Part B coverage requirements. However, the OIG found that Medicare paid 85 times more claims for noninvasive pressure support ventilators in 2015 than in 2009. The OIG study explores possible reasons for the significant increase in ventilator billing.
The OIG found the following:
- Combined expenditures for Medicare and its beneficiaries totaled $340 million in 2015, largely due to increased billing for ventilators;
- Three ventilator suppliers were primarily responsible for the ventilator billing increase, accounting for 54 percent of the nationwide growth in claims;
- Diagnoses for beneficiaries using noninvasive pressure support ventilators have shifted significantly from neuromuscular diseases to respiratory conditions; and
- Medicare paid $25 million for noninvasive pressure support ventilator claims with inappropriate billing indicators, including:
- Billing for multiple devices;
- Billing for separate accessories; and
- Billing to treat obstructive sleep apnea.
The Centers for Medicare & Medicaid Services (CMS) recently consolidated billing codes for ventilators and decreased the reimbursement amount for noninvasive pressure support ventilators. The OIG recommended that CMS monitor providers with the largest market shares of ventilator beneficiaries. Further, the OIG will refer inappropriately paid claims to CMS and determine whether to audit or investigate the three suppliers driving the increase in ventilator claims.
The OIG report is available at:
Department of Health and Human Services Office of Inspector General. “Escalating Medicare Billing for Ventilators Raises Concerns.” OEI-12-15-00370. 22 Sept. 2016.