CGS Administrators, LLC, Paid Unallowable Lower Limb Prosthetics Claims.

摘要

Previous Office of Inspector General (OIG) reviews found that Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) did not ensure that lower limb prosthetic claims met the coverage requirements in local coverage determinations (LCDs). LCDs are decisions by DME MACs on whether to cover a particular service in accordance with section 1862(a)(1)(A) of the Social Security Act (the Act) and are published to provide guidance to the public and the medical community. In response to one of OIG's reviews, on March 5, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a Technical Direction Letter (TDL) directing the DME MACs to develop claim-processing edits for all requirements in LCDs for lower limb prostheses. CGS Administrators, LLC (CGS), is one of the DME MACs. This review is part of a series of reviews to determine the compliance of DME MACs with LCD requirements for lower limb prostheses. The objective of this review was to determine whether CGS processed and paid claims for lower limb prostheses according to LCD requirements for calendar years 2010 and 2011.