Today I have two small things and then a really big thing to cover. First up, LinCare, a home oxygen supplier, was fined $29 million for improper billing of Medicare for home oxygen equipment. Medicare has a really complicated way of paying for certain durable medical equipment (DME). In the case of oxygen equipment like concentrators, Medicare pays a monthly rental payment to the supplier for 36 months, after which the patient gets to keep the equipment at no charge for as long as it continues to work and they continue to require it. The oxygen supplier can continue to charge Medicare for supplies like tubing.
In this case, it appears that LinCare did not stop billing at three years and continued to collect rental payments from not only Medicare, but also Medicare Advantage (MA) plans. Now, I know LinCare should not have done this, but how hard would it have been for the Medicare Administrative Contractors (MACs) and MA plans to program their systems to produce an alert when 36 rental payments are made? How about a little shared responsibility here? Oh, and by the way, this was a whistleblower case, and two people just made $2.8 million each.
Moving on, I have talked about Leqembi, the new medication for Alzheimer’s disease, in several past articles. Well, UnitedHealth Care (UHC) just released their coverage guidelines for the medication. Now, of course, for their Medicare Advantage patients, their coverage mirrors the CMS requirements as required by law, but they also adopted the same requirements for their commercial patients. That is actually a bit surprising, as they are free to perform their own efficacy analysis (which was not terribly convincing to many physicians), and to consider the cost-effectiveness of the medication, a factor that Medicare is not allowed to consider. The only tricky part is that UHC requires that the patient prescribing the medication be either a neurologist, a geriatric psychiatrist, or a geriatrician who specializes in treating dementia. That could certainly limit access in many areas of the country.
Dr. Ronald Hirsch is Vice President of the Regulations and Education Group at R1 RCM Inc. Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee. Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of RACmonitor.com. He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the third edition published in 2021.