Spike in ventilator claims draws the ire of OIG

Insurance claims forms

Medicare saw a spike in noninvasive ventilator payments over the last three years thanks to new ventilator technology government officials believe is contributing to widespread overbilling.

Medicare covers durable medical equipment rentals for continuous positive airway pressure devices, respiratory assist device, and traditional ventilators. However, according to a report from the Office of Inspector General, new technology that allows one device to operate in all three modes “creates an opportunity for abuse.” The technology allows suppliers to bill for more expensive ventilators even if the device is used for a less intensive medical condition.

In 2015, Medicare paid 85 times more for these types of non-invasive ventilators than it did in 2009, including a rapid spending growth over the last few years. OIG also noticed a “dramatic shift” in the use of ventilators to treat respiratory conditions as opposed to neuromuscular conditions, an indication that the equipment was being used for less intensive services.

Between 2012 and 2015, three suppliers accounted for 54 percent of spending growth. Overall, $25 million of Medicaid spending on noninvasive ventilator claims had signs of improper billing.

Durable medical equipment fraud has been an ongoing concern for federal regulators, leading to a finalized prior authorization rule at the end of last year that is estimated to save $580 million over the next decade.