MiraVista: Medicare News Blog

Electronic Bid Window Extended for Round 2 & National Mail Order Recompete

March 26th, 2015

Andrea Stark


Due to some technical difficulties experienced in the electronic bid system, the CBIC extended the window to submit electronic bids to March 26, 2015 at 8:59 PM Eastern (this evening).


Keep in mind they did not extend the window for delivery of hardcopy documentation which still had be received by the CBIC no later than midnight on March 25th.  If your packet was not received by that deadline, it will not be accepted and your bid will be disqualified, even if it is postmarked before the deadline.


For bidders that submitted documentation in time for the Covered Documentation Review process, a notification will be sent by May 21, 2015 either confirming that your packet is complete or to notify you which financial documents were missing from your packet. Bidders will not receive email correspondence regarding receipt of the packet unless it was submitted by the Covered Documentation Review deadline of February 23, 2015.

Executing ABNs: When a Patient Refuses to Sign

March 18th, 2015

Andrea Stark


Executing compliant Advanced Beneficiary Notices (ABNs) can be tricky. ABNs are particularly troublesome when you encounter a beneficiary that refuses to sign and accept financial responsibility. In these cases you should generally refuse service to the patient. But what if that is not a viable option? Perhaps the health of the patient would be put in jeopardy if you refuse service or what if the patient already has the equipment and now refuses to sign? In these cases, it may be possible to execute an ABN even if the patient refuses to sign, as long as certain requirements are met.


In order to effectively execute an ABN in instances when the patient refuses to sign, ALL of the following conditions must be met (no exceptions):


  • You must accept assignment on the claim.
  • Your ABN must include the specific reason(s) the claim is expected to deny.
  • The patient must have demanded the service, but still refused to sign the ABN or be held financially liable.
  • The patient’s refusal to sign must be witnessed by the notifier (you) and a second party (this can be over the telephone where the second party is called to witness the refusal while you are on-site).

These requirements are outlined by CMS in Chapter 30 of the Claims Processing Manual (; Section discusses Beneficiary Refusal, Section 50.13.2 Discusses the Refund Requirements applicable to DME providers, and Section 150 further details the implementation of the Refund Requirements on DME claims.


If, and only if, the above requirements have been met are you able to proceed. Be sure to include an annotation on the ABN stating that the patient refused to sign or take financial liability, but still demanded service. This should be signed by both the notifier (you) and the second witness. The notation can be included above the empty patient signature line or in the margins of the ABN. When filing your claim, utilize the GA modifier to indicate that the ABN was presented to the patient. If executed properly, Medicare will hold the patient financially liable for the claim.


We recommend that you send a copy of the notice to the beneficiary along with a notice that they will continue to accrue monthly liability on the equipment up until the date the equipment is returned.  They may return the equipment at any time to avoid future monthly payments.  The customer remains responsible for any monthly payments accrued while the equipment remained in their possession.



New Tool for Tracking ALJ Appeal Status

March 13th, 2015

Angela Hayden


The Office of Medicare Hearings and Appeals (OMHA) has released a new tool to check the status of appeals. The OMHA is the third level of Medicare appeals (Administrative Law Judge).  This agency made headlines after announcing a temporary suspension of new ALJ hearing request assignments in July 2013.  The announcement came after the agency received a staggering increase in ALJ requests which overwhelmed the agency’s capacity and created a massive backlog.  Since the announcement, the OMHA has deployed a number of efforts to tackle the backlog including launching new technological initiatives such as the ALJ Appeal Status Information System (AASIS) search tool.


AASIS allows suppliers that have submitted a request for hearing to enter either the ALJ Appeal Number from the Acknowledgement Letter/ Notice of Hearing OR the Medicare Appeal Number (Reconsideration) from the decision letter to search for the status of that request. Suppliers can enter up to 10 Appeal Numbers at once.  The status indicators are: Received, Assigned, Deliberation, and Decided.  Additionally, there are two other indicators when an appeal has been combined with another request or when it has been reopened.  The search results will include the status of the appeal, the date it was received, and additional information if the appeal has been assigned (such as hearing date, hearing office and the name of the presiding judge). The results also include a section of notes describing the status of the appeal.


While this can be a very helpful tool for suppliers it is important to note that the backlog still exists.  Because of the volume of requests being submitted, suppliers should not expect to see a status for 16 weeks after the request has been mailed.  AASIS is updated weekly and the inquiry page will report the date of the last update.  If your appeal has been decided on or otherwise closed more than 180 days, a status will not be available in the AASIS system. If you find that the number you enter is not returning results but meets the criteria outlined above, then you can contact the OMHA Appeal Status Hotline at 855-556-8475 and a representative can provide you with the status.


To utilize this tool, click on this link: http://aasis.omha.hhs.gov/.


HME News Interviews Andrea Stark on Face-to-Face

March 6th, 2015

Angela Hayden

Andrea Stark talks with HME News correspondent Anna McDevitt about the Face-to-Face rule in this exclusive interview. The Face-to-Face (FTF) rule affects a total of 166 HCPCS and requires that a physician document the face-to-face encounter with the beneficiary and sign off on evaluations performed by nurse practitioners, physician assistants or clinical nurse specialists. The evaluation of the beneficiary must have taken place within the six months prior to the detailed written order. Additional requirements handed down for those 166 codes disqualify the use of verbal orders to dispense equipment and instead subject these HCPCS to the detailed written order prior to delivery (WOPD) requirements as outlined in the Program Integrity Manual.  These provisions are broken into two phases of implementation: Phase 1 – the requirement for the detailed written order prior to delivery and Phase II- the requirement for the face-to-face notes to be the supplier’s possession prior to delivery.  Phase I began enforcement January 1, 2014, and we currently have an undetermined delay in enforcement of Phase II.


Andrea will be partnering with Healthcare Attorney Jeff Baird and Liz Beaulieu of HME News to discuss the newest developments in the Face-to-Face in the March 11th webcast “A Look Ahead: Legal and Reimbursement Headliners and Guidance for 2015”, click here for additional details on this event. Despite the delay in enforcement of Phase II, Andrea Stark recommends an early adoption approach to this rule as discussed in her interview.  Click on the image below to view:




Executing ABNs Not in Person

March 3rd, 2015

Andrea Stark


As a general rule, Medicare expects that Advanced Beneficiary Notices (ABNs) will be issued in-person. However, there are exception protocols for delivery “other than in-person” prescribed in Chapter 30 of the Claims Processing Manual 50.7.2 – Options for Delivery Other Than In Person.(http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf)


Per the CMS manual, ABNs can be issued via mail, telephone and even via email, BUT the linchpin is that the delivery cannot be disputed by the beneficiary to be considered valid. Having a system that enables you to affirmatively document the notification (and avoid dispute) is the most important component of this protocol. Utilization of tracking mechanisms and/or requiring signature confirmation for mailed notices, delivery confirmation receipts for emailed notices, and recordings of phone conversations can all be reliable tools where appropriate. (Just be mindful that you do this in accordance with state and federal laws as you do not want to run awry of wiretapping regulations).  However, independent data collection will lessen the likelihood that your patient will successfully dispute the delivery of the ABN.


Beyond the delivery of the ABN, the CMS guidance further instructs suppliers to make follow-up attempts to collect a beneficiary signature on the ABN.  These follow-up attempts need to also be documented as part of this protocol.  While not required, we also recommend including a notification that they are responsible for the equipment as long as it remains in their possession; however, if they do not wish to continue accruing future monthly liabilities, they may arrange to return the equipment to avoid any new charges.


When these protocols are followed, the GA modifier should be added to claims for billing purposes once the delivery of information is confirmed (where knowledge is viably transferred and the customer is considered in possession of the information).  Always maintain the documentation of both the initial delivery and follow-up attempts at collecting a signature in the patient’s file should the DME MAC request it. If theses protocols are followed you are not required to have a signed ABN to invoke the protections; however, this protocol is not effective and does not offer protections in scenarios where a supplier cannot confirm the equipment is in use, or cannot make identified contact with the beneficiary. Ultimately, in order to benefit from the ABN protections, the supplier must satisfy the burden of “informing the beneficiary” of their financial responsibility in terms that the patient can understand.


For more details about ABN protections and proper use of the ABN, please join us for an in-depth webinar: “Unraveling the Mystery of the Advance Beneficiary Notice: Harness the Protections and Profit Generating Potential of this Multi-Faceted Form” to be hosted on April 28.


New Proof of Delivery Requirement to be Incorporated in Future LCDs

February 20th, 2015

Andrea Stark


CMS released an update to the Standardized Documentation Language template in October of 2014.  This template is used to populate the Documentation section of the Local Coverage Determinations (LCDs).  The template was first implemented in February of 2012 to bring uniformity and consistency to the LCDs.


Most of the changes in the October update stem from previously posted clarifications and updates released by the DME MACs primarily related to the Face-to-Face rule.  By periodically incorporating the updates into the LCD they ensure that providers can rely more heavily and consistently on the one-stop shop known as the LCD and policy article.  However, there was a significant change to the documentation requirements for Proof of Delivery in instances where equipment is retained from a prior payer (the patient switches to Medicare for the first time).


CMS has always educated that at the time of transition, it is the supplier’s responsibility to evaluate the coverage criteria to determine the beneficiary meets Medicare guidelines.  It is also expected the supplier will secure an updated proof of delivery document and simultaneously determine that the equipment is in operational order and should last the patient five years from the date they enter the Medicare program.  In this update, however, CMS takes this assessment to a whole new level. Suppliers now have the option to obtain an attestation statement from the beneficiary (or their designee) that stipulates the supplier has examined the equipment, it is in good working order, and meets Medicare requirements.


The directive stipulates, “For the purposes of reasonable useful lifetime and calculation of continuous use, the first day of the first rental month in which Medicare payments are made for the item (i.e., date of service)  serves as the start date of the reasonable useful lifetime and period of continuous use.  In these cases, the proof of delivery documentation serves as evidence that the beneficiary is already in possession of the item.”


These changes will be incorporated into future LCDs and policy article revisions, which we will likely see published over the course of the upcoming months.  To see the CGS notice including the full text of the updated language click here.

The Clock Is Ticking: Recompete Registration Ends Soon

February 13th, 2015

Andrea Stark


If you are a provider participating in the Round 2 or National Mail Order Recompete programs for Competitive Bidding contracts, and you have not yet registered, time is running out.  The Competitive Bidding Implementation Contractor (CBIC) will close the registration window on Tuesday, February 17, 2015. Suppliers that have not yet registered (and wish to participate in bidding) will need to have the Authorized Official for the business establish an account via the CMS IACS system by 9pm EST on February 17, 2015.  Registration in the IACS system is required to obtain a user ID and password for the electronic bidding system DBidS. If you miss the registration deadline, you will not be able to submit a bid. Registering for an account provides you with the most flexibility, but does not obligate you to formally submit a bid.  If you are undecided, it is best to secure your access immediately.

As a recap, the following product categories are up for bid in Round 2:


  • Enteral Nutrition, Equipment and Supplies
  • General Home Equipment and Related Supplies and Accessories
    • includes hospital beds and related accessories, group 1 and 2 support surfaces, commode chairs, patient lifts, and seat lifts
  • Nebulizers and Related Supplies
  • Negative Pressure Wound Therapy (NPWT) Pumps and Related Supplies and Accessories
  • Respiratory Equipment and Related Supplies and Accessories
    • includes oxygen, oxygen equipment, and supplies; continuous positive airway pressure (CPAP) devices and respiratory assist devices (RADs) and related supplies and accessories
  • Standard Mobility Equipment and Related Accessories
    • includes walkers, standard power and manual wheelchairs, scooters, and related accessories
  • Transcutaneous Electrical Nerve Stimulation (TENS) Devices and Supplies


The National Mail Order contracts to supply mail order diabetic supplies are being recompeted on the same timeline. The covered documentation review deadline is February 23, 2015. Suppliers that wish to have their required documentation packets reviewed for missing documentation must have that in by February 23rd. The bid window, however, will remain open until March 25, 2015. See the latest edition of VistaNotes (Volume 6 Issue 6, available for purchase on our products page) for a condensed, but comprehensive, bidding guide for suppliers.


Why is National Bid Pricing Relevant to Your Business?

February 5th, 2015

Angela Hayden


Competitive Bid pricing will expand to all suppliers on January 1, 2016. This mandate is a directive of the 2015 End Stage Renal Disease and Prospective Payment System final rule posted on November 6, 2014.


If you supply respiratory equipment, enteral nutrition, mobility equipment (from walkers to power chairs), infusion equipment, TENS units, support surfaces, commodes, patient lifts, seat lifts, NPWT, or hospital beds you are affected by this rule, and now is the time to prepare for how these changes will impact your business.


Per the ruling, fee schedule amounts for items and services that are subject to competitive bidding will be adjusted on a regional level. The US will be broken down into a total of eight regions where this logic will be applied, including rural areas. Pricing will be adjusted based on how your area is classified within your respective region (rural or non-rural), but one thing is for certain, reimbursement is slated to decrease across the board.


In our recently aired webcast on January 13th, we partnered with HME News to deliver a better understanding of this complex ruling. We provided our attendees with an example of what pricing might look like after the expansion from this rule. Using the pricing adjustment logic explained in the final rule and current Single Payment Amount (SPA) data, we were able to determine what the new Regional SPA might look like for suppliers in a hypothetical location (Bartlesville, OK) post roll out. The results showed a 47% reduction in the reimbursement rate for oxygen concentrators in that area.


A realistic calculation is an essential tool to prepare your business for these future changes.  Now is the time to examine your processes, re-negotiate contracts with your vendors, and/or reallocate staff resources to eliminate inefficiencies in your system. MiraVista can equip you with tools you need to progress through this process.


If you missed the event and would like to get the full details for how this ruling is to be implemented, the event is still available on-demand in digital format.


Additionally, we will be hosting the second part of this series on February 11th to discuss the bundled payment demonstration. The bundled payment provision will directly affect the way that CPAPs and Standard Power Wheelchairs are reimbursed in up to 12 demonstration areas and will set a precedent that will likely impact other products in the future.  Register for the bundle that includes coverage of Part 1 and Part 2 of this series here.


See the HME News write up of the January 13th webinar here.

RAD Policy Updates Reflect Major Changes for Suppliers

January 29th, 2015

Andrea Stark



The Respiratory Assist Device LCD and Policy Article have been updated with new coverage criteria.  If you bill for this product you may have missed some of the significant and technical changes for this policy.  Changes took effect December 1, 2014. CMS made a number of modifications that impact the coverage criteria for RADs and documentation practices.


The first change appears in the coverage criteria section where CMS clarifies the definition of Central Sleep Apnea (CSA).  Central Sleep Apnea is defined by the following criteria:

  1. The sum total of central apneas plus central hypopneas is greater than 50% of the total apneas and hypopneas; and
  2. A central apnea-central hypopnea index  (CAHI) is greater than or equal to 5 events per hour; and
  3. The presence of at least one of the following:
    • Sleepiness
    • Difficulty initiating or maintaining sleep, frequent awakenings, or non-restorative sleep
    • Awakening short of breath
    • Snoring
    • Witnessed apneas
    • There is no evidence of daytime or nocturnal hypoventilation


The definition of Complex Sleep Apnea (another diagnosis group referenced in the LCD) was also updated:

  1. With use of a positive airway pressure device without a backup rate (E0601 or E0470), the polysomnogram (PSG) shows a pattern of apneas and hypopneas that demonstrates the persistence or emergence of central apneas or central hypopneas upon exposure to CPAP (E0601) or a bi-level device without backup rate (E0470) device when titrated to the point where obstructive events have been effectively treated (obstructive AHI less than 5 per hour).
  2. After resolution of the obstructive events, the sum total of central apneas plus central hypopneas is greater than 50% of the total apneas and hypopneas; and
  3. After resolution of the obstructive events, a central apnea-central hypopnea index (CAHI) greater than or equal to 5 per hour.


In the update, the qualifying CAHI for Central Sleep Apneas is defined as the average number of episodes of central apneas and central hypopneas per hour of sleep without the use of a PAP (during a diagnostic study). For Complex Sleep Apnea the CAHI is determined during the use of a PAP device (during a titration study) after obstructive events have disappeared.


Additional language was included to qualify a patient with Severe COPD.  In the prior policy, it states that before initiating therapy, Obstructive Sleep Apnea and treatment with a CPAP must be considered and ruled out.  This statement is modified in the new policy to add a note indicating “Formal sleep testing is not required if there is sufficient information in the medical record to demonstrate that the beneficiary does not suffer from some form of sleep apnea (Obstructive Sleep Apnea (OSA), CSA and/or Comp SA) as the predominant cause of awake hypercapnia or nocturnal arterial oxygen desaturation.”


Criteria for qualifying a patient with Hypoventilation Syndrome for an E0470 and E0471 have also been modified significantly to address the use of a Home Sleep Study to determine oxygen saturation.  The revision applies to the Hypoventilation diagnosis group, and the Coverage Guidance stipulates that not all types of HST are appropriate for CSA or Complex Sleep Apnea diagnosis groups). Under the prior policy, only a facility based PSG was allowed as a qualifying test for hypoventilation. The update adds a significant section on defining different types of sleep studies and defining which studies can be used to qualify a patient in specific diagnostic scenarios. This section also breaks down who may interpret the study (the same four parameters that exist in the PAP LCD: ABMS, ABSM, staff privileges at an accredited lab or residents waiting for their first exam in sleep medicine).


Throughout the policy, greater than and less than symbols are replaced with the written form.


It is important to consider these changes and how they will impact current protocols. In some cases these clarifications require additional scrutiny of the testing data and in others it opens the door to less restrictive requirements.  Currently, the E0470 (Respiratory Assist Device) is under prepayment review in Jurisdiction D; however, when the data supports examination, other contractors often follow suite and initiate reviews for these codes.



Date Stamp Rules Clarified by CMS

November 14th, 2014

Angela Hayden


CMS has released a clarification via a Joint DME MAC publication regarding the usage of date stamp protocols for compliance with the Affordable Care Act. Many suppliers have been struggling with denials stemming from improper date stamps. According to the Face-to-Face rule, implemented by the Affordable Care Act, “A date stamp or equivalent must be used to document receipt date.” This allows the auditor to verify that the DWO was in fact received prior to delivery per the requirements of the rule.


In this publication, CMS speaks to several “commonly accepted methods” of date stamping.  Those are: hard copy date stamps, hand-written dates, facsimile headers and electronic receipt dates.  The date stamp should include the word “received” and the month, day and year.


CMS goes on in the notice to caution providers utilizing facsimile headers to document receipt date.  Oftentimes, the headers can become distorted from multiple transmissions or can come across illegibly due to a poor connection. This makes it difficult for the auditor to determine the proper receipt date.  Another concern with facsimile dates is power outage or date reset – if the date resets and it is not caught timely it can invalidate orders down the road. When in doubt, utilize a physical date stamp to reduce risk.


Proper date stamping can make the difference between a payable claim and a denial.  Be sure that you have a date stamping protocol in place for all incoming documentation. See the update here: http://cgsmedicare.com/jc/pubs/news/2014/1014/cope27091.html

güvenlik kamerası


panel çit