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Newest FTF Development – Audits Begin for WOPD

Friday, March 7th, 2014

 

On December 3, 2013 CMS posted a clarification on the Face-to-Face rule that rattled the DME community.  The F2F rule, has effectively been divided into two major directives: 1) the requirement for a documented F2F within the six months prior to the written order, and 2) the requirement to secure a Written Order Prior to Delivery. CMS intends to enforce the Written Order Prior to Delivery for claims processed in January 2014.

 

Prior to the December announcement, enforcement of the Rule was delayed on two separate occasions.  The first was a three month delay in the enforcement from the original July 1, 2013 start date, and the second offered an unspecified delay of enforcement through an unspecified date in 2014.  However, on December 3rd, CMS came forward to indicate that only the F2F provisions were intended for delay and they never intended a delay for the WOPD requirement.  Amid several remaining unanswered questions, CMS and the MACs continue to move this portion of the directive forward.

 

As of February 18, 2014, we are beginning to see the first of what we except to be many audits as a result of this announcement.  The Jurisdiction C DME MAC posted a notice of a service-specific prepayment review of a number of HCPCS affected by the F2F rule:

 

  • E0607 – Home Blood Glucose Monitor
  • K0001 – Standard Manual Wheelchair
  • K0002 – Standard Hemi Manual Wheelchair
  • K0003 – Lightweight Manual Wheelchair
  • E0748 – Osteogenesis Stimulator
  • E2510 – Speech Generating Device
  • E2402 – Negative Pressure Wound Therapy Electrical Pump

 

This pre-payment review is an effort to verify compliance with the Face-to-Face provisions concerning the detailed written order prior to delivery (DWOPD) requirements.  Claims subjected to this audit will be developed for additional documentation including:

 

  • Written Order Prior to Delivery
  • Delivery Documentation
  • Pertinent patient records
  • Copy of the ABN if used

 

While this audit was announced by the Jurisdiction C DME MAC, we expect that the other MACs will be following suit in the days ahead.

 

Face-to-Face Clarifications Rattle DME Community

Monday, December 9th, 2013

Andrea Stark and Angela Hayden

 

A ground breaking clarification posted by the Centers for Medicaid and Medicare Services to the Face-to-Face Encounter home page on December 3rd, 2013, has sent providers reeling.  The clarification states “The delay of enforcement only applies to the face-to-face requirements in CFR §410.38(g)(3). CMS expects full compliance with the remaining portions of the regulation.” Earlier this year the final rule mandating Face-to-Face Encounters for select items of DME, affecting 166 HCPCS, indicated an effective date of July 1, 2013.  However, CMS issued a delay to October 1, 2013, and then further delayed enforcement until a date yet to be announced in 2014.  This rule not only requires that a face-to-face encounter with a physician, nurse practitioner, physician’s assistant or clinical nurse specialist take place and be documented within six months prior to the detailed written order, but an additional requirement also establishes the necessity to collect a Detailed Written Order prior to delivery (even in cases where a verbal or dispensing order had previously been sufficient).

 

CMS begun instructing contractors to educate providers on a few key expectations, notably that they are expecting DME providers to follow all of the written order prior to delivery requirements set forth in the rule (dating back to July 1, 2013).

 

We have discovered that behind the scenes, the Program Integrity Manual has already been updated in several key sections through Revision 468.  This revision cites it was: Issued: 05-31-13; was Effective 07-01-13; and has an Implementation of 07-01-13.  The Program Integrity Manual (PIM) is the instruction manual used by the auditing contractors to enforce Medicare policy.  These citations clearly state they are in effect and implemented as of July 1, 2013 which is quite troubling from a retroactive audit standpoint.  The following are brand new sections that detail CMS expectations about procurement of a written order prior to delivery for items subject to the face-to-face rule:  Section 5.2.3.2 Detailed Written Orders for Face-to-Face Encounter, 5.2.3.2.1 – Face-to-Face Encounter Conducted by the Physician, 5.2.3.2.2 – Face-to-Face Encounter Conducted by a Nurse Practitioner, and 5.2.3.2.3 – Detailed Written Order for Covered Items.

 

Another curveball popping up in education sessions from some of the DME MACs includes instructions that they expect providers to have signed medical record notes in hand before delivering equipment to comply with the rule (after the delay expires).  If CMS maintains this course, this interpretation will be particularly burdensome to physician practices that send all their documentation out for transcription prior to making the documents available.  The interpretation is also counter intuitive to several critical need products such as oxygen and other items on the list.

 

Providers and advocate agencies have been reaching out to specifically discuss the impossibility of a retroactive enforcement of these additional provisions due to the inextricable connected nature to the Face-to-Face provisions.  The industry has been told that a Med Learn Matters article is forthcoming, but we are hopeful we can come to a mutual understanding of the key issues prior to the release of formal education on these issues.  Uncertainty still remains regarding several key issues, however, as more information on this topic develops, MiraVista will continue to disseminate key updates.  Please see additional education on this topic on our blog and via our Products menu.

 

Using Competitive Bidding Modifiers

Friday, July 26th, 2013

Angela Hayden

 

Competitive Bidding Round 2 is now in full swing and many providers are struggling with the transition. A question that has cropped up repeatedly relates to the use of competitive bidding modifiers. As providers juggle two fee schedules (the traditional fee schedule and Round 2 Single Payment Amounts), understanding when to use the appropriate modifier for claim submission can be a challenge. Below we have pulled an excerpt from our most recent issue of our signature publication Vista Notes that provides a brief overview of the most commonly used competitive bidding modifiers. For comprehensive updates, we recommend that you consider a one-time or annual subscription.

 

“The KG modifier is used to distinguish between HCPCS codes that can be used with both competitively bid items and non-competitively bid items. Specifically if the item can be billed in multiple categories and it is SUBJECT to competitive bidding and therefore should be priced at the single payment amount (SPA), providers should append the KG modifier. The example used by Medicare is an IV Pole which can be used with both Enteral Nutrition (competitively bid) and Parenteral Nutrition (non-competitively bid). When using an IV pole (E0776) with enteral nutrition (subject to competitive bidding), providers should utilize the KG modifier to signify that it is for use with a competitively bid product. Similarly if a leg rest is used with a standard power wheelchair (subject to competitive bidding), the KG modifier should also be used.

 

The KK modifier is the anti-KG modifier. It is also used for supplies and accessories that are used across both competitively bid categories and non-competitively bid categories. Specifically if the item can be billed in multiple categories and it is NOT SUBJECT to competitive bidding and should be priced at the standard fee schedule amount, providers should affix the KK modifier. Therefore, in the above example, the E0776 billed with parenteral nutrition would be billed with the KK modifier to signify that the item is NOT SUBJECT to competitive bidding and is being used with a non-competitively bid product and therefore should be paid at the higher rate. Similarly the leg rests billed with a complex rehab chair should also be submitted with the KK modifier as complex chairs are not subject to competitive bidding.

 

The KL modifier is used with diabetic supplies to indicate that supplies are furnished via mail order. Effective July 1st mail order is redefined to include “all diabetic supply codes delivered to the beneficiary via any means.” Essentially, any diabetic supply that is not picked up in person at a retail location will be considered mail order. Under National Mail Order, only contracted suppliers will be eligible for reimbursement for mail order supplies. These suppliers must use the KL modifier to denote that supplies were delivered to the beneficiary unless the customer walks in to pick up the supply. (Note: Effective July 1, 2013 due to provisions in the American Taxpayer Relief Act, all diabetic supplies are reimbursed at the same rates/allowables regardless of delivery method. Therefore this modifier does not affect reimbursement rates, but is used to enforce mail order contracts.)

 

The KV modifier is used by physicians and treating practitioners that are not contracted providers, but will furnish exempt walkers and walker accessories to beneficiaries residing in a Competitive Bid Area (CBA). The KV modifier can only be used with the following list of HCPCS in order to be reimbursed: A4536, A4637, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0154, E0155, E0156, E0157, E0158 and E0159. Again this is used only for physician and treating practitioners providing this equipment to their own patients. They must have a DME supplier number and bill the walker with the corresponding office visit on the same day for proper processing.

 

The KT modifier is used for traveling beneficiaries. When a beneficiary resides in a CBA but travels outside of that CBA into a non-competitively bid area where they are provided a competitively bid item, that claim must have the KT modifier. Likewise if a beneficiary resides in a CBA and travels to a different CBA, they must be serviced by a contracted provider for that CBA, and the KT modifier must be affixed to competitively bid items. This modifier also applies to Skilled Nursing Facilities and Nursing Facilities that are not located in a CBA but provide competitively bid items, such as enteral nutrition, to a beneficiary that has a permanent residence in a CBA. The KT modifier essentially tells the claims processing system to bypass the expected contracted provider for the home CBA. Claims that are not submitted with the KT modifier in these cases will be denied.”

 

Competitive Bidding modifiers may in some cases cause modifier overflow, where the claim line limit of four modifiers is exceeded. In these cases, providers are advised to utilize the 99 modifier in the fourth position to indicate that the number of modifiers exceeds the limit. Additional modifiers should then be reported in the narrative or NTE section of the claim. When working with claims that exceed the four modifier limit, providers should prioritize pricing (including competitive bidding) and medical necessity modifiers (such as the KX). Informational modifiers such as LT and RT can then be reserved for the narrative or NTE section of the claim.

 

Understanding the proper usage of these and other claim components will assist providers in processing claims more efficiently, which will in turn ensure more expedient payment. For additional questions on claims processing or other reimbursement questions please contact our office to schedule an appointment with Andrea Stark for consulting at 803-462-9959 ext.246.

 

Face-to-Face Enforcement Delayed by CMS Amid Readiness Concerns

Friday, June 28th, 2013

Angela Hayden

 

(07/31/2013: Updated to correct broken link in the last paragraph and to reflect updates to MLN Matters article 8304)

 

CMS made some big announcements this week for the DME industry.  Most notable is the delay in enforcement of the Face-to-Face (FTF) regulations set forth in the Affordable Care Act. Originally set to go into effect for new orders on or after July 1st, the enforcement of these regulations is now delayed until October 1, 2013.  FTF affects a total of 166 HCPCS and requires that a physician (with an MD or DO credentials) 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. 

 

Official education on these requirements has been scarce until recently when CMS issued MLN Matters article 8304 which speaks directly to the necessity of documenting the FTF encounter, but did not speak to the requirement of the WOPD in its original release (it was later updated to clarify those requirements).  CMS cites the concern that some providers are unprepared for implementation and will need additional time to implement the proper protocols for compliance. However, in our opinion, lack of sufficient education on the entirety of the rule for suppliers and physician referral sources is the most compelling reason for the delay.   

 

It is important for providers to understand that the program itself is not delayed; Face-to-Face regulations will still exist starting July 1st. It is the enforcement of those regulations that is to be delayed until October 1st.  For providers, this means that auditing contractors will not deny claims for compliance with FTF requirements when identifying overpayments for new orders prior to October 1st, 2013.  Providers that are already in compliance with the FTF rule should continue that protocol. Those who have not yet established procedures should work diligently to become compliant by the deadline of October 1st. CMS will expect full compliance of all providers by the October 1st deadline.  

 

CMS has indicated that it will continue to update information concerning the face-to-face rule via their website at www.cms.gov/medical-review MiraVista will keep you informed as updates are released.  More detailed coverage of the Face-to-Face ruling can be found in our signature VistaNotes publication or in select digital recordings (specifically “New Face-to-Face Requirements Get Finalized for DME: Are you Ready for Implementation” recorded on 02/07/2013)  that can be found on our products page.

 

Licensing Challenges, Lawsuits and Prospects for Delay as Bidding Implementation Approaches

Thursday, June 20th, 2013

Andrea Stark

 

MiraVista continues to monitor the situation with contracted providers under Round 2 of competitive bidding.  We have been able to confirm, based on a letter from Marilyn Tavenner to Congressman David Roe from Tennessee, that approximately 30 Tennessee contracts were voided out of 98 awards.  CMS indicates they do not intend on immediately awarding replacement contracts (relying on in-state suppliers and grandfathered suppliers), but will “closely monitor the situation in the state”.

 

With voided contracts in Tennessee, these providers will not jeopardize the entirety of their CBIC contracts by not having everything in place on the start date of July 1, 2013. While disruptive, MiraVista maintains this is a welcome reprieve.  Most of these providers relied on the licensure database housed on the National Supplier Clearinghouse website when submitting their bids back in January 2012.  The database did not accurately reflect all of the states licensure requirements (specifically for Tennessee).   Most of the providers who received voided contracts were unaware of the additional licensing requirements that also mandate a brick-and-mortar location approved by the state to dispense any medical equipment in that state. These providers were notified by the CBIC on or about April 15, 2013 that contracts had been awarded based on the same, incomplete licensure information contained in the database (and not according to actual state licensure requirements in place at the time of bid submission, as was required by law).  The April letter directed the suppliers to submit a complete 855-S form to enroll a new TN location for their organization.  Submission of the application requires prior licensure approval, accreditation, and surety bonds for the new location. The Medicare application process to enroll a new location takes at a minimum 45-60 days.  All combined, it was an insurmountable feat to get all of this finalized with approximately 75 days’ notice start-to-finish.  Having these “problematic” contracts voided, takes the pressure off the risk of non-compliance and subsequent breach and loss of all other contracts in unaffected states.

 

We know other states have cited that the CBIC has awarded contracts to providers that do not meet licensure requirements in their state.  What remains to be seen is how CMS will address these other concerns.  MiraVista maintains that this is an increasingly complex issue CMS must contend with.

 

We believe other contracts will eventually be voided if the licensure requirements were in effect at the time of bid submission where licensure had not been procured by the supplier by the original, May 1, 2012 extension date. This precedent is now established with the Tennessee nullifications.  Yet we do not know how CMS will handle changing licensure requirements where rules change mid-stream.  Will they offer grace periods to allow contracted providers to come into compliance? We have learned that Mississippi now has a regulation similar to Tennessee in that a physical location is required to procure licensure, but the requirement was changed AFTER bid submission closed.

 

AAHomecare announced yesterday, June 19th that it has filed a lawsuit against the Health and Human Services in conjunction with a Maryland provider.  The lawsuit seeks to stop the program citing the licensing irregularities in other states to include: Colorado, Ohio, Maryland, North Carolina, Tennessee, Virginia and Washington.  We will continue to monitor the progress of this initiative.

 

We are most hopeful for the prospects of new legislation introduced just last week on June 14th, HR 2375 The Transparency & Accountability In Medicare Bidding Act of 2013.  The bill will mandate a minimum delay of six months for all bidding programs to include Round 2, National Mail Order and Round 1 Recompete.  Round 1 could not proceed until six months after Round 2 resumes.  It would obligate CMS to meet with three auction experts, an economist and an econometrician (collectively an “auction expert team”) for the purpose of an independent review and assessment of the program. The goal will be to address the design, development, adequacy of support for beneficiaries, market fairness, sustainability and functioning of the program.  It disqualifies any current or former CMS employee, contractor or individuals that were involved in the original creation or design of the program from being selected for the auction expert team. CMS will have to cooperate fully and disclose all confidential information related to the program to the auction expert team.  A report to include recommendations for changes must then be submitted to Congress within four months of engaging the auction expert team.

 

The bill gives us a real opportunity to elicit fundamental change which is desperately needed.  A Dear Colleague letter contained the foundation for the bill’s text.  The letter was signed by 226 Representatives and delivered to CMS on June 13th.  The letter relies on CMS to make the call to delay, but to date, CMS shows no sign that they will consider a delay.  However, if we convert the co-signers on the letter to co-sponsors of the bill, we have a strong chance of getting passage in the house and can begin work in the Senate.  Passage of the bill will mandate CMS to suspend the program.  This could move quickly, but will not be complete in the two weeks before the program start date of July 1, 2013.

 

We cannot accept minor band-aid fixes that do nothing to address the unintended consequences of conducting a flawed auction program.  The current program has forced unnatural market trends.    This has produced so many shifts in geographical presence, product offerings, state licensing complexities, and unsustainable rates all in the interest of “survival” and not “true competition”.  Auctions like the Market Pricing Program can work for DME as set forth in HR1717, but competitive bidding in its current form will fall far short.

 

 

The Clock is Ticking: PECOS Phase 2 Implementation Date Released

Friday, March 8th, 2013

Andrea Stark & Angela Hayden

 

Almost four years after the public implementation of the PECOS project, CMS started the clock on the countdown to Phase 2.  This second phase will implement edits to deny claims dated on or after May 1, 2013 for claims with physician data that does not link to a valid PECOS record.  Claims for DME, Home Health and Part B lab and similar services prescribed by a referring physician will be affected by the new edits.  This has been in the works for quite some time; however, because of the repeated delays to implementation, the call to action has waned.  With larger scale issues on the docket such as Competitive Bidding, PECOS seems to have been all but forgotten.  As previously reported on our blog and in several editions of our signature Vista Notes publication, we believed it to be imminent that suppliers would be given a 60 day window, for the Phase 2 announcement. Now that we are proceeding to implementation, suppliers must ensure that physician records match the PECOS database before the edits go into place. Don’t expect any more delays… the official countdown has begun.

 

Phase 1 (the informational messaging phase) began in October of 2009 using claim rejection, warning messages to communicate that the ordering/referring provider submitted on a given claim was not PECOS certified.  This front-end warning system was used until the implementation of Version 5010 when these claims were allowed to proceed past the front-end system and warnings are now reflected in the form of a remark code N544 on Medicare remittance advices.  Until now, these N544 remark codes have served only as a warning to providers of denials to come if action is not taken on these flagged physicians. Beginning May 1, under Phase 2, these remittance warnings will become actual denials on future EOBs.

 

Providers need to act swiftly to identify which physicians in their billing system are problematic and cannot be validated in the PECOS database.  Affected claims will be denied and cannot be reprocessed until the data is corrected or the physician has been certified.   At this stage of the game, most of the N544 remark codes are likely tied to typographical errors, transposed NPI numbers, or incorrect use of group NPI numbers instead of individual practitioner NPI numbers.  There are still a select number of practitioners that are either new or not linked to PECOS, and these will be a bit more difficult to resolve.

 

Here are a few steps to help you identify which records can be fixed in your billing software and which physicians will require contact:

 

  1. Start by verifying that the NPI from the physician record in your billing system ties back to the individual physician and not a group practice or facility by looking up the NPI in your system on the NPPES website. Make sure there are no spelling errors in the first or last name and that the NPI is correct for the doctor.
  2. Next, compare your physician record to the PECOS database located here (in the Downloads section click the CSV version of the Medicare Ordering and Referring File) to verify that this physician is confirmed as PECOS certified.
  3. When you do find a match (based on NPI), ensure that the first letter of the first name and the first four letters of the last name match exactly to the PECOS record.  If your record does not match the PECOS file, claims will be denied.
  4. Identify and parse out those physicians that do not have a match in the PECOS database and begin contacting them to encourage the completion of the enrollment process.  In the case of long standing physicians they may need to send in a renewal of their Medicare enrollment information, so the PECOS record can be created.  Remind the doctor that none of their referrals for DME, Home Health or lab referrals will be payable after May 1 until this issue is resolved.

 

While it is in the hands of the physician to complete the enrollment process, there are some resources that providers can use to explain what PECOS is and why this update or enrollment is necessary. The most recent piece of information is provided in an MLN Matters article released by CMS (#SE1305), which is a consolidation of previous instruction and can be found here: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf. Physicians should also be reminded that the PECOS database is used to populate the www.medicare.gov website and without enrollment, Medicare beneficiaries will not be able to validate or locate them for new business.

 

The bottom line is that real revenue is at stake if providers are not mindful of this deadline. By taking these steps and utilizing the resources available, PECOS Phase 2 Implementation can be a smooth transition for providers, but action must be taken now.  For additional guidance on navigating through this process you can attend our webinar on April 10th @2pm EST (registration details here) or contact our office to schedule a consult with reimbursement consultant, Andrea Stark at 803-462-9959 ext.246.

ALERT! Fire Up The Postage Meter…Deadline Today for Medicare Enrollment Changes

Friday, February 15th, 2013

Andrea Stark

**This is a snippet from an article in the February 2013 edition of Vista Notes**

 

See: http://tinyurl.com/NSCOpenEnrollment

 

The most substantial provision affecting DME providers in the American Tax Payer Relief Act of 2012 (ATRA) is the provision to reduce all diabetic supplies (including strips, lancets and control solution sold in retail stores) to mail order rates effective 4/1/2013.  This equates to a 14% cut in the upcoming months.  More devastating than this is the next provision to subject retail diabetic supplies to national mail order rates as soon as that program goes into effect on 07/01/2013.  We know now that this will equate to a 72% cut across the board even if you did not participate in the bid program.

 

Medicare providers that are enrolled as ”participating providers” will most likely have to take the supplies off the shelf and cease selling them in their stores because the prices are not sustainable.  “Non-participating providers” will be left with no choice but to file claims non-assigned.  While non-participating providers can CHOOSE to accept assignment on a case-by-case basis, they also have the right to file claims on a non-assigned basis.  Non-assigned claims allow providers to collect the retail price up front and, after the claim is filed, Medicare remits payment to the beneficiary directly.  Beneficiaries will likely come out of pocket only a few times before they switch to a much cheaper, contracted, mail-order provider that will be forced to accept the cuts.

 

Because of the doc-fix provisions in ATRA and ensuing fee schedule changes for physicians, Medicare did extend the deadline to change participation status through 02/15/2013.  If you intend to change your participation status with Medicare, you must submit a letter signed by the Authorized Official to the National Supplier Clearinghouse and have it postmarked no later than today 02/15/2013.  Normally the Open Enrollment deadline would have already been closed effective 12/31/2012.  If you are a participating provider selling retail diabetic supplies and you do not want to accept assignment on these products, you may want to consider changing your status.  However, if you have multiple lines of business, such as a hospital-owned DME, the participation status must be the same for all entities… if the hospital is participating; the DME line of business must also remain participating.  To quickly see if you are listed as a participating supplier, visit this link, and enter the zip code where you are located along with a product you sell, then hit search.  If you see a green “P” next to your business, you are registered as a participating provider and must accept Medicare fee schedule rates on any covered product you sell to Medicare beneficiaries (unless you file the paperwork to change your participation status).  If there is no green “P” next to your business, there is no need to worry about the deadline and you already have the flexibility to choose assignment on a case-by-case basis. Your final decision to participate or not should be heavily weighted on your product mix and the Medicare fee schedule viability as it relates to your business.  For additional questions, arrange to speak with Reimbursement Consultant Andrea Stark at (803)-462-9959 ext. 246.

To Accept or Deny? To Grandfather or Not? To Survive or Thrive?

Wednesday, February 6th, 2013

Andrea Stark

 

*Update on 02/07 corrects a typographical error regarding the number of payments made to contracted suppliers for transitioning beneficiaries with previously rented equipment.

 

Competitive Bid Prices are officially real and the cuts are deep.  With the announcement of Single Payment Amounts (SPAs) on January 30, the supplier community was stunned.  If you sell diabetic supplies anywhere in the country, or if you are in any of the Round 2 MSAs, you have big questions that need to be answered.  We outline below several considerations that each of you will need to contemplate in some form or other…

 

Contract Offers:  The first round of contract offers started to arrive on February 1 and gave business owners two weeks to determine what the next three and a half years will hold for the future of the business.  Acceptance is not an easy decision and should not be made lightly.

 

With hard, fast numbers in hand, you will want to ensure that you can be profitable with the margins you’ll be getting.  Consider variable costs that can wreak havoc on those margins such as wages, overhead expenses, and fuel prices to service what will equate to a much larger area.  Give consideration to the Medicare weight assigned to the HCPCs at the time of bid submission.  Weight was assigned by CMS to HCPCs based on Medicare historic utilization data (which is not always consistent with the most expensive item in a product category).  For example in the CPAP product category there were 23 HCPCs up for bid, Disposable filters was the top product with an overall weight of 35.5% of your bid submission.  The CPAP ranked #11 with an overall weight of 2%. This should guide you with where Medicare highlights the relative market importance.

 

Consider what contracts you are being offered.  Where will the referrals come from:  Hospitals? Nursing homes? Private Practices?  Sleep Labs?  Wound Care Clinics? Your product mix offerings will play a large role in whether or not you can expect any increases in new referrals.  If you expect to get your referrals from local hospitals, do you have enough contracts to make it worth the discharge planner’s referral?  If you won hospital beds and a competitor won beds, walkers, wheelchairs, and oxygen, chances are they will not split the referral to send you a bed when the patient needs multiple items.

 

What will life look like after the bid starts?  Do you have the resources to pull through the initial wave of new patients?  Many of the products like oxygen and CPAP setups for example will be documentation heavy.  Heavy documentation requirements will directly impact your DSO.  Remember, you’ll have to get your own supporting documentation for new customers that are switching from a non-contracted supplier (CMNs, orders, chart notes, compliance documentation, etc.).  Can you float the new inventory needs to accomplish these setups while you track down doctors for old documentation and wait 30-60-90 days for orders to get confirmed and reach a billable status?

 

Switching to a contracted supplier will be treated just like a traditional change in supplier today.  There will be no free passes, and you shouldn’t expect much cooperation from your former competitors that are losing their patients.  Keep in mind however, for every patient that switches from an existing DME capped rental product, you are entitled to start a new capped rental cycle as a newly contracted supplier (regardless of how many rental payments were made previously).  If the patient is an existing oxygen customer that switches from a non-contracted supplier, you are entitled to at least 10 months of rental payments (unless they have more than 10 payments left on their CMN for payment).

 

But on the flip side, contracted providers are not exempt from audit activity.  In fact, audit activity is traditionally based on increases in volume and billing concentrations… so expect to have a portion of your funds and resources tied up in pre-pay reviews.

 

Diabetic Suppliers:  With the SPA announcement we also learned that 15 suppliers would be offered a contract to handle the entire nation’s home delivery of diabetic supply needs.  Rates were cut by 72% in this category, and that really stings.  What is worse is that this newly contracted rate will be EVERYONE’s new fee schedule for diabetic supplies beginning July 1, 2013 thanks to the American Taxpayer Relief Act (ATRA).  ATRA is the same legislation that prevented the rest of the nation from falling off the infamous “fiscal cliff”.  A sleeper provision in this bill will force all retail operations to accept this new lower rate when they sell diabetic supplies to Medicare beneficiaries directly.  Another provision in ATRA will help you to slide into this cut by forcing an approximate 14% reduction on diabetic testing supplies sold after April 1, 2013.  The fee schedule updates apply to diabetic testing supplies like strips, lancets, control solution, etc.  They do not affect the glucose monitor purchase price.

 

Grandfathering: Let’s face it.  If 18,000 suppliers put their name into the round 2 hat and 867 got contracts, there will be more suppliers contemplating what life looks like without a contract.  Suppliers included in this multitude will be contemplating the grandfathering provision that applies to rented equipment.  For traditional capped rental items, like beds, CPAPs and manual wheelchairs, grandfathering will allow you to finish up the rental cycle for any setup that began prior to 7/1/2013.  You’ll still be paid at the rate you started out with (not the newly published SPA amounts).  You will not be allowed to setup any new customers after 7/1/2013… those patients will have to seek out service from a contracted supplier.  Additionally, if the item you are billing requires supplies (e.g. CPAP equipment), then you can bill the accessories for as long as the item is actively billing rental.  After 13 payments are made and the item caps the patient must get their supplies from a contracted supplier.  You will also retain the liability for capped equipment to ensure it is free from defect for the remainder of the useful lifetime of the equipment (5 years from the initial date).

 

These changes force suppliers to make tough decisions and while we cannot make the final decision for you, MiraVista will partner with you in asking the right questions and contemplating the unforeseen. As you have questions, MiraVista will help direct you to the answers that make the difference between just surviving and thriving.  Arrange to speak with Reimbursement Consultant Andrea Stark  or Operations and Analytical Expert Derrick Stark to discuss your concerns at (803) 462-9959 ext. 246.

 

When Beneficiaries Opt Not to Use Medicare Benefits

Friday, January 4th, 2013

Just as a reminder, if you sell an item to a beneficiary that wants to pay you cash and not use their Medicare benefits, you must procure an Advance Beneficiary Notice (ABN) where the beneficiary selects the option to waive their rights.  But it is not as simple as just getting a signature and checking the right box… you must also disclose any reasons you believe the claim would likely deny IF you were to file the claim.  Waiving benefits doesn’t give you a pass on documentation collection or medical necessity verification.

 

The reason you must go this extra step is because the waiver of Medicare benefits is a revocable designation.  At any time in the future if the beneficiary changes their mind and wants you to file a claim (or if the caretakers get involved and insist you file), you will be obligated to do so.  In the event that the claim is filed and then denies for medical necessity reasons (that were NOT disclosed to the beneficiary in writing), you will be back on the hook to refund monies you collected.  So, do the leg work… make sure that the protections you intended to have at setup are still there waiting for you in the eventual case you have to file that claim.

 

While there can be profit in the retail market, there are still pitfalls to be mindful of.  This is just one of the can’t miss topics to be discussed in our upcoming webinar with Andrea Stark and healthcare attorney Jeff Baird on Jan 15.  For the last three years, HME News has had Andrea and Jeff present a candid and practical update for the coming year.  In this webinar they’ll tackle entry into cash and internet sales market place, what you should, can and cannot do with regards to patient collections, and common sense protections to ensure you are not left in the wake of the technology revolution.

 

You can register for this event or reserve a digital recording through our website using the Seminars and Webinars link. Seats are limited so register today!

 

MACs Push the Envelope on What Constitutes Sufficient Documentation to Justify Refills

Friday, December 21st, 2012

Andrea Stark

 

The DME MACs continue to push buttons and create uncertainty for providers that provide consumable supplies on a regular basis. A recent bulletin takes a pretty swift shot at providers that utilize automated Voice Recognition software and technology to efficiently process refill requests for consumable supplies such as ostomy, urological supplies, surgical dressings, diabetic testing supplies, etc.

 

Prior to sending out refills suppliers must determine the quantity of each item the beneficiary has on hand.

 

In the educational articles posted by the MACs (see links below) they have taken a position that questions that result in a Yes or No response will not be accepted as meeting the documentation burden. Questions that spoon feed beneficiaries and only capture an amount of supplies the beneficiary is requesting or responses to questions stating the beneficiary has less than “X” number of days remaining are all considered vague and non-specific, and the contractors will not justify reimbursement based on this captured data. The article further stipulates that the MACs prefer (although they do not require) an actual count of supplies remaining. Basically if your questions produce an identical response from multiple beneficiaries it is likely to be discounted.

 

So can we continue to use IVRs without risk of incurring audit risk? That is a good question! We are requesting additional dialogue with CMS on these directives and hope to procure a more liberal take on what can and cannot satisfy this requirement. While we maintain the MACs are taking an overly restrictive position beyond the scope of what SHOULD be required to meet this burden, they have put their cards on the table and providers have to adapt accordingly. In light of the directives, MiraVista recommends that scripts be modified to require a unique response from beneficiaries by asking open ended questions. We believe that if the provider asks “How many days of supply do you have remaining?” or “When do you expect that you will run out of your current supply?”, that CMS will have to accept the answer as a unique response. If using an IVR system it is preferred that you collect an individual, open response from the beneficiary to establish compliance with the current CMS requirements. You could model your question along the lines of the following:

 

“Please take a moment and assess how much supply you have remaining, and then answer the following question: How many days’ worth of supplies do you have left? Enter a two-digit representation for the number of days remaining: 1 day should be entered as 0-1, 14 days as 1-4.”

 

In cases where the response indicates the beneficiary has more than 10 days worth of supply remaining, your shipment should be delayed or the beneficiary should be personally contacted to verify the response.

 

This is a featured article from the December 2012 edition of VistaNotes.

 

Links:

 

http://www.medicarenhic.com/dme/medical_review/mr_bulletins/

 

 http://www.cgsmedicare.com/jc/pubs/news/2012/1012/cope20351.html

 


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