True or false.

If Medicare pays an oxygen supplier 10 monthly payments under the Fee For Service (FFS) oxygen benefit before the beneficiary switches to a Medicare Advantage Plan (MAP), can the MAP reduce the number of capped rental payments payable under the Advantage plan for continued oxygen use from 36 to 26?

Contrary to a growing trend, we don’t think they can.

The Medicare Managed Care Manual (MMCM) that governs Advantage plan providers stipulates MAPs should only formulate coverage policy when there is no NCD, LCD, or coverage guidance in other Medicare manuals (Chapter 4, Section 90.5). In the case of equipment retained from a prior payer, there is very clear Medicare guidance.

Medicare Guidance is Unambiguous

CMS speaks directly to equipment retained from prior payers in its policy article Standard Documentation Requirements for All Claims Submitted to DME MACs:

“When a beneficiary receiving a DMEPOS item from another payer (including a Medicare Advantage plan) becomes eligible for the Medicare Fee For Service (FFS) program, the first Medicare claim for that item or service is considered a new initial Medicare claim.”

Medicare has a clear policy for treating the movement between coverage as breaks in service, even when the movement is between Medicare and Medicare Advantage Plans.

Medicare’s Oxygen Policy Article goes one step further in its position that Medicare FFS and Medicare Advantage Plans are not different flavors of the same coverage. There, CMS writes:

“If [a] beneficiary … joins [a] Medicare HMO and continues to need/use oxygen, when [the] beneficiary returns home or rejoins Medicare FFS, payment resumes where it left off.”

That means that, should a patient leave FFS for a MAP plan and later return to FFS, payments made by the MAP do not reduce the remaining capped rental payments payable by FFS upon the beneficiary’s return.

Longstanding Medicare policy is clear that changes between Medicare FFS and Medicare Advantage Plans, including movement between competing MAPs, is grounds for starting a new rental cycle. As such, reducing capped rental payments by any number of months paid by other plans qualifies as contradicting policy that the MMCM explicitly prohibits.

MAPs Don’t Apply Medicare FFS Deductible Amounts to New Beneficiaries

While the practice itself has no foundation, it also represents a double standard. MAPs typically impose a new and separate deductible amount for new beneficiaries. They do not credit them for deductible amounts incurred under FFS or other MAPs in the same year.

Medicare FFS recognizes that changing insurance imposes new administrative burdens tantamount to a new setup. Given there is no substantive difference in the clinical documentation burdens imposed by FFS, MAPs must behave similarly and pay the full number of capped rental payments due.

SOURCE LINKS:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c04.pdf
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=55426
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52514&ContrID=140

Even experienced suppliers frequently find themselves stumped by the seemingly straightforward question, “What exactly is an upgrade?” At MiraVista, we use a simple strategy to identify upgrades properly so our clients are able to collect from the patient when appropriate and minimize the risk of recoupments for unsupportable payments.

Chapter 20, Section 120 of the Medicare Claims Processing Manual defines an upgrade as “… an item with features that go beyond what is medically necessary.” Upgrades are usually features or services that exceed Medicare coverage because they are:

• In addition to the official code descriptor listed for the HCPCS procedure code, or
• More expensive/extensive than what Medicare deems reasonable and necessary to meet the patient’s medical need.

I often say that Medicare pays for the patient’s needs but not the patient’s wants.

Let’s take a look at the typical cane covered by Medicare. The official description for E0100 reads:

E0100 CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIP.

In order to determine what components, if any, are upgrades, we must first tease out the descriptions or features that are part of the code (and therefore cannot be used for upgrading the product):

• “… of all materials …” – because this is in the definition, suppliers cannot, for example, charge more for a metal cane than a wooden cane.
• “… adjustable or fixed …” - suppliers cannot tout an adjustable cane as an upgrade over a fixed cane.
• “…with tip” - suppliers cannot pass along a separate charge for canes with rubber tips at the bottom because those are included in the description.

An upgradable product must include a feature that exceeds the HCPCS code descriptor. Continuing with the cane example, suppliers could count as an upgrade a custom handle shaped from a mold of the customer’s hand because the descriptor does not mention hand grip variations.

When faced with whether or not a feature may be billable to a Medicare beneficiary as an upgrade, suppliers can get to the correct answer by asking:

1. Does this extra feature exceed the medical need covered by Medicare?
2. Is this feature already included in the description for the applicable HCPCS code?

SOURCE LINKS
https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/clm104c20.pdf

Starting today, the second phase of Medicare’s prior authorization program requires suppliers in 12 new states to obtain prior approval for select off-the-shelf braces before delivering products to beneficiaries. The requirement applies to:

• Back braces billed with procedure codes L0648 and L0650, and
• Knee braces billed with procedure codes L1832, L1833, and L1851.

​
Medicare rolled out the initial phase in April for suppliers in California, Florida, Illinois, and New York. Today’s phase-two implementation includes:
​

• Arizona
• Georgia
• Kentucky
• Maryland
• Michigan
• Missouri
• New Jersey
• North Carolina
• Ohio
• Pennsylvania
• Texas
• Washington

The program launches in all remaining states on October 10, 2022.

Types of Medicare Authorizations

Many suppliers approve of prior authorization as a reasonable way to reduce costs associated with denials and recoupments, so long as the process is efficient. The current program offers routine authorization responses in five business days, but two-day expedited responses are available upon request. With the approved prior authorization in hand, suppliers can release claims with confidence that Medicare will not deny or recoup related claims due to insufficient medical record documentation, invalid standard written orders, or issues with same and similar equipment.

Suppliers can bypass the prior authorization requirement in cases where any delay in the provision of equipment poses an immediate risk to the health of the patient, but suppliers assume all risk for the adequacy of coverage documentation. In emergency cases, suppliers should bill with the ST modifier to alert Medicare there is no corresponding authorization. Doing so will suspend claims for prepayment review of medical records, and payment may be delayed up to 45 days.

We advise suppliers to work closely with referral sources. Early conversations in the ordering process provide the best opportunity to review and discuss the level of detail in the supporting chart notes. The ultimate goal is to screen the records and ensure they make a compelling case for payment.

SOURCE LINKS
https://cgsmedicare.com/jc/pubs/news/2022/03/cope25544.html 
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/Operational-Guide-for-DMEPOS-PA-current.pdf 
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/DMEPOS-PA-Frequently-Asked-Questions-06-01-2018.pdf 

Hey there!

When CMS announced the complete elimination of all CMN and DME Information Form (DIF) requirements back in early May, I wrote several articles highlighting the fact that, while the move was a welcome improvement, it did not resolve the disparity created by the revised oxygen NCD’s elimination of oxygen CMNs and the DME MACs’ existing claim processing rules and guidance. For the record, I think elimination of CMNs in toto goes a long way in reducing historical hold times for suppliers and paperwork burdens for suppliers and the referring physicians. It’s a good thing, but …

Suppliers will have to prepare for the change to avoid claim rejections after the change takes effect on January 1, 2023.

After the effective date, Medicare will reject claims with obsolete CMNs and DIFs attached. That means suppliers shoulder the entire burden for modifying existing processes; Medicare will not disregard unnecessary attachments and process claims normally. Because these forms have been around for so long, their use permeates many of our established intake and billing processes. Fortunately, suppliers have several months to prepare.

Billing Software Updates

Software vendors will likely include programmatic updates to help suppliers navigate the elimination of CMNs and DIFs. At a minimum, they should flag and hold claims with obsolete forms attached beyond the effective date. While the notifications will help suppliers avoid rejections, they may also increase the workload for the billing team tasked with working held claims and other pre-submission validation reports.

Hopefully, most vendors will be able to automate – at least to some degree – the processes for decoupling the forms from future claims transmissions, and perhaps more importantly, updating inventory and pricing table configurations that include the eliminated forms.

Suppliers should engage their software provider soon to determine what tools may be available and possibly collaborate on the development of those tools.

Longstanding Coverage Criteria Doesn’t Change

The eradication of these forms is strictly transactional. The underlying Medicare coverage requirements will not change. As such, suppliers must rely exclusively on the medical records to establish medical need for affected products and services. It is important that every individual participating in the intake and billing process can identify the characteristics of a well-documented chart note and a compliant standard written order.

In summary, I am very excited about the elimination of these forms and the streamlining of the antiquated processes that require them. I am, however, mindful that changing anything of significance requires training and preparation. Medicare’s plans to simply reject claims that include CMNs and DIFs after January 1 implies the agency sees that responsibility as wholly belonging to suppliers. Luckily, DME suppliers have a long history of rising to the challenge.

Take care,

Andrea

SOURCE LINKS
https://www.ngscedi.com/web/ngscedi/w/eliminating-certificates-of-medical-necessity-durable-medical-equipment-information-forms-january-1-2023
https://www.miravistallc.com/blog/cmns-eliminated-oxygen-patients-still-in-limbo