Our consulting firm frequently gets questions from companies about how to move forward when patients experience interruptions in service. Suppliers routinely perform same and similar queries and find orphaned rental payments posted on prior CMNs with Medicare. This scenario often promotes uncertainty with the staff as to how to proceed with a new setup… will we get paid a full rental or will we have to eat those residual payments? While there are many variations as to why this happens, we will explore the most common scenario that impacts CPAP patients: non-compliance.
The tell-tale sign of non-compliance is seeing three months of payments on a Medicare CMN. From a documentation perspective, non-compliant OSA patients must go back to their physician and have a second office visit to diagnose the failure and repeat a facility-based sleep study before they can proceed with a second trial.
From a billing perspective, when you confirm the patient was on PAP therapy and did not achieve compliance, unfortunately Medicare will consider any duration of time in between as a break in service (BIS). This means that you are only eligible to receive the remaining 10 payments. And this understanding is important to ensuring the claim is set up correctly in your billing system. Because the first three months are now lost, you cannot afford any additional inefficiencies in the resolution of the remaining claims. In this scenario, you are not eligible to receive the higher rental payments associated with the KH or KI modifiers (which Medicare has already made previously). Furthermore, billing in excess of 10 months or with incompatible modifiers will result in denials, unnecessary touch points and uncollectible AR.
Clarity on this common scenario will keep your AR lean and your staff moving at light speed. If your staff struggles with sorting out when they can get a full capped rental restart and when they must extend a prior rental, join us on Nov. 17 for our webinar “Restart or Extend – Simplifying Medicare Capped Rental Scenarios.”
From a billing perspective, when you confirm the patient was on PAP therapy and did not achieve compliance, unfortunately Medicare will consider any duration of time in between as a break in service (BIS). This means that you are only eligible to receive the remaining 10 payments. And this understanding is important to ensuring the claim is set up correctly in your billing system. Because the first three months are now lost, you cannot afford any additional inefficiencies in the resolution of the remaining claims. In this scenario, you are not eligible to receive the higher rental payments associated with the KH or KI modifiers (which Medicare has already made previously). Furthermore, billing in excess of 10 months or with incompatible modifiers will result in denials, unnecessary touch points and uncollectible AR.
Clarity on this common scenario will keep your AR lean and your staff moving at light speed. If your staff struggles with sorting out when they can get a full capped rental restart and when they must extend a prior rental, join us on Nov. 17 for our webinar “Restart or Extend – Simplifying Medicare Capped Rental Scenarios.”
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