The Health Resources and Services Administration (HRSA) recently addressed two questions perplexing recipients working to calculate lost revenues for Provider Relief Fund (PRF) reporting:

1. What is the baseline comparison period for quarters ended March 31 and June 30, 2021?
2. Within each period of availability (POA), do quarters with higher revenue than the baseline offset losses from quarters with lower revenue than the baseline?

The Baseline Comparison Period is 2019

Initial reporting guidance contemplated a singular POA beginning and ending in the 2020 calendar year, thus allowing recipients to easily compare pandemic-affected revenues to corresponding quarters in 2019, the calendar year before the onset of the pandemic. When HRSA extended the use period for PRF funds beyond 2020, recipients were unsure if they should compare revenues in 2021 to the corresponding periods in 2019 or the immediate prior year. That is, should recipients compare revenue from the first quarter of 2021 to the same quarter in 2019 or 2020 when calculating lost revenue?

HRSA addressed the question directly in an FAQ added on July 1, 2021. The agency wrote:

“Quarters from 2019 will serve as the baseline period of comparison [using Option I (Comparison of Actual Lost Revenues) or Option ii (Comparison of Budgeted to Actual Lost Revenues)].”

As a result, recipients should compare revenues for each calendar quarter within the POA to the corresponding quarter in calendar year 2019 to calculate lost revenues eligible for PRF reimbursement. Answering the previous question, recipients should separately compare the revenues from the first quarters or 2020 and 2021 – both in the first period of availability – to the first quarter of 2019.

Quarters With Higher Revenue Than the Baseline Period do not Offset Quarters With Lower Revenue Than the Baseline Period

The PRF General and Targeted Distribution Post-Payment Notice of Reporting Requirements, most recently updated on June 11, 2021, spells out the types of lost revenues that recipients must report for each calendar quarter during the POA. It is, however, relatively silent as to how those elements are used to calculate the amount of lost revenues eligible for PRF relief. Recipients were unsure how to treat includable quarters with revenue increases, specifically questioning whether those quarters would offset losses calculated for other quarters.

In another FAQ added on July 1, the HRSA answered (emphasis added):

“For Option i and Option ii, lost revenues are calculated for each quarter during the period of availability, as a standalone calculation [emphasis added], with 2019 quarters serving as a baseline. For each calendar year of reporting, the applicable quarters where lost revenues are demonstrated are totaled to determine an annual lost revenues amount. The annual lost revenues are then added together.”

Ultimately, lost revenues for one or more quarters within the POA are eligible for PRF reimbursement regardless of increases in other quarters.

​In a training webinar on July 20, 2021, HRSA included the following example to demonstrate comparing revenues to baseline periods to determine eligible lost revenues:
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​Each calendar quarter during the period of availability, regardless of the calendar year in which it falls, is compared to its corresponding quarter in 2019. Those quarters with less revenue than the baseline are added together, disregarding quarters with increased revenue, to determine the lost revenues eligible for PRF reimbursement.

SOURCE LINKS
https://www.hhs.gov/sites/default/files/provider-post-payment-notice-of-reporting-requirements-june-2021.pdf
https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/faqs/provider-relief-fund-general-info/index.html#auditing-reporting-requirements
https://www.hhs.gov/sites/default/files/lost-revenues-guide.pdf
https://webex.webcasts.com/viewer/event.jsp?ei=1480779&tp_key=059854c38e
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CGS recently alerted suppliers that patients will no longer need a change in medical necessity to switch between supply types for continuous glucose monitors (CGM) and blood glucose monitors (BGM). Instead, the contractor will accept supplier attestations to affirmatively discontinue one service if the patient intentionally switches to the other.

CMS treats BGMs and CGMs as same or similar equipment. Medicare usually pays claims after a change in condition forces patients to switch from one to the other. However, in cases where patients return to using BGMs after unsuccessful CGM use, the MACs have typically denied claims because processing logic does not contemplate patients going back down the proverbial equipment ladder. The quirk leaves suppliers with little to no recourse for payment of medically necessary supplies.

Under the revised rules, suppliers should include the following narrative to prompt DME MACs to force the switch between testing supply types in the claims processing system:

“Beneficiary discontinued CGM and switched to BGM.”

In issuing this guidance, CGS makes clear it is not changing its position that BGM and CGM equipment are same and similar. As a result, Medicare will not pay for duplicate or replacement equipment after a switch. Beneficiaries that switch between devices must utilize patient owned equipment or purchase a replacement device out-of-pocket. Should the supplier provide alternative equipment before the end of the original equipment useful life, we strongly recommend securing an ABN.

SOURCE LINKS
https://cgsmedicare.com/jc/pubs/news/2021/05/cope22121.html
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CMS announced a system-wide error suppressed crossover claims to certain supplemental payers between April 8 and early May. The agency announced no plans to transmit the affected claims, so suppliers need to file directly with the secondary payers.

The issue affects Medicare claims finalized between April 8 and:

• April 25 (electronic claims).
• May 11 (paper claims).

Medicare did not send crossover claims to the following payers:

• Anthem BCBS
  • Connecticut.
  • New Hampshire.
  • Maine.
  • Vermont.
• BCBS
  • Michigan.
  • Maine.
• Empire BCBS Illinois.
• California Medicaid – Alameda Alliance.
• CHCS Services, Inc.
• C&O Employees Hospital Association.
• Mutual of Omaha Insurance Company.

We recommend suppliers query internal billing applications for open secondary claims covered by the above payers and opened in April or May to determine which claims require direct submission.

SOURCE LINKS
https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2021-04-29-mlnc#_Toc70512331
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In exchange for 36 rental payments, suppliers assume responsibility for a Medicare patient’s oxygen equipment for five years, the equipment’s stipulated reasonable useful lifetime (RUL). Upon expiration of the RUL, suppliers can deliver new equipment to continuing patients, and Medicare will start a new billing cycle. After all, these machines wear out and need replacement.

The process, however, is notoriously frustrating. Patient and physician cooperation, confusion over required documentation, and denied claims for new equipment are common pain points. Luckily, a few tweaks to the oxygen restart process can help suppliers avoid common pitfalls, increase revenue, and provide better service to longstanding patients.

Use Medicare Same or Similar Searches to Calculate the End Date of the Reasonable Useful Lifetime (RUL)

The initial CMN date on file with Medicare for stationary oxygen concentrators (E1390) establishes the start of the five-year RUL for both the stationary and any portable equipment provided. Suppliers often calculate the RUL based on internal billing data and initiate replacement without first confirming their own initial date agrees with Medicare’s records. If the date used does not agree to Medicare records, the DME MAC will deny claims for the new equipment.

Fortunately, online portals make it easy to validate the correct dates using same or similar information. Suppliers should search based on patient location: use the Noridian Medicare Portal for those in Jurisdictions A and D and myCGS for those in Jurisdictions B and C.

​The following example shows the information returned:

In this example, the initial CMN date is June 16, 2016, so the RUL of the current equipment expired five years later on June 15, 2021.

Bill Missed Payments Before Starting a Patient on New Equipment

Medicare reimburses up to 36 rental months during each RUL. Providing new equipment to a continuing patient for which a supplier has received less than 36 payments forfeits the revenue for unpaid rental months. As such, suppliers should bill missed rental months before providing new equipment. Suppliers can retroactively bill claims up to 12 months after the date of service, so long as the customer actually used the equipment for the dates billed. Claims must include a narrative directing Medicare to “Please extend the CMN to allow for remaining payments due to a break in billing or service.”

Same or similar query results also return the number of rental months paid during the current RUL. In the example results above, Medicare paid for 33 monthly rentals. Therefore, the supplier should retroactively bill three additional rental months under the current CMN before starting a new rental. Assuming the supplier has not billed for service dates since month 36 of the RUL and the patient continues to use the equipment, they could bill for April, May, and June 2021 dates of service.

Because extending the active rental cycle of the CMN does not alter the initial date, suppliers do not extend the reasonable useful lifetime when billing missed rental months. As soon as all rentals are captured, suppliers can immediately restart the rental anytime the initial date is over five years.

Moreover, suppliers should take care not to confuse length of need with rental months paid in the same or similar query detail. Recertified oxygen rentals always have a length of need of 36 months; that is how the Medicare claim processing system is configured to limit the maximum number of rental payments. When rental months paid do not equal length of need, however, suppliers must generate additional claims.

Don’t Chase Unnecessary Documentation

Contrary to what most suppliers expect, Medicare does not require the beneficiary to undergo another SAT or ABG test. Patients do not have to return to the doctor or have a face-to-face visit to restart their oxygen. To start a new billing period, suppliers should:

• Communicate with customer,
• Secure a new administrative initial CMN,
• Generate pickup and delivery tickets for the exchange, and
• Swap the equipment.

When preparing claims for the new equipment, be sure to:

• Include the RA modifier on the first claim, and
• Add a narrative that reads “Replace due to RUL Init mm/dd/yy.”

Exchange Stationary and Portable Equipment at the Same Time

Again, Medicare contractors look to the stationary oxygen CMN initial date to calculate each customer’s five-year anniversary date, including patients that start using portable equipment on a different date. For example, patients that start using a stationary concentrator for nocturnal oxygen often progress to daytime use and subsequently require a portable machine to get around in the home. Nonetheless, suppliers should restart both the stationary and portable equipment at the expiration of the stationary machine’s RUL.​

SOURCE LINKS
https://www.cgsmedicare.com/pdf/dme/oxygen_cmn_chart.pdf
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33797&ContrID=140
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52514&ContrID=140
https://www.medicare.gov/coverage/oxygen-equipment-and-accessories.html 
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