Billing & Reimbursement

On December 6, 2018, the DME MACs issued a joint publication notifying suppliers of a change in the way to bill for bilateral products dispensed on the same day. Previously, when two of the same items are given to patients for use on both limbs, the claim is billed with the RTLT modifier and 2 units of service. Effective for claims with dates of service on or after March 1, 2019, suppliers must bill bilateral products on two separate claim lines. One line will have the HCPCS code with the RT modifier

Many providers who primarily accept Medicare reimbursement are looking to cash as the answer. If a Medicare beneficiary wants to pay cash, do you have to let them know that the item may be covered by Medicare? The answer is yes. This goes for not only independent providers, but bigger national retailers as well.  If a provider has a reason to suspect that a customer is a Medicare beneficiary, it's better to err on the side of caution and go through the Advanced Beneficiary Notice

On May 6, 2019, the Office of Civil Rights published a press release regarding a settlement reached with a Tennessee diagnostic medical imaging services company for $3,000,000. This settlement was reached, in essence, due to the lack of a sufficient HIPAA compliance program. To summarize, the organization’s FTP server allowed uncontrolled access to the internet, exposing PHI for over 300,000 individuals. In the process of the OCR investigation, it was determined that the organization

One of the most important “profit centers” of a supplier is its compliance program. While a compliance program does not directly generate income for the supplier, a functioning compliance program will assist the supplier in (i) retaining the money it has previously been paid and (ii) not having to pay consultants and attorneys to assist in responding to a recoupment demand. Further, a functioning compliance program reduces the risk of (i) a whistleblower lawsuit being filed by

DME suppliers are currently preparing for Competitive Bid Round 2021. Only certain product categories are included in competitive bid. Please note, this is the first round for off the shelf back and knee braces to be competitively bid.  Bidder registration period and the bid window will likely open in June 2019 (this date may change).  EW members who are planning to participate in this current round of bidding, prepare now. VGM has put together tools to help our members go through

A Defense Department watchdog last year found that Tricare overpaid more than $16 million for breast pumps. Tricare has now scaled back its coverage to cut out "luxury or deluxe" features, like connectivity to cars and smartphones, and associated items like nursing bras, cleaning supplies and over-the-counter ointments. New moms will also be allowed to receive one breast pump, whereas the previous policy allowed for two. This new policy comes after the 2018 Office of Inspector General investigation

On January 30, 2019, CMS posted to their website that “As of January 30, 2019, there are no active Medicare Provider Enrollment Moratoria in any State or U.S. territories.” The Provider Enrollment Moratoria Waiver Demonstration will end when the moratoria expires. Since July 2013 a moratorium has been in effect that prevented home health agencies (HHAs) from enrolling into the Medicare, Medicaid, and the Children’s Health Insurance Programs (CHIP) in particular geographic

On January 23, 2019, Performant Recovery, the National DMEPOS RAC, added Pneumatic Compression Devices to their approved issues list. According to their website, Performant Recovery will perform complex reviews to determine if the pneumatic compression device is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied. Read more from

At the beginning of the year, most of us make resolutions. Have you thought about putting together resolutions for billing and reimbursement? The van Halem Group has put together a series of articles on best practices for the new year. Documentation resolutions should include your problem areas, like illegible signatures, illegible provider documentation, inconclusive date of receipt, and issues with identifying the patient on the medical records.  Read the whole article on van Halem's

Same or similar denials occur when claims information is checked against the patient’s CMN history. This will indicate when equipment is “same or similar” to that piece of equipment being billed on the claim. These types of denials can be avoided early on when providing DME equipment to patients. The most important part in preventing this type of denial is by having a thorough intake process. Suppliers are encouraged to use an intake form to assure all necessary information is