Billing & Reimbursement

Have you registered for Focus: The EW Conference yet? The early bird registration deadline is October 31. One of the most common questions we have been getting revolves around the education schedule. We are incredibly excited for this year’s schedule.   This year, we are featuring two keynote speakers. Regina Hampton, MD, FACS, CMF will be presenting on Sunday, Feb. 9 on breast cancer and surgery updates. As a nationally known breast surgeon and also the CEO of Cherry

If you are dispensing consumable/non consumable supplies or rented DME items are being used by patients, there must be information in each patient’s medical record to support that the item continues to remain reasonable and necessary. Issues may arise after you receive that original order with “99” refills with no further documentation on hand two years later. Even though you may have a valid order for dispensing, CMS wants to be sure that the item(s) continue to be needed by the

Health care is evolving from the traditional “fee-for-service” (“FFS”) model to an “integrated care” model. Under the FFS model, health care providers (physicians, hospitals, therapists, pharmacies, DME suppliers, etc.) operate in separate “silos.” Each provider is paid for the services/products it delivers…regardless of whether such services/products result in a positive patient outcome. Plus, in the FFS model, the providers do not coordinate

Baby boomers are retiring at the rate of 10,000 per day. Today's boomers aren't playing shuffleboard; they are active and participating in all sorts of activities. Increasingly, DME suppliers are seeking to diversify their income stream by selling products for cash. Assume that XYZ Medical, Inc. has a PTAN and its principal business is to provide Medicare-covered items on an assigned basis. In an effort to lessen its dependence on Medicare, assume that XYZ wants to promote, to its existing

Although CMS has not made any recent changes to the current proof of delivery (POD) documentation requirements and guidelines for Medicare, it is recommended as best practice to evaluate the procedures you have in place for meeting the Medicare requirements for proof of delivery and ensuring you have the documentation available in the beneficiary files to support and ensure Medicare compliance for payment purposes.   Suppliers must maintain proof of delivery documentation in their

The federal anti-kickback statute (“AKS”) prohibits a supplier from paying any money to a person or entity in exchange for (i) the referral of a federal health care program (“FHCP”) patient, (ii) arranging for the referral of an FHCP patient, or (iii) recommending the purchase or lease of a product covered by an FHCP. There is an “employee” exception and an “employee” safe harbor to the AKS that state that, if certain conditions are met, then the supplier

Effective September 1, 2019, MAXIMUS Federal will serve as the DME QIC for the entire United States and the U.S. territories. This means that any requests for reconsiderations received on or after September 1, 2019 will be processed by MAXIMUS. With the switch from C2C to MAXIMUS comes the ability to submit a Reconsideration electronically. MAXIMUS will accept appeals via ESMD to all suppliers through the QIC Appeals Portal. Redeterminations will continue to be handled by the DME

On January 23, 2019, the DMEPOS and Home Health Recovery Audit Contractor (RAC) Performant added Pneumatic Compression Devices to their CMS Approved Audit Issues log. The reviews are defined as complex reviews for claims with a paid date more than 3 years prior to the Additional Development Request (ADR) letter date. Performant indicates that pneumatic compression devices (HCPCS Codes E0651 and E0652) may have been provided to patients where all Medicare coverage criteria were not met. The review

CMS has announced that it will reject Medicare claims submitted with the Health Insurance Claim Number, with very few exceptions, starting January 1, 2020. All eligibility transactions must use the Medicare Beneficiary Identifier (MBI). Most providers are already using the MBI. For the week ending July 5, 2019, 76% of fee for service claims submitted by providers used the MBI. CMS changed their process from using the Health Insurance Claim Number to the MBI to provide greater security against

There are a few differences between a dispensing order and a written order. DME items may be dispensed upon a verbal or written dispensing order as long as a detailed written order (DWO) is obtained by the DME supplier prior to claim submission.  For Medicare purposes, it is generally understood that most DME can be dispensed upon the receipt of a dispensing order from a physician. It can be verbal or written. It must include: a description of the item, name of the beneficiary, name of the