Billing & Reimbursement

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

There are a number of land mines that could significantly lower your payer contracts' reimbursements if not handled properly. "Lesser of billed charges" Language The "lesser of billed charges" language can be found in almost all payer contracts and is typically worded like this: “Payer will pay provider the lesser of its billed charges or its payer allowable for each codes’ reimbursement.” Here’s an example: If your payer contracted rate at 100% including patient

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