Unless you’re a healthcare worker using durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) or are a home healthcare company, you probably have no idea what Medicare’s DMEPOS Competitive Bidding Program (CBP) is or how it affects healthcare equipment suppliers and patients.

Frankly, it’s been a thorn in the sides of many DMEPOS companies for years. Imagine their glee when the Centers for Medicare & Medicaid Services (CMS) proposed changes to the program.

All Medicare Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) Competitive Bidding Program contracts expired on December 31, 2018. As of January 1, 2019, there is a temporary gap in the entire DMEPOS Competitive Bidding Program that CMS expects will last until December 31, 2020. 

During the temporary gap, any Medicare enrolled DMEPOS supplier may furnish DMEPOS items and services to people with Medicare. In most cases, people with Medicare won’t need to switch suppliers on or after January 1, 2019. 

• Medicare beneficiaries may receive DMEPOS items from any Medicare-enrolled supplier until such time as new CBP contracts go into effect.
• When competitive bidding resumes, it will be under new program rules, as discussed below.

Future Competitive Bidding Program Rules

In a final rule scheduled to be published on November 14, 2018, CMS adopted a number of “market-oriented reforms” and technical policy changes for future rounds of competitive bidding. According to CMS, the new rules will simplify the bidding process, preserve beneficiary access to items and services, and make the DMEPOS CBP more sustainable.

Of particular note, CMS has finalized its proposed “lead item pricing” methodology. Rather than bid on each item/HCPCS code in a product category for each competitive bidding area (CBA), suppliers will submit a single bid for the item in the product category designated by CMS to have the highest total nationwide Medicare allowed charges.

Proposed Changes Are a Win/Win

According to a CMS Newsroom Fact Sheet, “Beginning on January 1, 2019, beneficiaries may receive DMEPOS items from any willing supplier (until new contracts are awarded under the DMEPOS CBP).”

Home healthcare supply companies are breathing a big sigh of relief about the proposed changes.

The proposed changes will benefit to small DME companies by allowing them to market their products and company to providers, facilities, and nursing agencies without limiting their customer base to non-Medicare insurances.

Even though Medicare fee schedule is low, it opens up the market to more customers and creates a fairer playing field for all companies, which will result in better service to beneficiaries.

For those companies who didn’t have contracts due to CBP, but now do, the only downside is they’ll need to jump back through the hoops of government regulations to get their Medicare claims paid.

To learn more about Medicare’s Temporary Gap Period or the future of Medicare Competitive Bidding, follow the link http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSCompetitiveBid/index.html?redirect=/DMEPOSCompetitiveBid/

CMS Proposed Polices and Payments rates for End-Stage Renal Disease providers for CY 2015

On July 2, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2015.

• This proposal would introduce new quality and performance measures to improve the quality of care by outpatient dialysis facilities treating patients with end-stage renal disease and proposes to implement the Affordable Care Act mandate to bring more competitive bidding for durable medical equipment.
• The rule also proposes changes to the ESRD Quality Incentive Program (QIP), including for payment year (PY) 2017 and PY 2018, under which payment incentives are applied to dialysis facilities to improve the quality of dialysis care.
• This rule also addresses issues related to the coverage and payment of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).

A separate fact sheet addressing the payment provisions of the ESRD PPS for CY 2015 can be found here: http://www.cms.gov/Newsroom/Newsroom-Center.html.

CMS Updates to Policies and Payment Rates for End-Stage Renal Disease Facilities for CY 2016 and Changes to the ESRD Quality Incentive Program

On October 29, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a final rule to update payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2016.

• The ESRD final rule is one of several rules for calendar year 2016 that reflect a broader Administration-wide strategy to provide quality care at lower cost by improving ways to deliver care, pay providers, and use information.
• Provisions in these rules are helping to move our health care system to one that values quality over quantity and focuses on reforms such as measuring for better health outcomes, focusing on disease prevention, helping patients live successfully at home, helping manage and improve chronic diseases, and fostering a more efficient and coordinated health care system.

To read the complete update click the link https://www.cms.gov/newsroom/fact-sheets/cms-updates-policies-and-payment-rates-end-stage-renal-disease-facilities-cy-2016-and-changes-esrd

CMS releases final rule for 2017 ESRD payment bundle

The Centers for Medicare & Medicaid Services issued a final rule on Oct. 28, 2016 that updates payment policies and rates for the End-Stage Renal Disease Prospective Payment System for 2017. The final rule also made changes to the ESRD Quality Incentive Program (QIP), including payment years 2019 and 2020.

Changes to the ESRD PPS for 2017

• The finalized CY 2017 ESRD PPS base rate will increase $1.16 to $231.55, compared to the 2016 rate of $230.39.
• The 2017 home and self-dialysis training add-on payment adjustment will be $95.60, an increase of $45.44, compared to the 2016 add-on of $50.16.
• CMS will provide coverage and payment for renal dialysis services in 2017 by an ESRD facility to an individual with acute kidney injury. Under the law, the payment will be the amount of the ESRD PPS base rate, as adjusted by the wage index.

CMS Updates to Policies and Payment Rates for ESRD Prospective Payment System, Quality Incentive Program, and Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury for 2017

On October 27, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2018.

• The ESRD PPS rule is one of several rules for calendar year (CY) 2018 that reflect a broader Administration-wide strategy to support the patient-doctor relationship in health care and promote flexibility and innovation in the delivery of care.
• In addition, this rule finalizes updates to the acute kidney injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI, as well as updates to the ESRD Quality Incentive Program (ESRD QIP), including for payment years (PYs) 2019, 2020, and 2021, under which payment incentives are made to dialysis facilities to improve the quality of care that they provide.

The ESRD PPS rule is one of several rules for calendar year (CY) 2018 that reflect a broader Administration-wide strategy to support the patient-doctor relationship in health care and promote flexibility and innovation in the delivery of care.

CMS is committed to transforming the health care delivery system – and the Medicare program – by putting a strong focus on patient-centered care, so providers can direct their time and resources to patients and improve outcomes.

To know about the changes read the complete text https://www.cms.gov/newsroom/fact-sheets/cms-updates-policies-and-payment-rates-end-stage-renal-disease-prospective-payment-system-quality

CMS release ESRD/DMEPOS Competitive Bidding Program Temporary Gap Period Announcement for 2019

Centers for Medicare & Medicaid Services (CMS) has released its final End-Stage Renal Disease (ESRD)/ Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) rule, which contain some, but not all of the additional competitive bidding and reimbursement reforms for which HME stakeholders have been calling.

On November 1, 2018, the Centers for Medicare & Medicaid Services issued a final rule that updates payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2019.

1. This rule also updates the acute kidney injury dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI, and finalizes changes to the ESRD Quality Incentive Program.
2. The policies in this final rule aim to increase access to items and services for patients, drive competition, increase affordability, encourage facilities to adopt transformative and innovative therapies, and reward ‘out of the box’ ideas that will produce long-term savings that can be passed on to patients.

This rule also finalizes changes to bidding and pricing methodologies under the:

• Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
• Competitive Bidding Program (CBP);
• Adjustments to DMEPOS Fee Schedule amounts using information from competitive bidding for items furnished on or after January 1, 2019.
• New payment classes for oxygen and oxygen equipment and a new methodology for ensuring budget neutrality for oxygen payment classes; and special payment rules for innovative multi-function ventilators or ventilators that perform functions of DME.

Starting January 1, 2019, there will be a temporary gap period in the entire DMEPOS CBP that CMS expects will last until December 31, 2020. During that time, Medicare beneficiaries may receive DMEPOS items from any Medicare enrolled DMEPOS supplier and in most cases, they won’t need to switch suppliers.

In addition, in the proposed rule, CMS solicited comments in a request for information (RFI) on the gap-filling process for establishing fees for new DMEPOS items.

Footnotes:

CMS is committed to transforming the healthcare delivery system and the Medicare program by putting a strong focus on patient-centered care, so providers can direct their time and resources to patients and improve outcomes. The ESRD PPS and QIP DMEPOS final rule is one of several rules for calendar year (FY) 2019 that reflect a broader Administration-wide strategy to relieve regulatory burdens for providers, support the patient-doctor relationship in healthcare, and promote transparency, flexibility, and innovation in the delivery of care.

In this final rule, CMS summarizes comments it received in response to an information solicitation on how the gap-filling process could be revised in a way that complies with the exclusive statutory payment rules for DMEPOS, but also prevents excessive overpayments or underpayments for new technology items and services.

We encourage you to reach us if you have any questions at support@wonderws.com

It is important for you to take charge of getting your DME.  You know best what you need and it is your responsibility to make sure you get equipment that will work for you. This process can go more smoothly if you attend to the details

1. Who can get DME?
2. What are the steps in getting DME paid for?
3. What are the most common reasons for denial of payment?

What is Durable Medical Equipment?

According to the Centers for Medicare and Medicaid Services, is a health care device that helps a person with a mobility limitation to conduct activities in their home and community.  This includes such items as wheelchairs, walkers, oxygen tanks, communication devices and hospital beds. The Centers for Medicare and Medicaid Services defines durable medical equipment  as any equipment that:

1. Can withstand repeated use
2. Is not useful to a person who does not have an illness or injury
3. Is appropriate for use in the patient’s home

It’s strange how they think we are all sick and stuck at home, and that getting around is a medical issue!

What Are Some Examples of DME?

 DME is considered to include:           

• Equipment that can help you to get around more easily such as canes, crutches, walkers, wheelchairs or scooters.
• Equipment that you may need to care for yourself at home such as hospital beds, raised toilet seats, oxygen tanks, or machines that make breathing easier.
• Equipment that can help you to hear or see better like hearing aids or magnifiers.

DME does NOT include:

• Equipment that is considered “items of personal convenience” or reusable items, such as rubber gloves, catheter tubing, or irrigation kits.
• Equipment that is not considered to be for “medical use,” such as grab bars, lifts or shower chairs.
• Equipment used exclusively outside of the home is often labeled recreational or “used to pursue leisure interests” and may not be covered as DME.

So getting around is a medical issue, but taking a shower is not?? Who writes these regulations?

Who can get DME?

People who are admitted to hospitals and skilled nursing facilities for surgeries, illnesses or injuries will get the equipment they need before being discharged.  In these situations, the equipment that people receive depends on why they were in the hospital. For example, if you go to a hospital for a hip replacement, the hospital will probably send you home with a walker and a raised toilet seat.

The process for getting DME without being in the hospital is different. You can pay for any piece of durable medical equipment yourself. However, because it can be expensive, people usually use their health insurance to pay for DME. Insurance carriers have different guidelines for what equipment they will pay for.  For example:

Medicare pays for DME when you:

1. have Medicare part B;
2. have a doctor prescribe a covered item of DME; and
3. need the device in order to function in your home.

How Do You Get The DME You Need?

Once you have decide that DME is the right choice for you, there are several steps involved in getting it.  If you are able to pay for the equipment yourself, you can go to any DME vendor in your area that has the equipment you would like and you can purchase it.  Depending on whether it’s in stock and available, you may be able to pick up the DME immediately or usually within several weeks. Follow these steps to get your DME.

What is a DME vendor?

A DME vendor is a company that specializes in DME.  DME vendors have staff who are experts in equipment. Some are physical therapists (PT), occupational therapists (OT) and Certified rehabilitation technology suppliers. The vendors work with the companies that make the equipment as well as your insurance carrier.        

How do you find a DME vendor?

Your health insurance carrier may allow you to choose your own DME vendor. However, your insurance company may have a recommended DME vendor, and they may only pay for equipment you get through this vendor. Many times the DME vendor who has the contract for your insurance may not be the best qualified to handle your needs. Ask your insurance carrier what you may do if you are not satisfied with their vendor. You are the consumer!

If you have a choice of vendor:

1. Your doctor can recommend a DME vendor.
2. Ask your friends if they can recommend a DME vendor in your area.
3. Telephone your local drug store, pharmacy or medical supply company and ask if they know of DME vendors in your area.

Who Follows Up On Your Order?

You do. To make sure everything has been filed and the process is going smoothly, you should follow up with your DME vendor. Remember, they handle hundreds of requests so you also will want to follow up with Medicare, Medicaid or your private insurance company directly to check on the status of your claim.

You should keep a copy of every form filed with your request and get any claim numbers and all contact information. Make sure your doctor knows also how long the process is taking and what is happening so that he/she will be able to assist you in following up when necessary.

Conclusion: 

Getting the right gear for your unique needs can be a challenging and time consuming process.  Using the information provided here and attending to the details can help make the process go a little more smoothly and reduce the chance of having your request denied.  It is important that you take charge of getting your DME. It is your responsibility to make sure you get the right gear.

If you need any help in contacting DME Vendors Contact us. Our team will guide and support you with selecting of right DME suppliers for your Medical issues.

The Integrated Care Resource Center recently released a briefing titled “Facilitating Access to Medicaid Durable Medical Equipment for Dually Eligible Beneficiaries in the Fee-for-Service System.” As the title states, the brief explores the approaches of Connecticut, California, and Illinois in ensuring dual-eligible beneficiaries receive the medical equipment they need.

⇒ Beneficiaries who are dually eligible for Medicare and Medicaid often experience difficulties accessing
durable medical equipment such as wheelchairs, in a timely manner. Whether Medicare or
Medicaid covers a specific item may be unclear.

To address this issue, some states, such as Illinois, California, and Connecticut, have developed procedures for provisional prior authorization from Medicaid for such items. States may supplement these procedures by posting lists of DME items that Medicare consistently denies as non covered, and allow DME suppliers to bill Medicaid directly for these items without first billing Medicare. This can make it more likely that suppliers will provide DME to dually eligible beneficiaries in a timely way, with less confusion and uncertainty about who will pay and when.

Policies Implemented by the Three States:

Currently, fourteen states have implemented provisional prior authorization policies supported by lists of DME items that Medicare does not generally cover. The ICRC explored the policies of three states to better understand how PA improves access for dual-eligible individuals.

California, Connecticut, and Illinois have slightly different DME billing policies. California and Illinois both implemented a feature that further facilitates the provisional PA approach. Each maintains an online list of DME items that Medicare generally denies as non-covered under Part B, but that Medicaid may cover. When it is clear from the list that Medicare will not cover the item, DME suppliers can submit their claims directly to Medicaid without first submitting them for a Medicare denial. In contrast, Connecticut developed a system that allows for prior authorization of DME before a Medicare denial.

Illinois’ Approach to DME Delivery

Illinois Medicaid simplifies the adjudication and payment of DME claims for dually eligible beneficiaries by enabling providers to use:

1.  An online information system called Medical Electronic Data Interchange that lets providers
   verify multiple elements of a beneficiary’s eligibility, including QMB status.
2. An online table for providers that specifies the services/items for which providers and suppliers can bill Medicaid directly because Medicare generally does not cover them under Part B. 

Online table for DME providers:

Illinois currently maintains a table on its website that indicates whether Medicare normally covers a specified DME item. 

California’s Approach to DME Delivery:

As in all states, the California Medicaid program (called Medi-Cal) requires that DME suppliers submit most
claims for dually eligible beneficiaries to the appropriate Medicare carrier or fiscal intermediary so they can
process the Medicare benefit first. However, providers are allowed to submit claims directly to Medi-Cal
when any of the following criteria apply:

• Medicare does not cover the item or service;
• The beneficiary’s Medicare benefits have been exhausted; or
• Medicare has denied the claim, or the recipient is not Medicare-eligible.

Online Table of HCPCS codes for DME Coverage:

Connecticut’s Approach to DME Delivery;

Connecticut began to operate its Medicaid program HUSKY Health through a self-insured, managed FFS
model in 2012. The Connecticut Department of Social Services has contracts with Administrative Service
Organizations for medical, behavioral, and dental health services as well as non-emergency
medical transportation. Community Health Network of Connecticut is the ASO that administers all
medical services, including DME.

Recent Federal Developments:

Two recent developments at the federal level may make it easier for states to provide prior authorization for Medicaid DME when Medicare may also cover the item:

1. Earlier Medicare authorization of some types of power wheelchairs. As of July 2017, a new Medicare prior authorization process is in effect nationwide for two types of power wheelchairs that may make the authorization process easier for dually eligible beneficiaries and power wheelchair providers by enabling them to get an earlier Medicare decision on those DME items.

Beginning September 1, 2018, 31 additional power mobility device codes will be subject to required prior authorization. These items are currently included in the Prior Authorization of Power Mobility Devices Demonstration, which is scheduled to end on August 31, 2018.

2. New incentive for states to develop lists of DME that Medicare will not cover. A new federal law,
effective January 1, 2018, limits federal matching payment for Medicaid DME that is jointly covered by Medicare to the amount Medicare would have paid, in the aggregate, for those items. This limitation does not apply to items of DME that Medicaid covers but Medicare does not.

Schedule a free online demo for more information http://localhost/main-site-update/live-demo/

HME businesses face increasing numbers of pre- and post-payment audits, which can be very stressful and costly events. Without a sound strategy for maintaining accurate and retrievable documentation, an audit request can disrupt operations and put your organization at financial risk.

When an audit strikes, the response must be swift and precise. The best approach to an audit letter is a quick response with proof that all documentation complies with requirements.

Five steps HME providers can take to give a speedy response and make sure all claims are audit-ready include:

1. Give Customer Service Representatives tools to improve intake:

• Knowledgeable customer service representatives at the front end are essential to collecting the right information at the start of service, but staff turnover and constantly changing requirements make it difficult to keep CSRs up-to-date on payer requirements.
• Technology can fill the knowledge gap if it does more than just park the data in a form prompting CSRs to collect specific documentation, which enables correction of the claim before it is filed.

2. Document to payer-specific rules:

• Improve efficiency by helping CSRs collect payer-specific requirements through established validation rules.
• While Medicare rules may call for a document to support specific Healthcare Common Procedure Coding System (HCPCS) codes, other payers may have a looser set of rules for that procedural code, which don’t require the same level of documentation saving time for the CSR.

3. Enable quick response to the audit letter:

• Staff should be able to quickly access the documentation when responding to an audit letter, which is not always easy in the case of long-term service.
• Establishing a link between billing records and the sales order documentation eliminates the risk of error when pulling documentation and ensures the information can be gathered efficiently.
• In addition, advanced HME systems allow users to collect, submit and track documentation electronically in response to CMS audits.

4. Automate document review within the workflow:

• There are times a critically needed product must be delivered before documentation is complete.
• This increases the need for a careful documentation review before submission of the claim to ensure progress notes support medical need and meet requirements.
• HME providers can easily determine whether or not to delay confirmation of a claim until the file is complete and the claim is substantiated by automating the review process throughout the workflow, utilizing optical character recognition technology and installing checkpoints that alert staff to missing or inaccurate information.

5. Capture data on all patient-care related interactions:

• Setting up a process to capture all telephone calls to patients, verbal orders from physicians or communication with other providers is critical, but difficult with the number of people involved in each case.
• Technology that documents actions by time, date and personnel involved provides additional support as an HME provider demonstrates compliance with billing requirements.

There’s no sure way to guarantee you won’t go through an audit; however, by ensuring the good HME business technology is in place you can take on most any audit challenge. With proactive compliance and timely response submission, audits can be resolved and claims are paid faster leading to improved cash flow.

Don’t wait for an audit Make every claim audit-proof from the start and For more information email us at support@wonderws.com

Are you on top of the CMS documentation guidelines?

The following points identify CMS guidelines for correct documentation that supports and validates the claim submitted for services/procedures:

• The record of the encounter/episode of care should be complete and legible
• Documentation should include:
  1. Reason for the encounter
  2. Assessment, diagnosis, and clinical impression
  3. Medical plan of care
  4. Date and legible identity of the observer
• The rationale is documented for ordering diagnostic and ancillary services
• Past and present diagnoses are documented
• Diagnosis and treatments are supported in the medical record and match the codes reported on the CMS-1500 for the patient’s services

Lack of a valid reason for an encounter is one of the most frequent pitfalls that leads to a denied claim, which could be because a patient may not present with a chief complaint (CC), or it’s difficult to determine the reason for the encounter, or when the CC does not correlate to the components of the assessment.

The data indicates all health care organizations should have regular documentation, coding and billing audits performed as part of their annual compliance plan. Communication and educational tools for providers and coding staff can be implemented to related documentation and coding-related issues from routine audits.

The Medicare Fee for Service (FFS) Recovery Audit Program’s (RACs) mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of healthcare services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states.

CERT and RACs shortlisted the top errors in CDI:

• Incomplete progress notes: They are either unsigned, updated or have insufficient details.
• Unauthenticated medical record: The medical record bears no provider signature, initials, supervising signature, or a legible signature.
• No documentation to support the service or procedure: Incomplete or missing signed order or progress note describing intent for service/procedure/test.

CERT Identifies Common E/M Services

Here are the top three services CERT targets:

• E&M services for established office visits
• Initial hospital visits
• Subsequent hospital visits

High error rates were reported by CERT for:

• Insufficient documentation
• Lack of support for the medical necessity
• Inaccurate E/M codes

CERT also targets:

1. Incomplete documentation

Including misspelled words or incomplete sentences that lack meaning led the auditor to believe the information was copied or the provider didn’t read it.

2. Holes in the record

These appear often in records, at times with drug names missing. It is especially notable when the physician has signed off on the record, proving that he didn’t bother to read it thoroughly.

3. Noncompliance with organizational policies

Practices should have a compliance plan in place that focuses on the CPT® codes your providers use most often for ensuring accurate and thorough documentation. The practice should train providers on compliance plan processes, require that they verify that they received and understand the training, and ensure that they follow the plan by defining disciplinary actions if they fail to do so.

Services must be reasonable and necessary

The provider must be clearly able to documents that the patient’s diagnosis justifies the treatment rendered to avoid the slightest indication that the treatment is for the convenience or comfort of the patient, provider, or supplier.

Drawbacks of auto-populate in an EMR

Providers should double check when the EMR auto-populates documentation. Ensure that the records do not demonstrate auto-population of the word ‘routine,’ as this might lead to diluting the provider’s case for the unique medical necessity of care for the specific medical condition.

Providers also shouldn’t quickly check off boxes in the EMR or in the record without carefully reviewing the accuracy of the documentation. Checkboxes lend themselves to quick completion of documentation that may be inaccurate.

Note:

Physicians who get paid for an over-documented service do not necessarily get to keep the money. Auditors on the payers’ side look for evidence-based documentation to prove medical necessity, and if they don’t find it, the payers ask for their money back. Physicians must be able to substantiate their claims of medical necessity with accurate documentation.

Learn More on timely documentation that reflects the scope of services provided. Contact us or Schedule a free live demo to overcome from Documentations Errors.

Durable Medical Equipment billing continues to scrutinized by Medicare and other Commercial Carriers, so everyone needs to understand DME Documentation Requirements. Without understanding and following documentation requirements, You’re putting your office at risk  to fail an audit.

Not only that, but you face refunding an insurance carrier or CMS, which would be an unfortunate and unnecessary revenue loss for your practice. It’s important to learn about the complicated documentation requirements for DME from a general rules perspective as well as what is needed for specific kinds of DME.

1.  Medical Necessity 

The lengthy documentation process for DMEs includes a paper trait that heavily supports medical necessity of the DME and for the suppliers that require prior approval, a provider prescription and clinical documentation are necessary and must support this requirement.

Medicare requires a prescription before approving payment for any DME. This prescription may originate with a physical therapist starting the documentation process and an approved physician providing the prescription.

Communication is key, as the script and supporting documentation need to prove medical necessity, In doing so, the following information is required.

1. Licensed provider’s plan of treatment.
2. Anticipated benefits and outcomes from using the DME.
3. Detailed member’s clinical and functional status so that a determination of medical necessity can be made.
4. Patient’s medical record.

2. Avoid Insufficient Documentation Errors

If any condition of payment is missing, including just one physician signature, your claim is at risk to fall into the insufficient documentation error category, which has the potential to prolong payment or cause a denial.

Beware: Your claim could fall in this error category if the reviewer couldn’t conclude that some allowed services were actually provided at the level billed, or were medically necessary.

Here’s how to avoid insufficient documentation error for DME:

• Check  which DME Healthcare Common Procedure Coding System (HCPCS) codes require a valid detailed written order.
• Make certain the physician’s National Provider Identifier is on the valid detailed written order.
• Know that Medicare will pay claims for DME only if the ordering physician and DME supplier are actively enrolled in Medicare on the date of service.
• As a condition of payment, be sure that a physician, Physician Assistant, Nurse Practitioner documents a face to face encounter examination with a beneficiary in the 6 months prior to the written order for certain items of DME.

3. Document Confidently

When dealing with payment denials, you need to get up to speed on:

• Understanding the latest policies from major insurance carriers on pre – authorization requirements.
• Using the right modifiers to confirm you have the proper documentation needed for reimbursement.
• Comprehending advanced beneficiary notices for Medicare  and Commercial insurance carriers.
• Knowing what proof of delivery rules you should be following.

DME items are not professional services, your practice is purchasing the equipment in hopes that you will receive a profit in return. DME present a particular challenge when it comes to payment.

If you are audited and don’t have  proper documentation, your organization will have to give that money back and possibly be penalized. So it’s time to get your DME documentation ducks in a row.

Schedule a free demo to know more about on DME Medicare Documentation http://localhost/main-site-update/free-practice-analysis/

Medical devices manufacturers face unique challenges when compared to other equipment manufacturers. Not only do they face the product complexity, the demand for more variety by customers, the competitive pressures, and the downward price pressures; they also face the following unique complexities.

What is ERP?

Enterprise Resource Planning software works across many functions of the business.

For example, inventory. Purchasing orders from a vendor are created and sent electronically once products come in they will enter into the ERP so that all products are accounted for in real-time, and with their actual costs and bar, code systems keep the inventory up to date, so that products can be ordered on a just-in-time basis.

Benefits of ERP Software:

• Easy to comply and track all regulation and compliance requirements
• Improve life cycle management
• Complete product and component traceability, serial no., batch/lot, component
• Improved collaboration and relationship with the doctors, medical experts, engineers, and suppliers
• Ability to handle multiple planning models, configurations
• Lower costs and waste thru lean practices
• Flexibility in adapting products to specific customer wishes
• Better control over design changes
• Ease of doing business for the customer
• Insights into accurate product cost with full view and application methods
• Manage high-level receivables

ERP can bring the inventory into each individual delivery truck, enabling the truck drivers to track inventory and always have items on hand. In this way, ERP turns trucks into mobile warehouses, and drivers become responsible for their own inventory.

A second trip to deliver to a patient costs on average of $70. With an ERP system integrated into curbside, proper patient sizing, inoperative equipment, and compliance documents are complete and accurate.

When a customer service representative enters a customer’s information of all the critical elements maintained within the ERP system.

Once a customer profile is set up all the documentation are attached to that customer drastically increasing the efficiency on the billing operation, because the ERP is synced up with the billing and insurance information.

They can also tell customers if they have pending payments due, speeding the payment process.

Once the Patient responsibility is identified and credit card will be placed in a file automatically to collect the money when the claim is adjudicated.

If the patient cannot pay that amount on a single payment then a plan can be established at intake.

The billing team can instantly access billing records, reimbursement rates, and documentation for any individual claim. This allows them to immediately remedy problems before submitting for reimbursement.

The integration of the ERP means that the billing team has a much higher rate of accuracy when submitting claims because the system will tell them when a claim is incomplete, virtually eliminating denials based on incomplete claims.

Are you ready to see how powerful ERP software can benefit your business? Schedule your personalized, one-on-one demo http://localhost/main-site-update/live-demo/ today.

You have more control over the terms of your payer contracts than you realise (including how much you’re paid).  Knowing how you can get the highest return from payer contracts is essential to your practice’s success especially when you consider that about half of your revenue is most likely tied to your commercial payer contracts’ fee schedules.

When researching a Payer, particularly if your practice has not previously contracted with that Payer, you should consider the following questions:

⇒Which products does the Payer/medical group/IPA offer (i.e., HMO, PPO, ACO, POS, Medicare, Medi-Cal, ERISA/self-funded, Workers Comp, etc.

⇒What is the Payer’s market share in your area

⇒What is the total number of enrollees by product

⇒Is the Payer financially solvent?

⇒Are your referral sources participating?

⇒How many and what is the nature of patient complaints that have been filed against the Payer?

⇒Does the Payer have any plans for increasing the number of enrollees in your service area or for adding new products? (read their press releases)

⇒What is the average turnaround time on payment of claims?

Best Practices for Payer Contracting

Negotiating a new or preexisting contract with a Payer can be tough, but it doesn’t mean that your practice has zero chance of getting what it wants. 

The key is to go in prepared. With a few proven strategies, called 10 Best Payer Contracting Practices you can increase your reimbursement and receive more patient referrals with a little help and it doesn’t matter whether you’re a novice or an expert negotiator.

1. PREPARE:

Practice 1

• Know your insurer. Know your history with the insurer. Volume of your clients;
• Why the insurer should include birth centres in their network

Practice 2

Benchmark against Medicare and other payers with which you have contracts to identify areas where you may be under reimbursed compared to the market. Use the “20/80” rule.

Practice 3

S – Strength

W – Weakness

O – Opportunities

T – Threats

SWOT Analysis for your payer fee schedules: Look for opportunities to increase reimbursement for services that are not reimbursed at market competitive rates, and assess your charge master.

Practice 4

Who will contract on your behalf and who at the Insurer “Reach out to the person responsible in your region for facility contracting at a Payer. Who is that person?

Practice 5

Proposal “After the Initial email or contact, prepare a Proposal Letter and Rate Sheet.

 2. NEGOTIATE

Practice 6

Deliver highly impact proposal letter to a facility contracts manager at the payer. Have available data regarding your outcomes, birth centre outcomes, licensing, accreditation, etc.

 Practice 7:

More follow up, follow up again and again, and keep the payer in constant communication.

 Practice 8

Evaluate payer proposals and look for ways to optimise counter offers. If payer does not provide a proposal or counter proposal, don’t take first “No” as an answer.

Practice 9

Review contract for language that affects operations, including reimbursement.

 3. MONITOR

Practice 10

Monitor payments, identify reimbursement issues quickly and work closely with your payer representatives to resolve any payment issues as quickly as possible.

What is a Closed and Narrow Network?

A closed network is a payer network which currently has participating providers similar to you and, therefore, is not adding more similar providers, including you, to their network.

A narrow network means it has just a few participating providers of a certain type and are not looking to expand further.

How to differentiate your value

• Clinical Benefits leading to cost savings
• Product Advantages
• Service Advantages
• Geographic Coverage
• Referrals
• Out of Network Business, Book of business potential

Review contract for language that affects reimbursements

• Term and termination (90 days without cause)
• Use of non-par providers, e.g., ancillary services, anaesthesia
• Timely submission of claims
• Timely claims payments (30-45 days from receipt of claims)
• Claims Payment Adjustments: You are responsible vs. a withhold from future payments
• Retrospective review of over payments, 90 days maximum, 180 is usual, pay them vs. payer deducts automatically
• “Favoured Nation”‐ Never!

 Payer Market Fee Schedule or your billed charges

• Identify the top revenue producing codes which drive 80%+ of your revenue and compare payer’s fee schedule to your billed charges
• Compare the payer’s market fee schedule to local Medicare rates and to the weighted average rates of your commercial payer fee schedule for top codes
• Always make sure your billed charges exceed the highest rate of any payer contracted
• Rate for the same HCPCS or CPT code and it is best to set them at UCR thresholds
• Often these payer fee schedules are very low

Percent of Billed Charges

• This seems like it has no downside
• However, be aware of limitations such as “not >X% of Medicare”,
• Also, with complementary payers, if it is set too high this may prevent claims adjudication by the primary payer

Footnotes

If you’re tired of having to work harder and see more patients just to maintain your practice, then look at your payer contract could reveal ways to increase your income without increasing your workload. Follow the 10 Best Practices, in order (Prepare, Negotiate and Monitor), know your value proposition. Before you sign a contract, audit the contracts’ language even if you have not had operational problems and be aware of the types of fee schedule amendments and optimise them.

Speak to one of our experts today for Payer Contracting Questions, please phone us at +1(302) 613-1356 or write us to  support@wonderws.com

We look forward to hearing from you and are glad to provide information that helps you to run a more profitable practice.