Medicare Part B DMEPOS providers are required to abide by all Supplier Standards in order to obtain and maintain their billing privileges. In this webinar, Attorney Michael Silverman will explain each of the 30 DMEPOS Supplier Standards so that providers are further educated about compliance requirements.
On January 31, 2020 the US Department of Health and Human Services (“HHS”) declared a public health emergency surrounding the COVID-19 coronavirus pandemic, which was renewed again for a period of 90 days effective July 25, 2020.
In an attempt to focus on patients over paperwork and to remove obstacles from access to patient care, HHS relaxed or suspended certain healthcare provider requirements. Several such changes directly impact current or prospective providers of durable medical equipment (“DME”) to Medicare Part B beneficiaries.
Here’s a high-level breakdown of some of those changes:
Any Medicare enrolled DMEPOS supplier that desires to service a Medicare Part B beneficiary with any medical equipment or device that is included in Medicare’s Competitive Bidding Program.
WHAT (is competitive bidding and what DMEPOS supplies are covered)?
In a nutshell, it’s essentially this: if a DMEPOS supplier wants to service a Medicare Part B patient with any of the following medical supplies covered by Medicare’s Competitive Bidding Program, such supplier must submit and win a ‘bid’ to provide such item in each and every geographic region covered by the Competitive Bidding Program in which they wish to be able to service beneficiaries within.
Ever since the Centers for Medicare & Medicaid Services (“CMS”) announced its DMEPOS Competitive Bidding Program there has been outcry from both providers and consumers. Particularly with respect to Competitive Bidding for the National Mail-Order Diabetic Testing Supplies Program (“National Mail-Order Program” or “Program”), which took effect on July 1, 2013, there has been a concern about the Program’s sustainability and potential for negative implications to beneficiaries. This is largely due to the low reimbursement rates, as set by the bid winning providers, and the possible spillover effect to the Medicare Part B beneficiaries’ access to quality supplies and services. While CMS had safeguards in place when the Program was implemented, many of the regulations have gone largely unenforced. Change is on the horizon as CMS strives to better police its own Program, but is it too little, too late?
In 2011, prior to the implementation of the National Mail-Order Program, CMS tested Competitive Bidding for diabetic testing supplies in nine geographical regions. In these test markets, the payment rates for a vial of test strips were reduced from $34 to $14. CMS’ goal with Competitive Bidding is to reduce costs to the Medicare Trust Fund and beneficiaries, as well as to curb fraud, waste and abuse in the industry. Wanting to ensure that the intentions of the Program were being fulfilled without repercussions, CMS conducted a study on the nine geographical test regions. In its 2012 report CMS stated that there were no negative consequences to the beneficiaries as a result of the Competitive Bidding Program.
Providers need to comply with all the Medicare ‘red tape’ but need not let fear of non-compliance inhibit their practice from offering Durable Medical Equipment Prosthetics & Orthotics Supplies (“DMEPOS”) to Medicare beneficiaries.
Here’s an overview of the steps providers need to take to enroll as a supplier of DMEPOS with Medicare to be eligible for Part B coverage and reimbursement:
It’s that time again, when the OIG publishes its annual Work Plan for the coming year, providing insight and a proverbial “heads up” on the areas where potential concern and program integrity efforts are being focused. Many of the focus areas are ongoing or have been the subject of previous Work Plans, and come as no surprise. Nevertheless, it is important for practitioners to familiarize or reacquaint themselves with the 2013 Work Plan projects in order to recognize and prioritize compliance areas currently on the OIG’s radar.
Of particular interest for practitioners are the various OIG review projects involving ancillary services. For example, the OIG is looking at outpatient therapy services by independent therapists, and will focus on high utilization of physical therapy to determine if claims were reasonable, medically necessary and properly documented. Similarly, high-cost diagnostic radiological tests ordered by primary care and specialty physicians are being reviewed to determine whether utilization rates match industry practices. The OIG also will review Part B payments for imaging services with an eye towards determining if utilization rates reflect industry practices and if practice expenses components within payment rates are commensurate with costs incurred. Electrodiagnostic testing (needle electromyogram and never conduction) is a new area under review, particularly with respect to utilization rates by specialty, the concern being that such services are vulnerable to abuse and inappropriate financial gain.
Errors in billing and claims administration are also the subject of OIG review, with perennially recurring projects directed at incident-to services, place of service coding and E/M services. A 2009 OIG review of prior claims found that non-physician practitioners often were not properly supervised or that unqualified non-physician practitioners performed services, in each case, resulting in payments that were not compensable. Since Medicare payment for services in a non-facility setting, like a physician’s office, is often higher than in the rate that applies in other service locations, there is also concern over whether claims for Part B services performed in ASCs and Hospital outpatient departments were coded with the proper place of service. Another, more recent area of focus involves the documentation supporting E/M services and questions whether Electronic Medical Record documentation processes may result in “cloned” entries (and potentially improper claims) rather than a deliberate process of selecting proper codes based on content of actual service. Part B payment for chiropractic services are also being reviewed, with this area being the subject of ongoing OIG concern since chiropractic maintenance therapy being considered not medically necessary.
Apparently echoing a series of fairly recent OIG Advisory opinions, the 2013 Work Plan also identifies Polysomnography and Sleep Disorder Clinics as areas of potentially questionable billing patterns and possible overutilization. High utilization rates have also raised questions regarding whether services are duplicative of diagnostic testing performed previously by attending physicians. Another ongoing and increasing focus of OIG scrutiny is physician-owned distributors (POD) of high utilization orthopedic implant devices. The Work Plan for 2013 specifically identifies PODs which provide hospitals with spinal fusion implant devices as being under OIG review to determine if such arrangements are associated with high utilization.
These are just some of the many areas of OIG review with which practitioners and facilities alike should become familiar in order to remain current with the health care regulatory compliance curve.
Health law is the federal, state, and local law, rules, regulations and other jurisprudence among providers, payers and vendors to the healthcare industry and its patient and delivery of health care services; all with an emphasis on operations, regulatory and transactional legal issues.