AMARILLO, TX – Earlier this year, in the Medicare Quarterly Provider Compliance Newsletter issued by CMS, the topic of coverage for DMEPOS furnished to inpatients was addressed. This came on the heels of a report issued by the OIG at the end of 2018 about the extent of improper payments made by CMS for DMEPOS furnished to beneficiaries during an inpatient stay in a hospital or other similar facilities.
OIG’s report states that it detected $34 million in improper Medicare Part B payments to DMEPOS suppliers for 120,614 claims for DMEPOS items furnished to beneficiaries during inpatient stays. With this in mind, let’s review the rules related to DME and beneficiaries admitted to facilities as inpatients.
Medicare Part A pays Acute Care Hospitals, Long Term Care Hospitals, Inpatient Rehabilitation Facilities, Inpatient Psychiatric Facilities, and Critical Access Hospitals using a variety of methodologies. These include the Inpatient Prospective Payment System, the Prospective Payment System, and the Reasonable Cost Basis. The amounts paid to the facilities under each of these Part A payment methodologies, however, is considered payment in full for all of the products and services furnished to a Medicare beneficiary during an inpatient stay—including any DMEPOS items furnished to the beneficiary.
If a beneficiary needs an item of DMEPOS during an inpatient stay, the facility must furnish the item or arrange for a supplier to furnish the items. If arrangements are made for a supplier to furnish the item, the facility will pay the supplier and include the item on its claim or report to Medicare. Medicare does not make any separate payment for the furnished items.
But there are some cases when it is appropriate for a DMEPOS supplier deliver an item to a beneficiary who is still an inpatient at one of the Part A facilities. Medicare will pay for an item delivered before a patient is discharged when the following conditions are met:
- The DMEPOS supplier delivers the item to the beneficiary solely for training or fitting of the item, and the item is for subsequent use in the beneficiary’s home;
- The beneficiary is being discharged to a place of service that qualifies as the beneficiary’s home and not to another inpatient facility or Skilled Nursing Facility;
- The supplier may deliver the item no earlier than two days before the beneficiary’s discharge date;
- The supplier must not furnish the item in order to eliminate the inpatient facility’s responsibility to furnish it; and
- The supplier may not submit a claim to request payment for the item until after the facility discharges the beneficiary.
Remember these limitations and requirements when working with facilities and their discharge planners to furnish items to beneficiaries before they are discharged from an inpatient stay.
AAHOMECARE’S EDUCATIONAL WEBINAR
Managed Care Contracts: How to Negotiate and How to Access Another Supplier’s Contract
Presented by: Jeffrey S. Baird, Esq., Brown & Fortunato, P.C.
Tuesday, November 19, 2019
2:30-3:30 p.m. EASTERN TIME
At the end of the day, DME suppliers primarily serve the elderly (Medicare) and those on the lower end of the socio-economic scale (Medicaid). Both the Medicare and Medicaid programs are gravitating towards “managed care.” Approximately 35% of Medicare beneficiaries are signed up with Medicare Advantage Plans, while approximately 70% of Medicaid beneficiaries are signed up with Medicaid Managed Care Plans. These percentages are increasing. Medicare and Medicaid Plans work essentially the same way: (i) the government health care program contracts with a “Plan” that is owned by an insurance company; (ii) the Plan signs up patients; (iii) the Plan signs contracts with hospitals, physicians, DME suppliers and other providers…these providers will take care of the Plan’s patients; and (iv) the government program pays the Plan that, in turn, pays the provider.
Increasingly, DME suppliers will be asked to sign managed care contracts. In so doing, the supplier needs to be careful. Not only must the contract provide sufficient reimbursement to the supplier, but the contract will have some “trap” provisions that may be harmful to the supplier. This program will discuss the most important provisions that are contained in managed care contracts. The program will discuss how the supplier can negotiate with Plans; and the discussion will point out the provisions that are often non-negotiable and the provisions that are open to negotiation.
Register for Managed Care Contracts: How to Negotiate and How to Access Another Supplier’s Contract on Tuesday, November 19, 2019, 2:30-3:30 p.m. ET, with Jeffrey S. Baird, Esq., of Brown & Fortunato, PC.
AAHomecare’s Retail Work Group
The Retail Work Group is a vibrant network of DME industry stakeholders (suppliers, manufacturers, consultants) that meets once a month via video conference during which (i) an expert guest will present a topic on an aspect of selling products at retail, and (ii) a question and answer period will follow. The next Retail Work Group video conference is scheduled for November 14, 2019, at 11:00 a.m. Central. Lisa Wells of Cure Medical and Jenn Wolff, a disability advocate and end-user, will present “Learning the Voice of the Customer/End User with Disabilities.” Participation in the Retail Work Group is free to AAHomecare members. For more information, contact Ashley Plauché Manager of Government Affairs, AAHomecare (email@example.com).
Todd A. Moody, JD, is an attorney with the Health Care Group at Brown & Fortunato, PC, a law firm based in Amarillo, Texas. He represents pharmacies, infusion companies, HME companies and other health care providers throughout the United States. Moody can be reached at (806) 345-6332 or firstname.lastname@example.org.