AMARILLO, TX – Medicare site visits can be challenging and stressful for DME suppliers. It is not uncommon for a supplier to fail a Medicare site visit because it did not have documentation readily available or because its personnel were not prepared. A failed site visit will prevent a DME supplier’s receipt of a PTAN, and it can lead to the revocation of an existing PTAN.
To obtain and maintain a PTAN, DME suppliers undergo a site visit to demonstrate compliance with the Supplier Standards located at 42 C.F.R. § 424.57(c). Site visits are completed by the National Site Visit Contractors (“NSVCs”). During a site visit, NSVCs collect information to determine compliance with the Supplier Standards. The site visit includes an interview of a designated employee, a request to view patient files, a request for copies of relevant documents, pictures of inventory, pictures of the interior and exterior of the building, and signature of a visit acknowledgement form.
NSVCs use Form Number CMS-R-263 to verify compliance with the Supplier Standards during site visits. The primary function of the form is to provide a standardized, uniform tool to gather information to determine if a supplier is qualified to be a Medicare DME supplier. The form addresses an inspector’s reason for the site visit, required facility information, the employee interview, licensing/certification, records, phones, and contact with beneficiaries. CMS is currently updating the DME inspection form through a notice to collect information. Final public comments are due on September 20, 2024, and the updated form will likely be effective by late November of 2024, subject to final approval. The proposed updated form does not change the Supplier Standards, but it includes requests for information that were not included on the previous inspection form, including the following non-exhaustive list of questions:
- Does the supplier accept returns of substandard … or unsuitable items … from beneficiaries? (42 CFR 424.57(c)(15))
- Does the supplier maintain proof of delivery of items furnished to beneficiaries? (42 CFR 424.57(c)(12))
- Does the supplier have a written/electronic complaint policy/procedure established? (42 CFR 424.57(c)(19))
- Does the supplier have a written/electronic document for logging complaints? (42 CFR 424.57(c)(13) and 42 CFR 424.57(c)(20))
- Does the supplier have a business phone number (other than a cellular phone) listed in a local phone directory under the business name? (42 CFR 424.57(c)(9))
The proposed updated form indicates the intent of CMS to enforce all of the Supplier Standards, and it is a reminder to suppliers to be prepared for thorough site visits. Almost every question on the form includes a requirement for the inspector to attach a copy of a document, describe compliance or lack thereof, or to photograph evidence of the lack thereof. Suppliers should not leave it to an inspector to request information, required by the inspection form, that is needed to demonstrate compliance with the Supplier Standards. Rather, suppliers should be prepared ahead of time to provide that information to an inspector upon his or her arrival. A supplier’s failure to prove compliance with a Supplier Standard, even if it is because an inspector failed to request proof of compliance, commonly leads to the denial or revocation of a PTAN.
Suppliers should use the updated form to strengthen their Medicare site visit readiness, and to avoid the common challenges of site visits. By making use of the form before a site visit, suppliers can prepare needed information to demonstrate compliance with the Supplier Standards and to educate their personnel on what to expect before encountering difficulties. The alternative is to submit second or third enrollment requests or be required to show compliance with the Supplier Standards through a corrective action plan or a reconsideration request. These alternatives cost time and money and can be avoided with prior planning.
Jeffrey S. Baird, JD, is Chairman of the Health Care Group at Brown & Fortunato, PC, a law firm with a national health care practice based in Texas. He represents pharmacies, infusion companies, HME companies, manufacturers and other health care providers throughout the United States. Mr. Baird is Board Certified in Health Law by the Texas Board of Legal Specialization and can be reached at (806) 345-6320 or [email protected].
Jordan T. Vogel, JD, is an attorney with the Health Care Group at Brown & Fortunato, PC, a law firm with a national health care practice based in Texas. He represents pharmacies, infusion companies, HME companies, manufacturers and other health care providers throughout the United States. Mr. Vogel can be reached at (806) 345-6351 or [email protected].
AAHOMECARE’S EDUCATIONAL WEBINAR
Billing Nonassigned: Steps to Replace Lost Income
Presented by: Jeffrey S. Baird, Esq., Brown & Fortunato & Noel Neil, ACU-Serve
Tuesday, October 15, 2024
1:30-2:30 p.m. CENTRAL TIME
DME suppliers, like other health care providers, are being squeezed by traditional Medicare and Medicare Advantage (“MA”). In the traditional Medicare space, an example of this is the loss by DME suppliers of the 75/25 blended rates. To offset, at least in part, the decrease in reimbursement from traditional Medicare, DME suppliers should look seriously at billing traditional Medicare beneficiaries on a nonassigned basis. The movement to billing nonassigned is aided by the willingness of aging Baby Boomers to pay cash for “Cadillac” products, as opposed to being relegated to accepting “Cavalier” products when the DME supplier takes Medicare assignment. Billing nonassigned means that the Medicare beneficiary pays cash up front to the DME supplier and is directly reimbursed by Medicare. This program will discuss the multiple issues arising out of billing on a nonassigned basis, including the following: (i) What does it mean to bill non-assigned? (ii) If the supplier bills an item nonassigned, can the supplier set the price without limitation? (iii) Must the supplier submit a claim to Medicare so that the beneficiary can be reimbursed? (iv) Can the supplier sell a capped rental item for cash? (v) Does the supplier need to obtain documentation supporting medical necessity? (vi) Is the supplier at risk of having to repay Medicare and/or the beneficiary in the event of a subsequent audit?
Register for Billing Nonassigned: Steps to Replace Lost Income on Tuesday, October 15, 2024, 1:30-2:30 p.m. CT, with Jeffrey S. Baird, Esq. and Noel Neil.
Members: $99
Non-Members: $129
