AMARILLO, TX – Providing oxygen will always be an important part of the DME industry. The reason is simple: DME suppliers furnish products and services to people who need them to function on a daily basis. Normally, the people who need such products and services are the elderly.
Gone are the days when DME suppliers would provide an oxygen concentrator to a patient and would receive rental payments from Medicare for the duration of the patient’s life. Now, the supplier is required to furnish the concentrator for five years…but will receive rental payments only for the first three years.
A common question arises: Are there scenarios in which the DME supplier can restart the 36 month rental period? The answer is “yes.” This three part series of articles will discuss when the 36 months can start over:
- Part 1 – After the Five Year Reasonable Useful Lifetime (“RUL”) Has Expired, Specific Incident of Damage Beyond Repair, or the Item is Stolen or Lost
- Part 2 – During the 36 Month Cap Period After a 60 Day (Plus) Break in Medical Need
- Part 3 – Abandonment of Oxygen Patients, Oxygen Patients of a Closed DME Supplier, and Oxygen Patients of a Bankrupt Supplier
During 36-Month Cap Period After 60-plus Day Break in Medical Need
If a Medicare beneficiary enters a hospital or skilled nursing facility (“SNF”), or joins a Medicare Advantage Plan, and continues to need/use oxygen during that period, when he returns home or rejoins Medicare fee-for-service (“FFS”), then payments resume where they left off. During the 36-month rental period, if the patient’s need for oxygen equipment ends but then resumes sooner than the remainder of the rental month of discontinuation plus 60 days, rental payment resumes where it left off.
If there is an interruption in medical necessity of greater than 60 days plus the days remaining in the last paid rental month, once the need for oxygen resumes, the supplier will need to collect supporting documentation of the new medical need including, but not limited to:
- New detailed written order (written order prior to delivery, if required)
- New Initial CMN (with new qualifying oxygen test results performed within 30 days of new initial date)
- Documentation supporting new medical need
- Documentation explaining interruption of need
- Documentation supporting length of interruption (e.g., pick up date, new delivery date)
The beneficiary must be seen and evaluated by the treating physician within 30 days prior to the Initial Date. The claim for the first month the new oxygen rental meeting the above documentation requirements should include:
- New Initial CMN
- Narrative statement, “Break in medical need greater than 60 days.”
During Months 37 – 60
During months 37-60, if the need for oxygen ends for more than 60 days plus the remainder of the rental month of discontinuation and new medical necessity is established, then a new rental period does not begin. The supplier that provided the oxygen equipment during the 36th rental month must continue to provide all necessary items and services for the duration of the 60-month reasonable useful lifetime.
Written Order Prior to Delivery (“WOPD”) and Face-to-Face Requirements
E0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443 require an in-person or face-to-face interaction between the beneficiary and his treating physician prior to prescribing the item, specifically to document that the beneficiary was evaluated and/or treated for a condition that supports the need for the item ordered. A dispensing order is not sufficient to provide these items. A WOPD is required. A new face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required by Medicare:
- For all claims for purchases or initial rentals
- When there is a change in the prescription for the accessory, supply, or drug
- If a local coverage determination (“LCD”) requires periodic prescription renewal (i.e., the policy requires a new prescription on a scheduled or periodic basis)
- When an item is replaced
- When there is a change in the supplier
- When required by state law
The face-to-face examination must be within six months prior to the date of the WOPD.
Jeff Baird will present the following webinar:
AAHOMECARE’S EDUCATIONAL WEBINAR
How the DME Supplier Can Work With an Accountable Care Organization (“ACO”)
Presented by: Jeffrey S. Baird, Esq., Brown & Fortunato, P.C. & Rossanna J. Howard, Esq., Brown & Fortunato, P.C.
Tuesday, November 13, 2018
2:30-3:30 p.m. EASTERN TIME
The Cleveland Clinic. It is a model that many point to when they talk about the future of health care delivery. The Cleveland Clinic uses a team approach with the goal of solving the problem and keeping the patient healthy. Unnecessary tests are not part of The Cleveland Clinic approach. So what does this have to do with ACOs? Created by the Affordable Care Act, the goal of the ACO is to “take ownership” over a patient base. The ACO strives to provide health care in a cost-effective way, avoid unnecessary tests, use a team approach, and keep patients healthy. The ACO is made up of hospitals, physicians, and other health care providers. The ACO will be influential in the decisions that patients make regarding what health care providers they will use. This program will discuss what an ACO is, how it is formed, and what it does. Equally as important, the program will discuss the role that the DME supplier can take in the implementation of the ACO model.
Register for How the DME Supplier Can Work With an Accountable Care Organization (“ACO”) on Tuesday, November 13, 2018, 2:30-3:30 p.m. ET, with Jeffrey S. Baird, Esq. and Rossanna J. Howard, Esq., of Brown & Fortunato, PC.
FEES: Member: $99.00; Non-Member: $129.00
Jeffrey S. Baird, JD, is chairman of the Health Care Group at Brown & Fortunato, PC, a law firm based in Amarillo, Tex. He represents pharmacies, infusion companies, HME companies and other health care providers throughout the United States. Baird is Board Certified in Health Law by the Texas Board of Legal Specialization, and can be reached at (806) 345-6320 or firstname.lastname@example.org.