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On Dec. 8, many providers and industry stakeholders tuned into the CIGNA “Ask the Contractors Teleconference” (ACT) that addressed the new oxygen regulations. CMS’ Joel Kaiser joined listeners on the call to offer clarification. While guidance was offered in several areas, many providers left the conference with more questions than answers in key areas.
The call began with a CIGNA representative providing a brief summation of oxygen provision set forth by MIPPA through CMS-1403-FC. The summation provided much of the same clarification that many have seen through the recent MLN Matters article. To view the article, click here.
The brief summary was followed by a lengthy question-and-answer session where CMS’ Joel Kaiser joined to offer clarification to many of the providers’ questions and concerns. One provider offered the following scenario to Kaiser: A provider has a patient that has capped, and is therefore required to continue to provide maintenance, supplies and contents to that patient for the reasonable useful lifetime of the equipment (60 months). The patient moves to a state that (a) is out of the normal coverage area of the original provider and (b) requires licensure in order to provide oxygen. This caller used Tennessee as an example. The question to Kaiser was, “how is a provider to be expected to provide oxygen and maintenance to a patient residing in a state where, by law, that provider cannot provide oxygen?” Kaiser responded by stating that current legislation requires that the provider who supplied to the patient at month 36 must continue to supply oxygen, maintenance and supplies for the reasonable useful lifetime of the equipment. He commented that the law is the law, and urged that, if there is an issue with legislation, providers should contact their Congressmen and provide comment. VGM agrees and urges providers to contact their legislators.
Below is a summary of paraphrased questions and answers provided during the teleconference:
Q: New regulations state that a supplier is responsible for servicing and contents if the patient moves. How will reimbursement work if a new provider is found in the new area?
A: You may contract with a provider in the new area and do the billing yourself or find a provider willing to take on the patient and do the billing him/herself.
Q: What about the fact that companies will be unlikely to accept such contracts for a maintenance fee and contents payments?
A: We expect this issue to arise and note the fact that CMS does welcome comments regarding moving patients…particularly those moving post-36 months.
A: Joel Kaiser: CMS has discussed this. The law very clearly mandates that the original supplier must continue to furnish maintenance and contents, no exceptions. There are different things the supplier might do, such as: provide stationary concentrators in the beginning, provide tubing and cannulas through the mail, contract with a new supplier, and work with a new supplier to set up patients with the new supplier to furnish and bill. CMS believes the supplier is paid up front (during the first 36 months) for 60 months of responsibility. There are no exceptions for patients who elect to relocate after they have capped. Kaiser did again note CMS’ welcoming of comments on this issue.
Q: Regarding reasonable useful lifetime…how does swapped-out equipment affect this? Is the 60 months tied to original delivery date or each piece of equipment?
A: Joel Kaiser: This issue has come up, but has not been specifically addressed. CMS will provide additional clarification in the very near future through either a MedLearn Matters article or through a Web posting. CMS acknowledges that this is a very important issue, but is not willing to comment directly on this at this time.
Q: How about equipment provided prior to 1/1/03? The supplier may provide new equipment immediately, and continue to bill. What documentation is necessary? New prescription? New CMN?
A: Joel Kaiser: We will provide guidance in very near future, but do not have immediate comment.
Q: CMS currently allows for billing for one unit of monthly fill (when applicable) after 36 months. What about adjustments for high or low liter flow amounts?
A: Joel Kaiser: Adjustments up or down for usage does not apply to contents payments. One payment for the monthly delivery and is not tied to post-36 month content payments. Adjustments only apply to pre-36 month oxygen equipment payments.
Q: What about a post-36 patient who is unwilling or unable to pay co-payment? Must the supplier continue to supply contents, maintenance and suppliers, even in this event?
A: Joel Kaiser: The law requires the supplier to continue supplying all of the above, and take up co-payment issues with the patient directly.
Q: Some suppliers’ accreditation may require a 90-day concentrator check. Now CMS says they only pay once per six months once the patient has capped. Has something changed?
A: No. You must do what your accreditation requires but will only be paid once per six months for such routine maintenance checks.
Q: Patients often leave Medicare coverage for an HMO and, after a significant break (six months in this example) return to Medicare coverage. In this event, does original supplier have to take the patient back?
A: Joel Kaiser: “Continuous use” only applies if the break in service is less than 60 days. If it is more than 60 days it is no longer a considered a “temporary interruption.” It is now considered a break in continuous use and the supplier is no longer required to take the patient back. That patient, however, will begin a new 36-month rental period.
Q: Liquid vs. Gas contents. CMS has decided contents payments would be the same for both. Is this the case?
A: Joel Kaiser: The $154.90 amount is for payment for both liquid and gas concurrently. Liquid payments are $77.45 and gas contents payments are $77.45. The higher payment is made only when both are delivered, or in the event that the patient is using liquid for both stationary and portable. If this is the case, you may bill for both ($154.90) liquid contents payments. In any event, payment for each of these scenarios includes delivery.
Q: May we bill for contents even if we don’t physically show up for delivery that month?
A: Joel Kaiser: As long as the patient has the contents they need and you’ve delivered them at some point, you may bill for contents each month. You may elect to only deliver to the patient every third month with three month’s contents. You would still have the ability to bill for each month’s contents. It is not necessary that you see the patient every month.
Q: If a supplier takes an oxygen patient from another area who has been on Medicare oxygen for 20 months, will that supplier be reimbursed for the remaining 16 months? Who is responsible for the patient?
A: Joel Kaiser: The original supplier is not obligated for the moving patient when the patient moves prior to capping, and the new supplier would get 16 months payments.
Q: May the provider provide the maintenance any time during the six-month period, or must it be six months after the previous maintenance billing?
A: Joel Kaiser: The intent is that the payment is made for the supplier to check the equipment six months later to make sure all is working. The supplier is tied to a definitive timeframe; not just any time during the six-month time period.
Q: Does a portable concentrator cap even though there are no contents payments?
A: Yes.
Q: Does maintenance and service apply only to concentrator?
A: Yes
Q: So we will be able to continue to bill for portable?
A: Contents only, when applicable. Not for portable concentrators.
Q: Medicare oxygen guidelines state that portability is provided for ambulation within the home. How many tanks must a supplier provide a patient who uses a significant amount of oxygen outside of the home to “go play bingo?”
A: Joel Kaiser: The responsibility of provider is to provide oxygen to get up away from their concentrator. There is no limit to how far the patient may go from their concentrator. You must provide oxygen that allows them do be portable, even if it means going “to bingo.” Nothing has changed. Suppliers must continue the same quantities of oxygen contents as they have in the past. New payment rules will not allow providers to begin withholding contents. We (CMS) had not heard issues regarding quantities in the past, and don’t expect to now that payment rules have changed.
Q: Some states are restricted due to state licenses? How must I provide to a patient that moves to a state where I cannot provide, because of licensure law?
A: Joel Kaiser: The law requires you to continue providing. There are no exceptions to this rule. The law does not state that you must physically provide it. Write to your local Congressperson with your concerns if you’d like, but the law is the law.
Q: Is there any consideration for high-usage patients for portable contents?
A: Joel Kaiser: Some patients will cost more than normal, and some will cost less than normal. Medicare payments are not tied to quantity. You are paid one monthly fee to provide a ‘service.’ It’s designed to all even itself out.
Q: How long may a provider bill portable for oxygen contents post-36 months? Might they bill for 10 years?
A: Joel Kaiser: Yes, you may bill contents for as long you are providing them. If, however, the beneficiary elects to receive new equipment at the end of the reasonable useful lifetime, then you’d begin billing for the equipment and not contents.
Q: At month 37, when a provider discontinues billing for the portable equipment and begins billing for contents only, is a CMN required?
A: No.
Q: Who is responsible for establishing the new provider if a patients moves prior to capping? Is it the provider or patient?
A: Both. The provider should assist in finding a new supplier.
Q: If we switched a patient’s modality in the last three years, does the 36-month period begin?
A: Joel Kaiser: DRA prohibits supplier from switching modalities unless it is physician ordered or the patient elects to upgrade (and signs an ABN).
Q: We saw some literature about using ABNs for high usage patients post-36 months. Is that legal?
A: Joel Kaiser: No, and CMS did not provide any such literature. The literature is ‘erroneous.’
Q: Nobody has mentioned much about accepting assignment and ABNs. Suppliers are also discussing getting rid of capping patients. May a non-assigned provider drop a patient if they do not take the 36th month?
A: Joel Kaiser: The provider who takes payment for month one must continue to provide through the reasonable useful lifetime per DRA/MIPPA. The only exceptions would be for moving patients or patients who elect to find a different provider.
Also, Joel even acknowledged that providers exiting the oxygen business are still required, BY LAW to continue providing to existing patients. They may choose to take no new patients, but must continue to furnish to existing patients.
VGM encourages providers to review comments and contact their legislators. To obtain your legislators’ contact information, visit the VGM DC Link by clicking here. For more information on how to contact your Congressional members, see the Legislative Update from Dec. 8.
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