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Important News for DMEPOS Jurisdiction C and D Suppliers

Posted on in Billing/Reimbursement

By Ronda Buhrmester and Dan Fedor, VGM Reimbursement Experts

Recently, C2C Innovation Solutions, the second level of appeals, shared updates with the supplier community. 

Let’s start with a little bit of a background. C2C began a Formal Telephone Demonstration project in January 2016 that consists of two phases in Jurisdiction C and D only for diabetic testing strips and oxygen equipment.

The first phase has allowed suppliers the opportunity to participate in a formal recorded telephone discussion with C2C and offer verbal testimony. The DME suppliers discuss the facts of their cases and provide any additional documentation that would assist in reaching a favorable determination.

The second phase of the demonstration is with reopenings. C2C will be able to look at those claims found unfavorable or partially unfavorable that are in the ALJ. They can only go back to January 1, 2013, which is the C2C decision date on the letter, not the date of service. C2C will open up only those claims that they feel can be overturned to a favorable decision. Don’t worry, will not lose your place in line at the ALJ if they don’t see where the claim can be found favorable.

Remember: these current phases have been only for oxygen equipment and diabetic testing strips in Jurisdiction C and D.

It Starts with a Letter to the Supplier

For both phases of this demonstration, selected suppliers receive a letter that invites them to a scheduled phone discussion. The supplier has 14 days to respond to the letter. The discussion can be about technical issues or medical necessity, meaning if something is missing or can be obtained easily by the supplier, this can be accomplished during the discussion with the reviewer. 

Instead of the 60-day timeframe, if the appeal was selected for this demonstration, there is a 120-day timeframe to allow for scheduling, the discussion to take place, additional documentation to be submitted and to review the testimony and additional documentation that was received through the discussion process.

C2C has stated that, because the demonstration started with the formal telephone discussions, there have been 16,000 letters mailed and 9,000 telephone discussions have been held with an 80 percent favorable decision rate for the suppliers.

Reopenings reviewed over 366,000 potential reopening claims and worked with the ALJ on either reopening or having to withdraw from the ALJ approximately 45,000 claims.

Is the Demonstration Being Expanded to Other Areas?  

YES! All other DME areas are being implemented in phases with all areas to be included by March 17, 2017:

  • January 17: Hospital beds, enteral/parental, nebulizers and drugs, ostomy, urological, PAP and therapeutic shoes for diabetes
  • February 17: Orthotics, miscellaneous drugs, negative pressure wound therapy, pneumatic compression devices, repairs
  • March 17:  Manual wheelchairs, power mobility devices and complex rehab (except in Pennsylvania), infusion pumps, prosthetics, surgical dressings and other miscellaneous respiratory drugs

Have Claims at the ALJ or C2C? Here’s What You Can Do

If you currently have claims at the ALJ for any product category, you can request the C2C to review for a possible reopening, and you can do this now. Go to www.C2Cinc.com, where you will find a form to complete. If you have a large volume sitting at C2C or ALJ, let us know so you can be connected with someone at C2C, and they will let you submit a spreadsheet instead of completing forms for each individual case. If they cannot reopen the claim, you will not lose you place in line at the ALJ. 

Also, if you are submitting a claim for first-time reconsideration and you would like a formal telephone discussion, write this on the reconsideration form. C2C will take this into consideration.

An important note: C2C uses the contact information submitted with the appeal letter. Make sure all of your staff is aware of this information. The reason is there has been concern with some suppliers’ lack of response to the letter and to telephone calls from C2C. This is a good opportunity for suppliers, especially those that have many claims pending at reconsiderations and at the ALJ. If you miss the deadline for the telephone discussion, you will be going through the standard reconsideration process.  This is important to know because under the demonstration project, the C2C contractor is allowed to be more flexible with the coverage criteria and regulations. Outside of the demonstration project, going through the standard reconsideration process, the normal medical policies, rules and regulations apply.

Jurisdiction A and B Suppliers Can Request Project Expansion

Suppliers in jurisdiction A and B are considered a control group for this demonstration. However, requests can be submitted for CMS to consider opening up this project to your jurisdictions. What you need to do is email C2C with the request to expand it to Jurisdiction A or B. Send the requests to dmepdfeedback@c2cinc.com. Suppliers in Jurisdiction A and B: Send in your requests!!

Check out the C2C Innovation Solutions website for information. Let us know if you have any further questions. 

Ronda Buhrmester, CRT, CFm

ronda.buhrmester@vgm.com

888.665.6518     

Dan Fedor

dan.fedor@vgm.com

844.794.8459