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From Dan Fedor: Being PAR Puts You in a Hazard

Posted on in Billing/Reimbursement

By Dan Fedor, U.S. Rehab Reimbursement Specialist

No, not as in a water hazard or a sand trap on a golf course, but a hazard to your business! Yes, if you are listed as a participating provider with Medicare, you may be putting your business in a hazard of losing money every time you serve a Medicare beneficiary. The reason is, when you are PAR, you must accept assignment (the Medicare allowable fee schedule) every time you accept a Medicare beneficiary. And with the current fee schedule, you may be losing money!

Let's not settle for PAR; let's avoid that hazard and enable your company to have the choice to accept assignment ONLY when you can, and thrive like an eagle! 

Below is a recent Q & A from Noridian DME MAC D regarding PAR and non-PAR

Q: What should the supplier do if they no longer want to remain a participating supplier?

A: If the supplier is currently a participating supplier and wishes to change their status to a non-participating supplier for the next calendar year, they need to submit a written request to the National Supplier Clearinghouse (NSC). This request must be on company letterhead, contain the organization's tax ID, and be signed by the authorized or delegated official on file with the NSC. This request must be sent to the NSC by Dec. 31 of the current year in order for it to take effect for the following calendar year.

Q: Can a non-participating supplier change the assignment on a claim-by-claim basis?

A: A non-participating supplier may choose to bill the claim as "assigned" on a claim-by-claim basis with a few exceptions. Section 114 of the Benefits Improvement and Protection Act of 2000 (BIPA) states that all drugs and biologicals must be billed as assigned. Bid-winning suppliers in competitive bid areas must accept assignment on all equipment category claims where a competitive bid contract is held. Non-contract suppliers must accept assignment on all competitive bid items (e.g., claims for traveling beneficiaries or grandfathered items). Medicare also requires claim assignment for all dual eligible QMB beneficiaries (beneficiaries entitled to benefits from both Medicare and Medicaid).

Q: Is there a limit on how much a supplier can charge on non-assigned claims?

A: The "limiting charge" does not apply to DMEPOS items because they are not paid under the Physician Fee Schedule where the "limiting charge" concept is applicable. The assignment decision only binds the supplier to the DME fee schedule as payment in full; it does not impact in any way the usual and customary billed amounts that a supplier submits on their claim. The supplier should have consistent, usual, and customary charges that are billed to retail and non-retail customers. In a non-assigned claim transaction, the supplier will collect their usual and customary charge (and will not be bound to the Medicare DMEPOS Fee Schedule). Medicare cannot issue any guidance on usual or customary charges.

For non-assigned claims, Medicare will remit payment (based on the Medicare fee schedule) directly to the beneficiary. Because payments will be made to the beneficiary and not to the supplier, a supplier who chooses not to accept assignment of Medicare benefits is not considered a party to the claim.

Q: Does a supplier need to get a beneficiary authorization signed for each claim?

A: Once the supplier has obtained the beneficiary's one-time authorization, later claims for those same services – either assigned or non-assigned – can be filed without obtaining an additional signature from the beneficiary. Any supplier using the one-time authorization procedure agrees to the following:

  • Authorization must be renewed if a new item is rented or purchased.
  • Retain the signed and dated one-time payment authorization form in the supplier's file.

The one-time authorization applies to assigned and non-assigned claims with the exception of DME rentals. The one-time authorization for DME rental claims is limited to assigned claims. For non-assigned DME rentals, the supplier must get a beneficiary authorization signed prior to billing each rental claim. Without a specific authorization, the supplier would be unable to bill the rental claim to the fee-for-service Medicare program.

Q: Can all claims, whether billed as assigned or non-assigned, be audited?

A: Yes! Claim assignment has no bearing on audits. Pre-payment and post-payment audits can occur for any claim, regardless of whether it was originally billed as assigned or non-assigned.

Please join me for a FULL DAY of reimbursement training (5 hours/0.5 CEUs) at a VGM Breaking Bad Seminar near you! Click here for more details and to register.

Dan Fedor
VGM Group, Inc.
Proud Employee Owner
O: 844-794-8459
C: 570-499-8459
E: mailto:dan.fedor@vgm.com
F: 844-307-5729