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Medicare Suppliers: Nov. 15-Dec. 31 are Important Dates…You Need to Know Why

Posted on in Billing/Reimbursement

By Ronda Buhrmester and Dan Fedor, VGM Reimbursement Specialists

These dates should sound familiar for those dealing with the Medicare industry. It’s that time of year for open enrollment, which means if your company is currently enrolled as a participating supplier, now is the time to change your status to non-participating. Why is it important to consider changing your enrollment status? 

Enrolled as a participating supplier means that the supplier accepts the Medicare fee schedule and will bill all claims on an assigned basis.

Being enrolled as a non-participating supplier means there are options for the supplier to either submit the claim on an assigned basis or on a non-assigned basis. With the current reimbursement rates, having the option to bill as non-assigned is key in order to survive. Suppliers cannot continue to accept the cuts to reimbursement while still accepting assignment. Times have changed, and the good ol’ days of accepting assignment on every claim may need to be reconsidered in certain situations. 

What Holding a CBA Contract Means

If the supplier has the contract in a competitive bid area (CBA), the supplier must accept assignment on those items within the contract. However, this same supplier can be enrolled as non-participating and can submit claims as non-assigned for those items NOT included in the competitive bid. Some of those items that are not included with competitive bidding are:

  • Ostomy supplies
  • Urological supplies
  • Mastectomy products
  • High-frequency chest wall devices
  • Ventilators
  • And more

Suppliers located in a CBA that do not have a contract for CB items would not get reimbursed for CB items on any claim – assigned or non-assigned. If the beneficiary chooses to use a non-contracted supplier and waive their Medicare benefits, the item would be a cash transaction. In such a case, the supplier should make sure to use an ABN (option 2).

The enrollment status follows the tax ID. For example, most hospital systems are under the enrollment status of the hospital, which is participating. In order to change to non-participating status, the hospital-based HME supplier would have to get a separate tax ID.

Myths that Still Exist

Check out these myths that still exist within the industry:

  1. A participating supplier gets reimbursed at a higher rate? False. This applies to physician services, not DMEPOS suppliers.
  2. There are many advantages to being enrolled as a participating supplier. False. The only reward for being enrolled as a participating supplier is getting listed in the supplier directory!
  3. On non-assigned claims, there is a limiting charge to the beneficiary. False. There is not a limiting charge for DMEPOS suppliers.
  4. For any rental equipment being submitted for payment each month as non-assigned, the supplier cannot charge the beneficiary until the AOB (payment authorization) has been received. False. There are two separate transactions on non-assigned claims with rental equipment. One is the charge to the beneficiary that can still occur even if the AOB has not been signed by the beneficiary for that particular month. The other transaction is the claim can be submitted once the AOB has been signed by the beneficiary and returned to the supplier.
  5. With non-assigned claims, there is not any liability for the suppliers. False. Actually, the liability still exists with that claim. It does not matter if the claim is being submitted as assigned or non-assigned; the supplier can still get a denial and still get an audit on a non-assigned claim.

Here’s What to Do to Change Enrollment Status

If your company is considering changing its Medicare enrollment status to non-participating, use your company letterhead stating that the enrollment status is changing to non-participating for January 1, 2018, and include your supplier number, NPI, and tax ID along with contact information.

Do know that once January arrives, this does not mean changes have to be made immediately. The current business model can continue as is, then changes can be made at any time.

Keep in mind, open enrollment occurs ONLY during the period of Nov. 15–Dec. 31 of each year.   

For any questions please reach out to your reimbursement team.

Ronda Buhrmester
ronda.buhrmester@vgm.com
217-493-5440

Dan Fedor
dan.fedor@vgm.com
570-499-8459