Member Q&A: Billing, Reimbursement, and Documentation

Published in Member Communities on December 04, 2019

Below are a series of questions focused on billing, reimbursement, and documentation topics that U.S. Rehab Director of Reimbursement and Education, Dan Fedor, has recently encountered. An expert in all things related to mobility documentation, billing, and reimbursement, Dan Fedor provides his insight below to some hot topics facing the CRT industry, including ATP scribing, modifiers, and Medicare Advantage versus Original Medical Fee for Service (FFS). 

Is it acceptable for the supplier’s employed ATP to act as a scribe for the LCMP during the specialty evaluation? 

This practice is not acceptable as there is an inherent conflict of interest since the supplier and LMCP can’t have any financial relationship. By scribing for the LCMP, this provides something of value (in kind) which violates the LCD. This can also lead to a possible Anti-Kickback violation. 

Below is the joint response from DME MACs:  

This is not an acceptable practice. For the LCDs with LCMP evaluation requirements (power mobility devices, manual wheelchairs, wheelchair options/accessories, and wheelchair seating), each profession has a separate and distinct role in the process to document the medical necessity of the item to be ordered. Each LCD clearly states the role and function of each professional evaluating the beneficiary. The LCDs specifically indicate that the “licensed certified medical professional,” such as a PT or OT, or a practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the beneficiary’s home. In addition, the LCDs indicate that there should be no financial relationship between the supplier and the LCMP. The ATP is hired by the supplier. If the ATP is scribing for the physical therapist, there is an inherent conflict of interest. Moreover, by serving as a scribe, the ATP makes the therapist more “efficient” by saving time, thus allowing them to see more patients, what is often described as “in kind” assistance. The requester may wish to seek an advisory opinion from the Office of Inspector General (OIG) to confirm. 

Since it is now directly confirmed from all four DME MACs that having the ATP scribe for the LCMP during the specialty evaluation is not an acceptable practice, suppliers must be prepared to help educate LCMPs about the documentation requirements for complex rehab wheelchairs and accessories so they can efficiently prepare a comprehensive specialty evaluation with the necessary content for qualified patients to receive the ordered equipment in a timely manner. 

What is the secret modifier recipe for DME Capped Rental claim? 

Dan Fedor recently joined Senior Director of VGM Payer and Member Relations, Ronda Buhrmester, for a webinar titled: “SUPER Secret Modifier Recipe Revealed!” This webinar revealed the proper order and meaning of a variety of modifiers and explained how to submit a clean claim for each type of modifier.  

Below is an example of the secret recipe for a capped rental modifier: 

INGREDIENTS 

1 RR = rented item 

Depending on flavor:

  • Month 1 = KH
  • Month 2-3 = KI 
  • Month 4-13 = KJ 

BP—Purchase option of capped rental item (power wheelchair bases K0835-K0864) 

DIRECTIONS 

  1. Items in this category rent for 13 months. 
  2. For the first three rental months, the rental fee schedule is calculated to limit the monthly rental of 10% of the average of allowed purchase prices on assigned claims for new equipment during a base period, updated to account for inflation. 
  3. For each of the remaining months, the monthly rental is limited to 7.5% of the average allowed purchase price (in other words, the payment is reduced by 25% beginning in the fourth month of rental). 
  4. After paying the rental fee schedule amount for 13 months, no further payment may be made. 
  5. Note that for power wheelchairs and parenteral/enteral pumps, the monthly rental percentage may differ. 
  6. For power wheelchairs bases take the first month rental divided by .15 for the purchase allowable. Then for the rental of power wheelchair bases, it’s 15% for each of the first three months then 6% each month for 4-13. 

For more examples on modifiers and claims, click here to view the recording of Dan and Ronda’s webinar, “SUPER Secret Modifier Recipe Revealed!”  

How can providers navigate the complexities of Medicare Advantage (MA) plans over Original Medicare Fee for Service (FFS)? 

Many Medicare beneficiaries are being enticed by celebrities on TV to select a Medicare Advantage (MA) plan over Original Medicare Fee for Service (FFS) with all the standard benefits of Medicare at a lower out of pocket cost. These plans often state they provide additional benefits as well. While some MA plans are able to do this with the increased number of members—thus spreading the costs over a larger pool—others, from what suppliers are experiencing, are able to do this by NOT actually providing the same benefits as Original Medicare. 

First, review all contracts thoroughly and make sure it’s clear what they pay and how they pay (rental/purchase). Don’t just accept “we follow Medicare guidelines,” because that doesn’t mean they follow Medicare’s payment rules since they are not required to per CMS. If you can’t accept what they offer, don’t. Try to negotiate a fair contract, and if they won’t, don’t accept it. 

Second, let MA plan customers know that you can’t accept their insurance and the reason why. They are only hearing from celebrities promoting their plans of how great they are, but not how they negatively impact their true, medically-necessary benefits with unsustainable prices and payment methods (13-month rental for complex rehab power wheelchairs and accessories). While the MA plan customer may be able to get a gym membership and eyeglasses, they may not be able to obtain the wheelchair they need. Educate them that they CAN select Original Medicare FFS (switch back) if they find that the MA plan isn’t as good as the celebrities made it appear. 

Finally, let Medicare recipients who are struggling with making sense of all the MA plans and sales pitches know that they can call Medicare directly at 1-800-633-4227 (1-800-Medicare). A Medicare representative will be able to offer accurate, unbiased information about selecting the best plan for them. 

For more information on this subject, listen to the recording of Dan's webinar, “’We Follow Medicare Guidelines’ They Say...”.

U.S. Rehab members have free, easy access to Dan Fedor for billing and reimbursement consulting. With his vast knowledge of mobility documentation and reimbursement procedures, Dan can provide assistance on any mobility-related billing/reimbursement issue through webinars, conference calls, or on-site training. Members only have to pay for travel expenses. Become a U.S. Rehab member today for Dan’s exclusive industry expertise! 


comments powered by Disqus

From Our Experts

COVID-19 Resources: Upcoming Obligations and Deadlines thumbnail COVID-19 Resources: Upcoming Obligations and Deadlines Craig Douglas provides an overview of documentation requirements for the Paycheck Protection Program and the HHS Provider Relief Fund. From The van Halem Group: Bid Winners in the Off-The-Shelf Bracing Category Should be Wary of Lead-Generation Services thumbnail From The van Halem Group: Bid Winners in the Off-The-Shelf Bracing Category Should be Wary of Lead-Generation Services In a recent blog from The van Halem Group, information about the latest competitive bidding updates and off-the-shelf bracing is provided. If you are a competitive bid winner in the OTS category, you will likely be inundated with calls from lead-generation services that will promise to make you a lot of money and drive a lot of business to you. You need to know the laws and do your due diligence. "We Follow Medicare Guidelines" They Say… When suppliers encounter a customer that has an MA plan, they must determine if they must be in network if required and the coverage policies. Many plans inform their customers, as well as the suppliers, that they “follow Medicare guidelines.” Knee and Back Braces: What You Need to Know About Billing, Reimbursement, and Audits thumbnail Knee and Back Braces: What You Need to Know About Billing, Reimbursement, and Audits In this episode, Wayne van Halem, President of The van Halem Group, and Ronda Buhrmester, Senior Director of Payer Relations for VGM & Associates, work through the important details around billing, reimbursement, and audits when it comes to knee and back braces, the two categories included in Competitive Bidding Round 2021. Knee and Back Braces: What You Need to Know About Billing, Reimbursement, and Audits thumbnail Knee and Back Braces: What You Need to Know About Billing, Reimbursement, and Audits In this episode, Wayne van Halem, President of The van Halem Group, and Ronda Buhrmester, Senior Director of Payer Relations for VGM & Associates, work through the important details around billing, reimbursement, and audits when it comes to knee and back braces, the two categories included in Competitive Bidding Round 2021. Member Spotlight: A Look Back at Our Amazing Members! thumbnail Member Spotlight: A Look Back at Our Amazing Members! This year, we had the pleasure of featuring some of our amazing VGM & Associates members who do so much for the DMEPOS industry. Connection Over Convenience: How to Make Your Connection with Customers More Valuable Than Convenient thumbnail Connection Over Convenience: How to Make Your Connection with Customers More Valuable Than Convenient As we begin to carefully approach "living as usual,” Christina chats with us about what methods of adaptation are necessary to capture and connect with our customers and prospects. An Inside Look with Clint, Episode 2: Market Data thumbnail An Inside Look with Clint, Episode 2: Market Data Clint Geffert sits down with Ryan Ball from VGM Market Data.