What Dme Is Not Covered By Medicare – Sellers with insurance contracts should understand how these contracts affect cash sales transactions. To help providers avoid legal landmines as they navigate the DME reimbursement landscape, healthcare attorneys Jeffrey Baird and Lisa Smith hosted a free webinar on August 2, 2017. Below are selected questions and answers from Brown & Fortunato, along with a glossary of terms. These FAQs are generalizations and do not apply to every situation with provider or payer contracts, so the answers below may not apply to your situation. Providers should contact payers directly and/or consult with an experienced medical attorney for answers specific to their situation. These FAQs are for informational purposes only. These Questions do not constitute legal advice and should not be relied upon by the reader without consulting a health care attorney. If you have any questions, please contact Jeffrey S. Baird at (806) 345-6320, jbaird@ or Lisa K. Smith, Esq., (806) 345-6370, lsmith@.
:: ABN is a form that allows a paying Medicare patient to make an informed decision about what is covered by Medicare but not covered for some reason (eg, lack of medical necessity). When an ABN is properly issued by a medical patient, financial responsibility shifts from the provider to the patient. A provider must offer a Medicare patient an ABN for signature only if the provider has reason to expect that Medicare will not pay for the covered item. For more information about ABNs, see the Medicare ABN Interactive Tutorial (December 7, 2017).
What Dme Is Not Covered By Medicare
Q: Do commercial payers use ABNs, or what do providers have to use to transfer financial responsibility to non-Medicaid patients?
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:: Before cash transactions, commercial payers may require forms other than the ABN, such as a waiver of financial responsibility or waiver of claims signed by the patient. The shipper should check the specific requirements before conducting any money transactions with the payer.
:: Due to unique payer contract agreements, accreditation requirements, and federal, state, and local laws, we are unable to provide payment guidelines for patients with commercial insurance. Providers should contact payers directly and/or consult with a health care attorney for answers depending on their situation.
Q: For a patient who wants to pay for a medically unnecessary item, what insurance documents must the DME provider obtain to minimize liability?
:: For items that the payer may decline to pay, the provider must obtain a signed Medicare ABN form or commercial financial waiver form.
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Q: If a patient wants to file a claim with their health insurance for a cash advance purchase, what documents might they need?
:: Providers with a Medicare PTAN must submit a claim to Medicare on behalf of the patient, and Medicare will not pay for items received from the provider without a PTAN. Most other types of insurance require the patient to provide medical claims when seeking reimbursement, unless the DME provider files the claim on the patient’s behalf. The payer may also require an invoice from the patient, a letter explaining the medical necessity of the claim, and supporting documents supporting the claim. The payer has the right to determine what to pay. The patient should determine the appropriate claim form with the payer.
:: Submitters are responsible for creating their own UCR scope. These amounts must be consistent with internal policy and set in a non-discriminatory manner.
Q: Is there a limit to how much a Medicare provider can pay a Medicare patient for an unsubmitted claim?
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A: No. Medicare payment caps do not apply to DME providers, so there is no upper limit on how much providers can charge a patient for DME items. When Medicare pays, amounts paid by UCR must be reported on demand. For more information, please see Medical Equipment and Supplies Balance Payment (as of January 2001); 42 US. 201320a-7(b)(6)(A). DME Provider Participation and Appointment Reminders (December 6, 2017)
Q: Does the product coding review in the DME PDAC coding system require the product to be billed to Medicare or sold to patients for cash?
:: Checking a subject’s PDAC code in the coding system does not determine whether the subject is billable to Medicare or sold for cash. Although the PDAC requires a PDAC code check for some items, most products, including cpap and portable oxygen concentrators, do not require a code check. A PDAC HCPCS code check is free for unnecessary items. In the absence of PDAC coding verification, it is the provider’s responsibility to ensure that the item meets the applicable HCPCS definition and, if so, to use the appropriate HCPCS code when submitting claims. To search for HCPCS codes based on the subject description, the DMECS keyword can be requested, or the provider can contact the DME PDAC directly.
Q: If a patient has oxygen equipment (eg, the patient purchased it with cash), will Medicare pay for the oxygen equipment (eg, feeding tube, nasal cannula)?
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A: Accessories, maintenance, and repairs are not legally covered by Medicare for patient-use oxygen equipment (Local Coverage Article: OXYGEN and Oxygen Equipment – Policy Article A52514, September 9, 2017). However, the provider may obtain a voluntary ABN signed by the patient and require the patient to pay cash for these items.
Q: If a Medicare patient pays for a Medicare-covered item from a provider who does not have a Medicare PTAN, does the waiver of receipt that the provider is not a Medicare provider satisfy the requirement to notify the patient?
:: It is possible that if the disclaimer is displayed “prominently”, the patient may see the disclaimer before completing the purchase. Under Medicare rules, a provider without a Medicare PTAN must reimburse the money they collect from a Medicare patient unless the patient signs an ABN, so Medicare won’t pay for items from that provider because they aren’t enrolled in Medicare. In the absence of a signed ABN, if the supplier can prove that it has given the customer prior written notice, it can retain the money collected from the customer. 42 US. 951395m (j) (4) (A). CMS guidelines recommend that the printed sign be placed where customers can see it. Whether a disclaimer printed at the bottom of a store receipt will be considered an appropriate written notice depends on how well it is placed on the receipt and how likely the patient is to see the notice before the purchase is completed. For example, does the patient have to sign a receipt before the sale is complete?
:: Any product labeled “Rx only” requires a patient prescription.
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Q: Can patients use their Health Savings Account (HSA) or Flexible Spending Account (FSA) for covered items that the HCPCS code for PDAC does not define?
A: Yes, if the items are considered qualified medical expenses for use with an HSA or FSA. For most items, assigning an HCPCS code from the PDAC is optional.
Q: If a Medicare-paid PAP machine is discontinued within five years of the RUL, can the provider charge the patient a monthly cash payment for the PAP loan?
:: If Medicare has paid for the 13-month rental, this PAP transfers ownership to the patient, and the provider provides replacement equipment at no cost to the patient or Medicare, if the DME determines a MAC. the item supplied by the supplier will not last 5 years reasonable life. If the PAP cannot be repaired, the patient may choose to have the equipment replaced, in which case Medicare will pay under the cap to rent the new equipment. Irreparable damage refers to cases where equipment is damaged, as opposed to equipment falling down stairs, for example.
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Q: Are there restrictions on physicians selling a topanicol product or portable oxygen concentrator (POC) as a cash product to Medicare patients?
:: The Star Act and regulations limit a physician’s ability to refer Medicare or Medicaid patients for DME to a provider with whom the physician has a financial relationship, or who provides DME to their own patients unless the Stark exception is met. You should seek legal advice as to whether your particular arrangement qualifies for Star.
Q: Does Medicare allow providers to pay the full price for a patient to rent a medically necessary device (eg, cpap, portable oxygen concentrator)?
A: No. Claims falling under the category of limited lease payments cannot be treated as purchased goods. The patient cannot pay the purchase price in full because the claims are not submitted. The provider must collect the monthly UCR rental payment from the patient and submit a monthly claim to Medicare for unspecified housing. (as of June 1, 2017)
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Q: Can a non-participating provider pay cash if a patient receives two tablets (A7032) at the same location on the same day?