Medicare coverage for xpap - questions ???

For those interested.


III. Medicare Supplier Standards


Below is a summary of the standards Medicare requires of home medical equipment providers. Our company (my DME) meets or exceeds all of these standards.

1.A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements and cannot contract with an individual or entity to provide licensed services.

2.A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.

3.An authorized individual (one whose signature is binding) must sign the application for billing privileges.

4.A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs.

5.A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.

6.A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.

7.A supplier must maintain a physical facility on an appropriate site. This standard requires that the location is accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.

8.A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation.

9.A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited.

10.A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.

11.A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from contacting a Medicare beneficiary based on a physician’s oral order unless an exception applies.

12.A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.

13.A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.

14.A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries.

15.A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.

16.A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.

17.A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.

18.A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.

19.A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.

20.Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.

21.A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.

22.All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals). Implementation Date - October 1, 2009

23.All suppliers must notify their accreditation organization when a new DMEPOS location is opened.

24.All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.

25.All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.

26.Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation date- May 4, 2009

27.A supplier must obtain oxygen from a state- licensed oxygen supplier.

28.A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f).

29.DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.

30.DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.


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mcdover wrote:The criteria for coverage is NATIONAL and set by CMS.

Bold added by me.

I'm not disputing that, now. But it is obvious the policy as set by CMS is not the same, and apparently overrides, the policy that is in the Medicare manual. You seem to be unwilling to acknowledge there is a conflict between the CMS policy and the Medicare manual. When I started looking for the answer I went to the Medicare.gov and cms.gov websites and this is what I found.

Medicare Claims Processing Manual
Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
Table of Contents
(Rev. 1961, 04-30-10)

30.5 - Capped Rental Items
(Rev. 1, 10-01-03)
For these items of DME, contractors pay the fee schedule amounts on a monthly rental basis not to exceed a period of continuous use of 15 months. In the tenth month of rental, the beneficiary is given a purchase option (see §30.5.2). If the purchase option is exercised, contractors continue to pay rental fees not to exceed a period of continuous use of 13 months and ownership of the equipment passes to the beneficiary. If the purchase option is not exercised, contractors continue to pay rental fees until the 15 month cap is reached and ownership of the equipment remains with the supplier (see §30.5.4). In the case of electric wheelchairs only, the beneficiary must be given a purchase option at the time the equipment is first provided (see §30.5.3).

This comes from the link for Publication 100-4 on this page http://www.cms.gov/Manuals/IOM/list.asp. At the top of that page is this statement.

The Internet-only Manuals (IOMs) are a replica of the Agency's official record copy.

On the parent web page to that one http://www.cms.gov/Manuals/, we see this statement.

The CMS Online Manual System is used by CMS program components, partners, contractors, and State Survey Agencies to administer CMS programs.

Is the Medicare manual, the document that comes up when you search for it today on cms.gov, the manual that is presented as the latest and greatest, out of date and wrong? Or is it simply overridden by current CMS policy? Why is it so hard for you to understand where I am coming from when I am reading the official internet copy of the agency's official record copy?

For those interested.


III. Medicare Supplier Standards

Thanks Avi123

Trying to figure out Medicare and DME's. Having some trouble getting started with Lincare as my dme and I called Medicare today. The only DME's in my area are Lincare and Apria. Medicare said that Lincare is not a Medicare "participating supplier". They did not mention Apria as a "participating supplier" either. What is that supposed to mean? The woman at Medicare was not very patient with me so I couldn't probe too deeply. She mentioned "Oxygen Plus" and "Omni Care" - never heard of them.

It has been mentioned here that there is a difference between a "medicare contractor" and a "medicare provider", also what is a "participating supplier" - what should I be looking for? I am not sure that I will be able to untangle the confusion with Lincare so need some direction as to where to look for another dme. I have googled dme's in my area and come up with nothing else.

I also tried to find a list of dme's on medicare website and that did not lead me anywhere.

Thanks!

Bright Choice wrote:he only DME's in my area are Lincare and Apria. Medicare said that Lincare is not a Medicare "participating supplier". They did not mention Apria as a "participating supplier" either. What is that supposed to mean?

Participating providers accept what Medicares states is the allowable amount to be charged and the excess is written off.
Then Medicare pays their 80% (if Part B deductible has been met) and patient is responsible for the remaining 20 % and if patient has Medicare supplement it will pay that 20 %. They accept "assignment".. Medicare sends the check to the provider.
This is for standard Medicare coverage.

The special Medicare Advantage plans with HMO and PPO limits or co pays, may be different but it is usually base on Medicare assignment.

While this explanation is for a lift it is still DME equipment
[urlhttp://www.medicare.gov/coverage/Search/Result ... esults+%3E][/url]

http://www.infoline.org/informationlibr ... ent%20.asp

Non participating providers that are enrolled in Medicare will send the necessary forms but Medicare usually sends you the check because the Non Participating providers often will request payment from the patient. Not always. It is possible that with non participating providers that the could bill above the "allowable" amount that Medicare usually sets instead of writing off the difference. This should be explained full and you should be made aware of your financial responsibility right up front and how much it will be. With these there is the potential to have much more out of pocket expense.
So best to try to find DME that is participating Medicare member.

Ask each supplier whether they will "take assignment"--that means they will bill Medicare directly and agree to take only what Medicare allows. (Medicare pays 80% and you pay 20%). If they won't accept assignment there are online vendors who WILL (not CPAP.com, unfortunately).

I think both Crapria and Lincare generally do accept assignment--but it makes sense to ask. In any case they cannot charge you more than Medicare allows unless they give you an "ABN" or Advance Beneficiary Notice to warn you first.

pugsy and janknitz and the rest of you - you are always on top of it! Thanks! I don't know how you guys do it.

If qualify for ASV under Medicare: 1) Dx: must be Central apnea or complex apnea 2) >than 50% of your total events must be central or mixed events
no compliance data or follow-up visits with physicians required for continued 13 month rental. After 13 months you own the equipment. 2 year warranty.