Part 1

1. Are you receiving Black Lung (BL) Benefits? (Yes/No)
   • Yes. In this case, BL is the primary payer only for claims related to BL
2. Are the services to be paid for by a government research program? (Yes/No)
   • Yes. In this case, the government research program will pay primary benefits for these services. 
3. Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for your care at this facility? (Yes/No)
   • Yes. In this case, DVA is primary for these services.
4. Was the illness/injury due to a work-related accident/condition? (Yes/No)
   • Yes. In this case, WC is the primary payer only for claims for work-related injuries or illness, go to part 3.
   • No. Go to part 2

Part 2

1. Was illness/injury due to a non-work-related accident? (Yes/No)
   • No. Go to part 3. 
2. Is liability insurance available? (Liability insurance is insurance that protects against claims based on negligence, inappropriate action, or inaction, which results in injury to someone or damage to property.) (Yes/No)
   • No. A no-fault insurer is a primary payer only for those services related to the accident. Liability insurance is the primary payer only for those services related to the liability settlement, judgment, or award. Go to part 3.

Part 3

1. Are you entitled to Medicare based on:
   1. Age; Go to part 4.
   2. Disability; Go to part 5.
   3. End-Stage Renal Disease (ESRD); Go to part 6. 

Please note that both ‘Age’ and ‘ESRD’ or ’Disability’ and ‘ESRD’ may be selected simultaneously. An individual cannot be entitled to Medicare based on ‘Age’ and ‘Disability’ simultaneously. 

Part 4: Age

1. Are you currently employed? (Yes/No)
2. Do you have a spouse who is currently employed? (Yes/No)
   • If the patient answered ‘No’ to questions 1 and 2, then Medicare is primary unless the patient answered ‘Yes’ to questions in parts 1 and 2. Do not proceed further. 
3. Do you have group health plan (GHP) coverage based on your own or a spouse’s current employment? (Yes, both/Yes, self/Yes, spouse/No)
   • No. STOP. Medicare is the primary payer unless the patient answered ‘Yes’ to the questions in parts 1 or 2.
4. If you have GHP coverage based on your own current employment, does your employer that sponsors or contributes to the GHP employ 20 or more employees? (Yes/No)
   • Yes. GHP is primary. 
5. If you have GHP coverage based on your spouse’s current employment, does your spouse’s employer, which sponsors or contributes to the GHP, employ 20 or more employees? (Yes/No)
   • Yes. GHP is primary.
   • No. If the patient answered ‘No’ to both questions 4 and 5, Medicare is primary unless the patient answered ‘Yes’ to questions in the past 1 or 2. 

Part 5: Disability

1. Are you currently employed? (Yes/No)
2. Do you have a spouse who is currently employed? (Yes/No)
3. Do you have group health plan (GHP) coverage based on your own or a spouse’s current employment? (Yes, both/Yes, self/Yes, spouse/No)
4. Are you covered under the GHP of a family member other than your spouse? (Yes/No)
   • If the patient answered ‘No’ to questions 1,2,3 and, 4. STOP. Medicare is primary unless the patient answered ‘Yes’ to questions in part 1 or 2. 
5. If you have GHP coverage based on your own current employment, does your employer that sponsors or contributes to the GHP employ 100 or more employees? (Yes/No)
   • Yes. GHP is primary. 
6. If you have GHP coverage based on your spouse’s current employment, does your spouse’s employer, which sponsors or contributes to the GHP, employ 100 or more employees? (Yes/No)
   • Yes. GHP is primary.
7. If you have GHP coverage based on a family member’s current employment, does your family member’s employer, that sponsors or contributes to the GHP, employ 100 or more employees? (Yes/No)
   • Yes. GHP is primary.
   • No. If the patient answered ‘No’ to questions 5,6 and 7, Medicare is primary unless the patient answered ‘Yes’ to questions in parts 1 or 2. 

Part 6: ESRD

1. Do you have group health plan (GHP) coverage? (Yes/No)
   • Yes. If applicable, get (patient’s and spouse’s/ family member’s) GHP information.
   • No. STOP. Medicare is primary. 
2. Are you within the 30-month coordination period that starts MM/DD/CCYY? (The 30-month coordination period starts the first day of the month an individual is eligible for Medicare (even if not yet enrolled in Medicare) because of kidney failure (usually the fourth month of dialysis). If the individual is participating in a self-dialysis training program or has a kidney transplant during the 3- month waiting period, the 30-month coordination period starts with the first day of the month of dialysis or kidney transplant.) (Yes/No)
   • No. STOP. Medicare is primary. 
3. Was your initial entitlement to Medicare (including simultaneous or dual entitlement) based on ESRD? (Yes/No)
   • Yes. STOP. GHP continues to pay primary during the 30-month coordination period. 
   • No. Initial entitlement is based on ‘Age’ or ‘Disability’.
4. Does the working-aged or disability Medicare Secondary Payer provision apply (i.e., is the GHP already primary based on age or disability entitlement)? (Yes/No)
   • Yes. GHP continues to pay primary during the 30-month coordination period. 
   • No. Medicare continues to pay primary. 

We shared a questionnaire to be asked to Medicare beneficiaries while admitted to deciding on Medicare Secondary Payer (MSP). You can refer CMS document for detailed information. Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. Our billing services include benefits verification, charge entry, payment posting, denial management, AR management, provider enrollment, provider credentialing, and many other RCM services. If you are looking for any assistance in medical billing for your practice, contact us at info@medicalbillersandcoders.com/ 888-357-3226

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And as to speak about DME suppliers, the complex nature of reimbursement is another challenge they constantly face. Since patients can rent expensive equipment rather than purchase, DME billers and coders must be conscious of exactly how to code claims and when to send them for getting the precise reimbursement amounts. What this means is that the code should lay down the equipment was rented and not purchased. The rental period should be recorded separately on the claim so that the insurance company will pay a small reimbursement for each of those days.

Outsourcing your DME medical billing tasks facilitates a smart solution for your hospital billing requirements, assisting you to organize the entire billing and collection process at a portion of your current operating costs. If you want to make the in-house workload a bit lighter, it’s a great idea to consider outsourcing your DME billing.

Here are some important ways by which Medical Billers and Coders prove to be a great help for DME suppliers:

• To reduce the number of inaccuracies, many suppliers opt to outsource the billing and coding process to an entity that specializes in medical billing software and coding. Professional billers focus exclusively on the filing of claims, so there is no pressure on them to treat urgent patients or save lives. They take the workload off you and your staff, giving you ample time to focus on other matters.
• DME billing and coding management software have more expertise and necessary resources. To save the overhead costs you can outsource services in the lump sum, which might have been costly to handle internally.
• Patients that do not qualify for insurance claims can benefit greatly from the wide variety of skills and alternatives that experts in our organization can assist with.
• Retaining staff for billing purposes can get costly. Hiring a new person means costs of training, the employee’s salary, taxes, as well as compensation for the turnover. But contracting with an offshore entity eliminates these problems as they already having trained professionals.
• When patients have any issues in their DME billing, they can directly connect with medical representatives that have in-depth DME billing knowledge. This will diminish the burden placed on in-house staff. The medical billing agents will be able to answer questions, handle grievances, and provide the services to your patients. Keep in mind that customer satisfaction is the purpose of any business and it will definitely increase.

These are some of the paybacks you get when you consider hiring an outsourced DME billing and coding company. It will lead your facility towards decreased patient frustration, a financially solid bottom line, expectable cash flow, and increased net revenue saving time, money, and resources.

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The DMEPOS and PEN fee schedule files contain the Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the adjusted fee schedule amounts under Section 1834(a)(1)(F) as well as codes that are not subject to the fee schedule Competitive Bidding Program adjustments.

For CY 2019, the following Fee Schedule Adjustment Methodologies apply and fee schedule amounts are based on the area in which the items and services are furnished.

Fee Schedule Amounts for Areas within the Contiguous United States

To determine the adjusted fee schedule amounts, the average of Single Payment Amounts from CBPs located in eight different regions of the contiguous United States are used to adjust the fee schedule amounts for the states located in each of the eight regions.

These Regional SPAs or RSPAs are also subject to a national ceiling 110 percent of the average of the RSPAs for all contiguous states plus the District of Columbia) and a national floor (90% of the average of the RSPAs for all contiguous states plus the District of Columbia).

This methodology applies to enteral nutrition and most competitively bid DME items furnished in the contiguous United States, that is, those included in more than 10 Competitive Bidding Areas (CBAs). Fees schedule amounts for competitively bid DME items included in 10 or fewer CBAs

Fee Schedule Amounts for Areas outside the Contiguous United States

Fee schedule amounts for items furnished in areas outside the contiguous United States (noncontiguous areas, such as Alaska, Guam, Hawaii) are based on a blend of 50 % of the adjusted fee schedule amount and 50 percent of the unadjusted fee schedule amounts updated by the covered item updates specified in Sections 1834(a)(14) and 1842(s)(B) of the Act.

Areas outside the contiguous United States receive adjusted fee schedule amounts so that they are equal to the higher of the average of SPAs for CBAs in areas outside the contiguous United States (currently only applicable to Honolulu, Hawaii) or the national ceiling amounts described above and calculated based on SPAs for areas within the contiguous United States.

For the January 1, 2020 fee schedule update, the adjusted fee schedule amounts in non-bid areas will receive a CPI-U update per Section 414.210(g) due to the adjustments being based on SPAs

2019 Fee Schedule Update Factor of 2.3 Percent

For CY 2019, an update factor of 2.3 percent is applied to certain DMEPOS fee schedule amounts. Fee schedule amounts that are adjusted using information from CBPs are not to be subject to the annual DMEPOS covered item update.

In accordance with the statutory Sections 1834(a)(14) of the Act, certain DMEPOS fee schedule amounts are updated for 2019 by the percentage increase in the CPI- U for the 12-month period ending June 30, 2018, adjusted by the change in the economy-wide productivity equal to the 10-year moving average of changes in annual economy-wide private nonfarm business Multifactor Productivity (MFP).

The MFP adjustment is 0.6 percent and the CPI-U percentage increase is 2.9 percent. Thus, the 2.9 percent increase in the CPI-U is reduced by the 0.6 percentage increase in the MFP resulting in a net increase of 2.3 percent for the update factor.

MBC for a coding & billing skills upgrade

Navigating the medical coding and compliance world gets easier with expert guidance.

To help you with this transition, you need to have an efficient medical billing and coding partner like MBC to handle new information, securely handle data, and manage operational efficiencies easily.

MBC is one of the known knowledgeable healthcare industry’s most expert veterans to outsource your medical billing and coding requirements. They are the medical billing experts providing medical billing and coding services for all surgery. They support billing and coding services for all kinds of surgical procedures. Their customer services are the most noted in the industry.

The post Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule Update 2019 appeared first on DME billing and coding blogs.

To ensure accurate reimbursements and timely revenues, it is imperative to hire an outsourcing agency as it works as a smart solution and completes all the billing and coding requirements; and assists in organizing the entire processes at a fraction of the in-house operating costs. It also makes the in-house billing and coding department’s work a lot easier, less time consuming, and lesser issues related to legalities.

• Equipment that provides therapeutic benefits to patients who are in need due to certain medical ailments is categorized as DME. It is also known as Home Medical Equipment (HME) and is able to withstand repeated use.
• Equipment’s considered as DMEs are prosthetic devices, wheelchairs, oxygen equipment, insulin pumps, walkers, hospital beds, power mobility devices, etc. It is known that around 80% of the bills contain errors of some sort of the other, either incorrect details or the inability to follow the latest rules and regulations.
• It also gets difficult for a hospital administration to reduce errors, verify demographics and insurance on a regular basis, follow up on claims and payments, hence the need to outsource billing and coding services becomes essential

Policies for DME Codes Remember that any time you use an HCPCS Level II code that ends in 99, such as, E1399 Durable medical equipment, miscellaneous, provide supporting documentation to bill that code.

Once Medicare receives a miscellaneous code, the claim is suspended and medical records are requested. The records are then checked for several possible issues. Next, the miscellaneous code is reviewed to see if another code is more appropriate to a bill.

Also, keep in mind that most medical gears have a code appointed. If the piece of equipment does not have a code assigned, then the manufacturer’s invoice is reviewed for an allowable. In the final stage, the medical necessity is verified before payment is made. If the in-house billers are facing a dilemma regarding code for a particular item you can check with Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC).

Their guidance to manufacturers and suppliers on proper usage of HCPCS codes in regards to DMEPOS services identified for Medicare billing.

Not just churning out clean claims DME medical billing companies also provide daily reporting and real-time access to all the claims processed. These reports assist the medicinal services experts with understanding their practice/business better. It distinguishes diverse reimbursement rates for every strategy by various insurance agencies.

Month-end reports additionally help to comprehend comprehensive, bundled procedures by demographics. It additionally provides a demographic classification of a patient by insurer. A/R report clearly indicates the outstanding balances by A/R days, insurance, and patients.

Medical Billers and Coders have more than 100 Durable Medical Equipment (DME) Clients and for all of them, we have provided a customized solution relating to the practice revenue, number of patient visiting facilities, type of equipment, and demography. With our revenue managers, we channelize the billing to reduce billing errors and maximize revenue growth.

The post Durable Medical Billing (DME) facilities need outsourcing medical coding? appeared first on DME billing and coding blogs.

In simple terms, Durable Medical Equipment refers to wheelchairs, braces, shower chairs, and other assisted living equipment needed by the patients. These gears are generally purchased as an outpatient entity.

Preapproval in DME billing is critical

It does not matter if your patients are insured through Medicare, Medicaid, and Workers’ Compensation or through a private insurance carrier. Almost all DME claims must be pre-approved prior to the submission of the medical billing claims.

Many of these policies have strict guidelines, which must be followed in order for the DME medical billing claim to be reimbursed. Some providers will require that the DME be purchased through their own sources and have a listing of specified providers. Many HMOs are very strict about the DME they will reimburse a medical billing claim for.

Keep in mind that documentation and pre-approval is the key. And when you think you have enough, go for one more item to make sure you have a strong claim.

Do remember that Durable Medical Equipment is one of the stringent and watched aspects of medical billing and coding. This is due to the amount of fraud that has been committed by dishonest people.

Here are some important guidelines for handing your DME medical billing claims:

• Ensure you have the required letters of medical necessity/doctor’s prescription on hand to prove a legitimate need.
• If pre-approval is required for equipment, services, or procedures, make sure you have that documentation on file.
• There may be an exclusion of certain equipment or other benefits associated with the DME. The patient may qualify for a wheelchair, but not a specialized wheel for the chair to accommodate an aspect of the patient’s home.
• Usually, there are yearly or lifetime dollar limits on DME claims paid.

Medicare has the authority to set the standard for many carriers as to what they will and will not pay for in a DME claim.

To give you an example, Medicare will not pay for bathroom equipment such as commode chairs that might be needed by an MS patient. Many private insurance providers use the guidelines of Medicare and consequently exclude such equipment from reimbursement. This is where preapproval and documentation are the strong suits for getting these DME claims paid.

Conclusions

The codes for DME billing are broad because there can be so many different circumstances surrounding the need for this type of equipment. Durable medical equipment can be anything from a wheelchair to cochlear implants to complete or partial prosthetics.

For this reason, it is important to note not only what kind of durable medical equipment is required, but also what conditions caused the need for this type of equipment. Ensuring this will make the coding process simpler for DME billing companies and will allow the insurance company to have a better understanding of the diagnosis and procedure.

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AR is calculated as:

Total charges for last 6 months/number of days in last 6 months = average daily charges

Total AR / average daily charges = days in AR

AR can be duly managed if the medical billing and coding professionals are knowledgeable about coding parameters, insurance rules, timely claim filing and follow up (of regular and rejected claims). Usually, the healthcare facility is paid by the insurance and the patient. A delay in either of these negatively affects revenues and leaves a great deal on the table. Hence, it is imperative to monitor the AR on a continuous basis. And this must be done by professionals who know the healthcare practices’ contract terms claims adjudication. The professionals managing AR must also know how to calculate copays which the patients are required to pay.

Other practices to be followed are: prior authorization, copays collection, insurance verification, referral management, and financial policies made clear to the patient.

Technology:

For an effectual revenue cycle, the workflow of the revenue cycle must have standard processes that need to be followed, including a unified front and back office. For this, a practice management system (PMS) or the electronic medical record (EMR) must be in use. Technology makes work a lot easier and must be embraced. The EMR maintains vital information such as patient records, visits, reimbursement related documents, and other details of claims and follows ups, assisting in managing ARs well.

Metrics:

Although other metrics are equally important in the healthcare business, with tighter margins, it is getting all the more imperative to manage the number of days in AR (the days refers to the number of days between the patient discharge and when the payment is made, creating a direct impact on the revenues). Further, the personnel responsible for collecting AR must be informed of the applicable benchmarks to be used for measuring performance. AR’s performance must be measured each month to know of any potential collection issues and the result it has been having on cash flows. The ultimate goal is to minimize the time between the claim submitted and the payments received. AR days measure this time and let the healthcare facility know their medical financial stability.

Benchmarks for collections:

30 days for a high performing, 40-50 days for an average performing and 60 days or more for a below-average performing medical billing department.

Variables of A/R:

1) Payer mix:
The medical billing and coding professionals handling AR must know the payers who pay sooner and those who don’t. “Cash in 60 days” is the time shown for newer bills. If this is not shown, it indicates a delay.

2) Payment discrepancies:
Meeting with payers is a good option to solve discrepancies, taking steps to avoid them in the future, and dealing with pending claims to ensure timely payments.

3) Aging bucket:
This bucket deals with 0-30 days, 31-60 days, and 61-90 days. A report must show the amount of A/R in each aging bucket. This is then converted to a percentage of total AR. A monthly report showing these measures can be particularly helpful to monitor AR and its performance.

If these practices are followed well, there should be no concern in getting reimbursed timely and accurately. Minimizing AR must be a team effort. The quicker the turnover in AR, the lesser amounts of efforts required in looking around for cash from other sources.

For more information on medical billing and coding visit us on Medical Billers and Coders (MBC) with over 18 years of experience in Medical Reimbursement management.

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Indeed, even with the rising number of claims being denied all the time, DME facilities must not lose heart. There are numerous ways to answer the issue of, how to rectify increasing claim denial rates. Practices can obviously target regular zones of through where a claim denial occurs, but looking beyond the traditional norms is not just enough. Today, even a minute DME billing and a coding mistake can lead to a denial or delayed reimbursement. And in such a scenario, if you are not applying the right kind follow up procedures, the chances of you getting paid are scarce.

The first thing ‘you’ as a DME supplier should comprehend is as to why the claims are being denied?

For DME billing service, there’s nothing more disappointing than a denied claim. Most of the time you get to hear that the work was done but a minute coding error lets the claim to be denied, which is pretty frustrating.

When this happens, DME suppliers need to resubmit their claims with the expectation that they corrected the issue and would now be able to get the money they are owed. Another point to remember here is that even though the facilities enhance their denial and collection rate, the amount of time they took to work over it, can never be reimbursed. In all cost-saving avenues, it will cost you $25 to $30 to manage with the overall denial and follow up procedures. The best thing one can do here is to appoint a durable medical equipment billing companies to handle all the charges and denial management procedures, so you can concentrate on the business side of the work.

Cleaner Claims is the name of the game

Dissecting each claim manually is an overwhelming task. Filtering through a large number of codes and recognizing what is being denied and by which payer will never ever let you get a grip on proper denial management process.

The goal for every facility and medical biller is to get their claim paid on the first pass. With how far billing software has advanced can be kept under control as practices can implement web-based denial management procedures that are quick and cost-effectively to see improvement in first-pass resolution rate almost immediately.

Ideally, a Denial Management System Should Include:

Charge Entry Scrutiny:

Check claims in real-time to confirm diagnosis and procedure codes as you ensure compliance before submittal.

Set Advanced Rules Engine:

Track payer denial activity and identify new regulations. New and developed medical billing software can anonymously track these rules over the user base and automatically distribute new rules over the entire network for complete claims qualifications.

Claim Notifications:

Automatic claim alerts for events like claim resubmissions and claims status to improve payment transparency can guarantee reimbursement until the last cent.

Power of Analytics:

Customizable real-time reporting to make sure claims are being paid in full and spot areas where improvements can be made.

Flexibility in denial management approach:

The ability to integrate with other software systems and be easily upgraded for changes in rules and coding is also an effective denial management system.

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