Yes, You Can  Do That!

By Joe McTernan, AOPA Director of Reimbursement Services

Nothing makes the reimbursement staff at AOPA happier than being able to give our members a positive response. We take many telephone questions about specific billing scenarios, and often we have to gently let the caller know that Medicare policy does not allow him to bill for the particular service or device in the way that he proposes.

We know it can be frustrating to members to hear about all the things they can’t do. Medicare policy creates some restrictions in billing. But that’s not the whole picture—this month’s “Reimbursement Page” will focus on things that members can do in order to maximize reimbursement while avoiding potential exposure to fraud and/or abuse. AOPA wants to make sure you know about all the techniques you can use to make your business more profitable!

Protect your investment
Prosthetists and orthotists are allied health professionals who have an ethical obligation to provide services and devices that they believe will most benefit their patient. They are also business people who should not be afraid to operate at profitable levels. Many people believe that it is impossible to achieve the first objective without sacrificing the second.

This is simply not true. You can successfully provide limbs and braces that are clinically appropriate for your patient while controlling your acquisition costs and reducing unnecessary and expensive claim denials.
One effective method of protecting your financial investment in your business is the appropriate use of the Advanced Beneficiary Notice (ABN). This document is easy to complete, and allows your patient to accept financial liability for your services when Medicare deems them not medically necessary.

Medicare does not expect beneficiaries to be familiar with the policies that govern Medicare coverage. Providers, however, are expected to be familiar with Medicare policy, and are held liable for any charges for services determined to be not medically necessary. When such a determination is made, the beneficiary is permitted to keep the device, but the provider may not collect any payment from the patient unless he or she signed an ABN. The purpose of the ABN is to inform the patient, prior to delivery of the service or device, that you believe that Medicare will deny payment of the claim due to a lack of medical necessity.

On the ABN itself, you must document the specific reason you believe the claim will be denied. The blanket use of ABNs is not permitted by Medicare and will not release you from financial liability. If the patient refuses to sign the ABN, you must then make a business decision whether you are willing to accept financial liability for the claim.

Reduce your claim denial rate
Any time a claim that you submit is denied, it costs your business money. Statistics show that the vast majority of denied claims are denied due to missing or incomplete information. While these clerical errors are easy to correct, it still takes time for your staff to gather the information necessary to resubmit the claim.
Making sure that your staff has the proper training and knowledge necessary to submit complete claims the first time around will save your business big dollars in the long run.

Understand Medicare inpatient billing rules  
It is a common misconception that any time you receive a call to treat a patient at a hospital, rehabilitation center, skilled nursing facility (SNF), or long-term care center, the facility that called you is responsible for
paying you for your services. While this is often the case, a thorough understanding of the inpatient billing rules will save you time and money by making sure you are communicating with the appropriate payer before you provide the service.

The payment rules for both acute hospitals and rehab hospitals are the same. If you evaluate a patient in
either of these settings, and you deliver a completed device prior to the date of discharge, the hospital is responsible for payment and must pay you directly for your services. This applies even if the patient will continue to use the device after discharge.

There are two exceptions to this general rule. One exception is the two-day rule, which states that if you deliver a completed device to a patient within two days of discharge date, and there is no medical need for the patient to use the device during the last two days, you may bill the device to the Medicare Part B DME MAC using the date of discharge as your date of service.

Before you take advantage of the two-day rule, you must document the reason you delivered the device prior to discharge. If the device is needed at any time during the inpatient stay, the two-day rule no longer applies and the hospital must be billed for the service.

The second exception for services or devices delivered to patients in the hospital is those provided on the actual date of discharge. Hospitals do not receive a prospective payment system (PPS) payment for the date of discharge, so any services provided on the date of discharge are billable to the DME MAC.

When providing service to patients in an SNF, there are many instances where you may bill the DME MAC directly. The first thing you should do is determine whether the patient is in a Medicare Part A-covered stay. Medicare Part A covers 100 days of SNF care per benefit period. A new benefit period begins when a patient is admitted to an SNF after a minimum three-day hospital stay and does not end until the patient no longer qualifies for skilled care, or has been discharged from the SNF for 60 consecutive days.

The best way to determine if the patient is in a Medicare Part A-covered SNF stay is to contact the business office of the SNF and ask them. While physicians or nursing staff may know who is covering the patient’s stay, the business office will always know a patient’s current status because they need to know where to send the bill.

If a patient is in a Medicare Part A stay and you are providing an orthosis, the SNF is responsible for payment. If the patient is in a covered Part A stay and you are providing a prosthesis, the majority of the device is exempt from SNF PPS and may be billed to the DME MAC. CMS publishes an annual list of SNF PPS exempt codes. The current list may be found at the following Web site: www.cms.hhs.gov/SNFConsolidatedBilling/02k_2008Update.asp#TopOfPage.

“File 1” at this site contains the list of codes that may be billed directly to the DME MAC.

If you determine that the patient does not qualify for a skilled level of care or if the patient has exhausted his or her Medicare Part A benefit, you may bill all of your services to the DME MAC. The same rules regarding delivery within two days of discharge and delivery on the actual date of discharge that apply to hospital billing also apply to services delivered in the SNF.

Medicare Part A does not cover long-term nursing care. Therefore, any services you provide to patients in a long-term care facility are billable to the DME MAC.

AOPA’s reimbursement staff is here to serve the AOPA membership, even if it sometimes results in unpopular answers. Hopefully, this month’s “Reimbursement Page” has restored faith in our ability to say “yes”!

For more information, contact Joe McTernan at (571) 431-0876, ext. 211, or jmcternan@AOPAnet.org.