Saturday, January 31, 2004

What’s new in PWC claims
With Peggy Walker

Q. Power chairs - What has changed?

A. Basic coverage criteria is the same as it was in 1993, so how did all those fraudulent claims get paid?

The electronic billing system allows claims to be paid with wording from the CMN. This was developed as a way for suppliers to bill without having to send a hard copy.

A person never saw the claim unless there was something that stopped it. That is why the CMN is called a “processing” tool. The system paid the claims by the answers on the CMN. Some took advantage of this system and items were paid that should not have been paid.

How is this going to affect the true Rehab supplier?

Texas suppliers have been affected greatly. Many suppliers have been placed on pre-pay and their claims will be slower to process. All four regions will have to follow the CMS & OIG’s directive on the clarification of policy. There will be more consistency across the four DMERCs on the approach to medical review of these claims.

What should you do?

- Make sure the patient is “seen” by the physician before you start your process.

- Make sure the basic coverage criteria is met.

- Make sure that the physician is aware of the basic rules.

- Remember, if they need the item it will be covered.

- If the patient “walks” into your store, a wheelchair of any type is not covered.

- DOCUMENT everything.

Peggy Walker, RN is Billing & Reimbursement Advisor for U.S. Rehab: 800-642-6065