Cap provision gives hope

Wednesday, December 31, 2008

BALTIMORE --Recently released guidance on the 36-month oxygen cap may contain a silver lining for providers, at least those with long-term patients.
On pages 846 and 847 of the guidance, Medicare states that, after five years from the day of setup, providers can supply oxygen patients with new equipment and bill Medicare for another three years.

That’s music to the ears of Lee Guay, a coordinator for Apex of St. Peters in Helena, Mont. Thanks to the provision, 40 oxygen patients who he thought were capping out Jan. 1 are eligible for new equipment. The patients have been on oxygen for at least six years.

“This is pulling some providers out of the fire,” Guay said.

There are several caveats to the provision. First of all, providers must still go two years without billing Medicare for equipment—the time between the 36-month cap kicking in and the five-year useful lifetime of the equipment ending.

Secondly, beneficiaries must want new equipment.

“People are saying, ‘Oh, the provider can do it automatically,’” said Cara Bachenheimer, senior vice president of government relations for Invacare. “But beneficiaries have to choose, because they’re going to have to start paying a 20% co-pay again.”

Lastly, the provision may not be as straightforward as it seems. For example, providers may have to prove equipment is irreparable before supplying new

“We’re telling people to proceed cautiously,” said Kelly Riley, director of The MED Group’s National Respiratory Network.