Providers in bid areas see glitch in payments

Friday, October 18, 2013

YARMOUTH, Maine – Some providers in Round 2 competitive bidding areas (CBAs) say they’re running into trouble billing for complex rehab accessories. 

“Sometimes we get paid, sometimes we don’t—it’s very haphazard,” said Joe McKnight, vice president of business development for Anaheim, Calif.-based Aero Mobility.

Because complex rehab is excluded from competitive bidding, providers in Round 2 CBAs must use a KY or KE modifier on claims for accessories like batteries, chair backs and cushions to notify CMS that they’re not bid items.

Unfortunately, the modifiers don’t appear to be working.

“These claims are incorrectly denying for competitive bidding or underpaying at the competitive bid rate,” said Mary Shutes, director of reimbursement at Rochester, N.Y.-based Monroe Wheelchair. “Accessories on complex rehab chairs should be paid at the fee schedule amount and not the single payment amount.”

Since it is a billing processing error, providers may resubmit the claim until it is processed correctly, rather than filing an appeal. This still adds an administrative burden, says McKnight, especially as these denials increase.

“It’s burdensome to provide custom rehab as it is,” he said. “This is another reason we need a separate benefit.”

At this point, all providers can do is sort out each claim on a case-by-case basis, they say.

“(Medicare Administrative Contractors) are saying, ‘Bill for it this way and if it doesn’t work call us,’” said Martin Szmal, founder of The Mobility Consultants. “Or they’ll say, ‘Resubmit, and we can try to adjust this in-house.’”

NCART Executive Director Don Clayback says CMS is aware of the issue. 

“Suppliers are following the right processes,” he said. “CMS recognizes this is not the way those claims should have been processed, and they’re planning to make the necessary correction.” HME


I'm not convinced these are simple billing errors with the DME MACs.  The DME MACs are the ones who notify providers of these changes so I highly doubt they weren't already on board when these modifiers took effect.  Also, I believe this is the DME MACs sneaky little way of auditing your paperwork--I wouldn't put it past them to deny the re-opening of your claim, in which you then have to send it to redetermination.  Either way you better have your paperwork ready to go.


I agree. We who were not bid winners are also having our grandfathered equipment claims denied, probably for the same reason AJ states- a sneaky way of asking for documentation. When you think about the fact that this our own government doing this to us, it is maddening.