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Many Medicare beneficiaries are being enticed by celebrities on TV to select a Medicare Advantage (MA) plan over original Medicare fee for service (FSS) with all the standard benefits of Medicare at a lower out-of-pocket cost. These plans often state they provide additional benefits, such as gym memberships, transportation and eyeglasses, so how can they provide more benefits with a lower cost? Seems too good to be true, doesn’t it? How can these private, for-profit insurance companies provide more for less, pay all these celebrities to promote their insurance on TV and make a profit? While some of these plans are able to do this with the increased number of members, thus spreading the costs over a larger pool, others, from what suppliers are experiencing, are able to do this by not actually providing the same benefits as original Medicare.

When suppliers encounter a customer that has a Medicare Advantage plan, they must determine if they have to be in network if required and the coverage policies. Many plans inform their customers, as well as the suppliers, that they “follow Medicare guidelines.” Most would take this that they will cover and process claims the same as original Medicare would. However, while these plans are required at a minimum to furnish all medically necessary Medicare-covered DME (policy), they are not required to follow Medicare’s payment rules (prices, rental/purchase, modifiers, clean claim timeliness, etc). Clarification of this long standing outstanding question was recently received from CMS. So this appears to be the other way these plans can promote that they offer more for less because they can reduce the prices for DME and pay them in a different manner that saves them money (rental over purchase).  

All suppliers need to be aware of this and take this into consideration when determining if they can accept a contract/ customer with one of these MA plans. It is vital to obtain their policies and payment rules in writing prior to accepting a customer so you know what you are getting into. If they verbally say, “We follow Medicare,” ask them what that means. Ask if they follow Medicare’s policies (coverage) and payment rules and try to get this in writing prior to agreeing to provide DME to these customers.
Here is a section of the information received from CMS regarding Medicare Advantage plan requirements:

“While MA plans are required to furnish all medically necessary Medicare-covered DME, they are not required to follow original Medicare payment rules in furnishing those services. MA plans will generally furnish MA enrollees with all medically necessary DME through contracted DME suppliers. Since MA plans are capitated by CMS, the MA plan is financially responsible for furnishing all medically necessary, Medicare-covered services, which of course includes DME items and supplies. In addition to their financial and coverage responsibilities, MA plans have the ability to negotiate prices with their contracted providers and also to use utilization management tools consistent with Medicare coverage standards.”

What this means is if an MA plan determines that it is best for them to rent complex rehab power wheelchairs rather than extending the purchase option that is available to original Medicare beneficiaries, they can do that. They can negotiate reimbursement prices, as well, and from what providers are experiencing, some are also denying accessories that original Medicare allows per policy. A recent widespread example: electronics (E2377, E2311 and E2313).

Providers need to be aware of these other ways MA plans can provide more for less, while incurring the costs of all those commercials with celebrities. This other way squeezes the DME supplier and is impacting access, as more and more suppliers are saying no to contracts or customers with one of these plans.

What can you do?

First, review all contracts thoroughly and make sure it’s clear what they pay and how they pay (rental/purchase). Don’t just accept, “We follow Medicare guidelines,” because that doesn’t mean they follow Medicare’s payment rules since they are not required to per CMS. If you can’t accept what they offer, don’t. Try to negotiate a fair contract and if they won’t, don’t accept it.

Second, educate MA plan customers that you can’t accept their insurance and the reason why. They are only hearing from celebrities promoting their plans of how great they are, but not how they negatively impact their true medically necessary benefits with unsustainable prices and payment methods (13 month rental for complex rehab power wheelchairs and accessories). While the MA plan customer may be able to get a gym membership and eyeglasses, they may not be able to obtain the wheelchair they need. Educate them that they can select original Medicare FFS (switch back), if they find that the MA plan isn’t as good as the celebrities made it appear.

Please notify Medicare recipients struggling with making sense of all these plans and their sales pitches that they can call 1-800-633-4227 (1-800-Medicare) to speak to a Medicare representative for accurate unbiased information about selecting the best plan for them.

Dan Fedor is the director of reimbursement and education for U.S. Rehab, a division of VGM. Reach him at dan.fedor@vgm.com.

by: Bradley Smith - Tuesday, October 1, 2019

When AdaptHealth's plan to become a public company was announced in July, ears perked up throughout the HME industry. New IPO listings by DME providers are rare. That could change following Adapt’s IPO.

To recap, Adapt will combine with DFB Healthcare Acquisitions Corp., which is currently traded on the NASDAQ under symbols DFBH and DFBHW. Once the combination of companies is completed, it is expected that DFB will change its name to AdaptHealth Holding Corp. and remain listed on the NASDAQ under a new ticker symbol (yet to be determined). As a press release on the merger noted, this new entity intends to continue Adapt's aggressive acquisition strategy. Since 2012, the provider has acquired 56 companies with an aggregate purchase price of approximately $286 million and has identified a significant volume of potential acquisition opportunities it plans to target late this year into early 2020.

So, why is this news so significant? Compared to other industries, the number of publicly traded DME providers is below average. The DME providers that are publicly traded include well-known national companies, such as Lincare, Inogen, VieMed and Protech.

However, there is a significantly larger portion of national or regional providers that remain privately held. Many of these companies are backed by private equity. The majority, if not all, of these providers grow via a similar buy-and-build strategy that their private equity business partners accelerated. Adapt's success is greatly attributable to this strategy.

When Adapt goes public, I expect the market to respond favorably. Historically, public markets respond positively to companies that embrace a growth-through-acquisition strategy, with stock prices increasing incrementally with each successful acquisition. If this trend continues following Adapt's IPO, one can expect private equity-backed DME providers to line up at the NASDAQ, eager to cash in their chips. The most likely suspects include AeroCare, Apria, Rotech (again), Community Surgical and Shield.

Bradley Smith, ATP, CMAA is a former DME owner, and is currently a Managing Director/Partner with the international healthcare M+A firm, VERTESS.  Reach Brad directly at (817)793-3773 / bsmith@vertess.com.
 

Kathy Lester
Executive director of the Council for Quality Respiratory Care

As we head into the final stretch of bidding for Round 2021 of competitive bidding, suppliers across the country are realizing just how different the program is now compared to the past.

One question I hear a lot is: How does capacity and demand influence the payment rate that CMS sets? Since this is one of the most technical—but important!—pieces of the competitive bidding program, I’m here to break it down and help you feel more confident when you go to submit your bid.

In short, the capacity you submit in your bid can have major impacts to the competitive and noncompetitive rates for Round 2021, so it is critical to get it right. To understand how this all works, let’s explore the impact of capacity and demand in how CMS sets rates.

Why do capacity and demand matter?

Capacity is a critical component of each bidder’s bid because CMS uses it to determine the “maximum winning bid,” which is essentially the clearing price for the lead item. At the same time, CMS also uses beneficiary demand to determine the winning bid. These two numbers influence the final rate just as much as the bid you submit.  CMS then uses the maximum winning bid to set the single payment amount (SPA). Then the SPA essentially becomes the basis for the rate in non-CBAs and the SPA plus 10 % is essentially the rate for the non-CBAs defined as rural.

For bidders, thinking about cost is not enough. You must also think about your capacity. The greater your capacity, the greater role your bid amount will have in the process of setting the final SPA. When bidding, overestimating your capacity has the potential to influence payment amounts based on inaccurate information. It is the bidder’s responsibility to get the capacity number right.

In addition, beneficiary demand plays a critical role in setting SPA rates. For each lead item, CMS determines beneficiary demand based on the historic beneficiary utilization of each lead item and will increase that historical utilization by estimating the projected increase in the number of beneficiaries in the CBA and the projected increase in the utilization of the lead item in the CBA.

How does CMS define capacity?

There are two components of capacity. The first is historical capacity, using the most recent 12 months of claims data to show what your capacity was during the last year. The second part is estimated future capacity, which is the “number of lead item units that (a supplier) believe(s it) can furnish in the competitive bidding area (CBA) in one calendar year.” Unlike previous years, CMS no longer requires expansion plans from bidders.

Note that CMS will undertake a ramp up revenue review to determine if a bidder has sufficient funds to furnish the number of lead-item units it estimated for future capacity. To do so, CMS will multiply the bidders’ projected growth by the preliminary SPA then divide that number by the bidder’s actual revenue to create a percentage. If CMS finds that the bidder overestimated capacity, then CMS will reduce the capacity and additional bidders are needed.

Because capacity is used to set the SPA, CMS will then use bidders’ capacities to determine where the bidders’ capacities equal demand, starting with the lowest bid amount working up. The greater a bidder’s capacity, the fewer suppliers will be needed to establish the maximum winning bid, which will lead to a lower SPA.

How does CMS adjust bidders’ capacity?

After bids are submitted, CMS will review each bidder’s capacity amounts and may alter them. The process works like this: First, each bidder defines its estimated capacity in the bid it submits. If the bidder meets the financial threshold set by CMS, then CMS will use the greater of the bidder’s estimated capacity or historical capacity. To ensure competition between at least five bidders in each CBA for each product category, CMS will cap the bidders’ capacity at 20% of demand.

In some instances, CMS may adjust a bidder’s estimated capacity down. If a bidder has no experience in the product category or CBA, CMS will adjust the capacity down to zero. If a bidder demonstrates experience in the product category and the CBA, CMS will use the highest capacity amount (historic or estimated future capacity). And if the bidder has experience providing the product category but not in the CBA, CMS will use a formula to adjust and discount the estimated capacity.

If a bidder’s capacity is lowered and CMS determines demand for the CBA/product category has not been met, then additional bidders will be added until the capacity is meant, which will increase the SPA.

Conclusion

As you can see, capacity and demand are critical to setting rates in competitive and noncompetitive bid areas. Ultimately, it is up to bidders to ensure that all information about their capacity is accurate.

To learn more about this important process, visit the CBIC website or the industry’s education website, which also offers useful explanations, tutorials, bid calculators and more.

Kathy Lester is executive director of the Council for Quality Respiratory Care.

Don Clayback
executive director of NCART

You probably can feel it in the air. You’re sensing that this is not just any ordinary day and you’re right. Since it’s Monday, we’ll help explain that feeling. Today, Aug. 19, is the first day of National CRT Awareness Week.  

National CRT Awareness Week is being held to increase awareness of what Complex Rehab Technology (CRT) is, the important role it plays in the health and independence of children and adults with disabilities, and the need for Congress to pass pending legislation to protect CRT access.  

The focus of the week is to spread the CRT message. That CRT consists of medically necessary and individually configured manual and power wheelchairs, seating and positioning systems, and other adaptive equipment. That this specialized equipment is critical to people with significant disabilities to help manage their unique medical needs and to maximize their function, independence and access to the community. And that the proper provision and use of CRT reduces medical complications, clinical interventions, hospitalizations, institutionalizations, as well as the need for long-term care and support.

The good news is that everyone can take part. Many organizations already have their plans in place and we’re looking for others to join in. Here are some ideas for how to get involved either this week or as we move through the rest of the month:

  • Invite everyone in your organization to visit www.protectmymobility.org and send emails to Congress (or make phone calls). Include your customers, patients and others.
  • Use social media to tag your members of Congress in a post asking them to co-sponsor and pass our CRT bills.
  • Create a video of yourself or a group explaining the importance of CRT and asking others to visit www.protectmymobility.org. Be creative and share on social media.
  • Schedule a meeting with your members in their district offices and bring along other constituents to share their perspectives on CRT access.
  • If appropriate, invite your members or their staff to visit your facility so they can see how unique CRT is for themselves.


This is a key time for CRT advocates to be taking action as Congress is in recess and your members are back in your home districts. Once Members return to the Capitol in September they'll be discussing and voting on important legislation.

We want our CRT bills to be included in those conversations:

Protect Complex Rehab Wheelchairs – This is the first of our two legislative initiatives. H.R. 2293, introduced by Reps. John Larson, D-Conn., and Lee Zeldin, R-N.Y., and S. 1223, introduced by Sens. Bob Casey, D-Pa., and Rob Portman, R-Ohio, will halt inappropriate Medicare payment cuts for critical components of complex rehab manual wheelchairs and permanently exclude them from the competitive bidding program.

Create CRT Separate Benefit Category – This second legislative initiative represents needed comprehensive change. H.R. 2408, introduced by Reps. Jim Sensenbrenner, R-Wis., and Brian Higgins, D-N.Y., will establish a separate benefit category for CRT within the Medicare program to allow better access and safeguards through proper segregation and improvements in coverage, coding and supplier standards.

National CRT Awareness Week is a great opportunity to help spread the CRT message and encourage others to get involved. Use the email links, phone call guides, and other background information at www.protectmymobility.org and add your own ideas. Thanks for letting your members of Congress know their constituents at home want them to pass pending CRT legislation to protect important access for people with disabilities.

Don Clayback is executive director of NCART. Reach him at dclayback@ncart.us or 716-839-9728.

Topic:


Attention to detail is everything.
 
History is full of examples when overlooking small details led to much larger problems. From the leaning tower of Pisa, which was built on soft ground causing it to tilt, to a missing key that prevented the Titanic’s lookouts from getting binoculars to spot icebergs in the water, careful planning is critical.
 
So when it comes to Round 2021 of the Medicare Competitive Bidding Program (CBP), which opened for bidding in mid-July, bidders must pay close attention to cross their Ts and dot their Is.
 
The new bidding process is much improved from the CBP of the past. But being so different, it is vital that all suppliers who plan to submit a bid understand the new changes. As you examine how you might bid based on lead-item pricing, the clearing price rate setting, and new higher bid ceilings—among other important changes—don’t forget about the Process for Reviewing Covered Documents. 
 
To have your “covered documents” reviewed by the CBIC for completeness, bidders must submit those documents through the Connexion platform by the covered document review date deadline of Aug. 19. A covered document “means a financial, tax, or other document required to be submitted by a bidder as part of an original bid submission under a competitive acquisition program to meet the required financial standards.” For Round 2021 of the CBP, these are the tax return extract, income statement, balance sheet, statement of cash flow, and credit report with numerical credit score or rating.
 
With so many details that you need to cover, it might be easy to forget to upload one or more required financial documents into the Connexion platform. But just as even the best laid plans can fall apart due to one missing piece, so can your bid if you fail to submit all of the required financial documents that the CMS requires. The covered document review process will provide you peace of mind, knowing that your financial document submission is complete and properly submitted through the Connexion platform. Bidders should therefore make every effort to take advantage of this process.
 
Bidders who upload their covered financial documents in the Connexion platform before Aug. 19 are included in the Covered Document Review Process (CDRP). During this process, CMS will determine if any of your required financial documents are missing and will alert you within 90 days so that you may upload them. After the bid window closes on Sept. 18, only the covered documents identified and requested in a written notification from the CBIC as a result of the covered document review date (CDRD) process will be considered. Therefore, the Covered Document Review Process is a great opportunity for you to keep your Round 2021 bid on track. While the CDRP does not determine if your required financial documents are accurate, acceptable, complete, or in accordance with RFB instructions, many suppliers will find it quite useful to ensuring they submit every required piece of information.
 
We urge every supplier who plans to bid to submit all of their required documents early so that they can take advantage of this opportunity.

For more information, visit the CBIC website or the industry's education website.
 
Cara Bachenheimer leads the Government Affairs Practice at Brown & Fortunato and Kim Brummett is Vice President of Regulatory Affairs at the American Association for Homecare.

Nick Macmillan
Nick Macmillan is director of market access and strategy for Ventec Life Systems

What is a multi-function ventilator?

CMS defines a multi-function ventilator as a single device that integrates a ventilator, portable oxygen concentrator, cough stimulator, suction and nebulizer, which traditionally requires a separate piece of equipment for each therapy. VOCSN is the only device that integrates all five therapies and qualifies as a multi-function ventilator.

Who is eligible for a multi-function ventilator?

Any new ventilator user that qualifues for a ventilator and at least one of the four additional functions of the device (oxygen, cough, suction, nebulizer) is eligible for VOCSN. Specifically, current ventilator users that meet one of the equipment rental schedules below are eligible for VOCSN:

  • Ventilator users that have used cough, suction, and nebulizer for less than 13 months, meaning title of the capped rental item has not transferred to the patient.
  • Ventilator users that have used oxygen therapy for less than 36 months, meaning title has not transferred to the patient.
  • Ventilator users that own one of the rental items (or reached the 36-month cap for oxygen) but have exceeded the reasonable useful life of five years and are eligible for a new device.


How does this ventilator code differ from existing HCPCS codes for invasive and non-invasive ventilators?

E0467 provides a higher monthly reimbursement rate than E0465 (invasive) and E0466 (non-invasive) and can be applied to patients using the multi-function ventilator for invasive, non-invasive, and/or mouthpiece ventilation.  

What are the benefits of billing E0467?

DME providers can bill a single code that is uncapped and no longer need to track different rental schedules for the different devices that transfer ownership after 13 or 36 months. For example, a DME in Arkansas billing multiple codes for a patient using a traditional ventilator, portable suction pump, and nebulizer would see an increase in reimbursement of $3,222.15 after the first 12 months and an increase of $10,988.26 after 36 months when billing a single code for a multi-function ventilator under E0467.

What payers are covering the VOCSN multi-function ventilator?

VOCSN is billable under HCPCS E0467 as a multi-function ventilator and reimbursable under the Medicare fee schedule. TRICARE uses the same Medicare reimbursement rates established by CMS. Adoption of E0467 for reimbursement by private payors and Medicaid is rapidly expanding and new payers are added weekly. Generally, both Medicaid and commercial payers follow the E0467 reimbursement guidance to pay approximately 20% more than their current ventilator reimbursement.

Can you bill for a second purpose ventilator?

Billing for a secondary multi-function ventilator also follows the same eligibility guidance that requires medical necessity for the secondary multi-function ventilator to serve a different medical purpose that is determined by the beneficiary’s medical needs (i.e. a beneficiary who is confined to a wheelchair and requires a ventilator mounted on the wheelchair for use during the day and needs another ventilator of the same type for use while in bed).

Is E0467 subject to competitive bidding?

Even though VOCSN can provide invasive, non-invasive, and mouthpiece ventilation, E0467 is not subject to the competitive bidding process.

For more information, join an upcoming webinar on August 14.  

Nick Macmillan is director of market access and strategy for Ventec Life Systems.

Doug Westerdahl
president and CEO of Monroe Wheelchair

In today’s world, navigating the insurance industry can be difficult. It can be especially hard for those with complex disabilities. This group of people depends on complex rehab technology (CRT) to live an independent life. CRT is used by people with complex medical needs and includes equipment like individually configured wheelchairs, custom seating systems, adaptive bathing equipment and gait trainers.

Currently, Medicaid does not have concrete guidelines to protect CRT in New York State. There is no guarantee that individuals with complex disabilities will have appropriate access to the items and services that they require. The Governor has a chance to do what is needed by signing the A7492/S5741 bill into law to preserve the independence, improve the quality of life, and reduce the health care costs of New Yorkers across the state who depend on it. 

I am the owner of Monroe Wheelchair, a complex rehab technology supplier based out of Rochester with branches in Albany and Syracuse. I’ve been in this business for 40 years and am proud to say we have grown to a company of 92 employees providing equipment and supporting services to more than 15,000 people with disabilities across the state. A large portion of what our company provides is CRT. 

The process to provide CRT is meticulous and labor intensive. A specially trained and credentialled assistive technology professional (ATP), is needed to work with each of our CRT customers. Their role is to ensure that medically appropriate equipment is built from the ground up to support each individual’s unique physical and functional needs. 

The process begins with collecting medical documentation to be reviewed to determine necessity, and all functional mobility evaluations must be conducted by clinicians. Demo equipment must be tested, authorizations obtained, and each component must be coded, ordered, pieced together, delivered and billed correctly. The entire process can take anywhere from 60-120 days and is a far cry from providing standard durable medical equipment where someone could walk into the store with a prescription from their doctor and leave 30 minutes later with their new equipment.

Insurance coverage for CRT has changed over the years, making it increasingly challenging to continue offering this service to our community. Reduced reimbursements, budget cuts, changes in policy or coverage, and archaic coding systems are additional hurdles that threaten how and what my company is able to provide, while still offering excellent service and keeping our doors open. 

I want to see this specialized equipment protected and defended because I understand its importance. This bill has been passed by the New York State Legislature and it would protect individuals with complex needs without adding additional cost to the state or its taxpayers. All that is needed now is the signature of the governor.  To me, my employees, the clinicians we work with, and the people with disabilities that we serve, signing this bill into law is a no-brainer. Our collective hope is that Gov. Cuomo feels the same way. 

You can help us fight for this needed bill. Tell Gov, Cuomo why it matters to you by visiting www.protectCRT.org.

Andrea Stark
reimbursement consultant, MiraVista

With CMS launching a new mandatory prior authorization program for group 2 support surfaces in July, suppliers are understandably concerned about accommodating patients with immediate needs for pressure support, particularly upon hospital discharge.

Discharge planners typically start care coordination when the doctor signs the order to go home. Suppliers point out that the authorization process takes time. Suppliers must gather supporting documentation from multiple sources, and contractors will scrutinize requests before approving them.

Unlike many other conditions requiring home medical equipment, those treated with group 2 support surfaces rarely develop overnight or go unnoticed by admitting clinicians. To avoid delays in delivery and extended hospital stays, coordination among hospitals and suppliers must begin at admission for beneficiaries in need of pressure support.

Patients qualify for group 2 support surfaces via three pathways:

  • Multiple stage II ulcers on the trunk or pelvis, with evidence of prior treatment for at least a month using a Group 1 support surface and a comprehensive ulcer treatment program.
  • Large or multiple stage III or IV ulcers on the trunk or pelvis.
  • Surgical procedure for a myocutaneous flap or skin graft.


Suppliers should:

  • Develop standard procedures to obtain prior authorizations.
  • Educate hospital staff about the new mandatory prior authorization program.
  • Request contact upon admission when ulcers or other qualifying conditions are present.


Though there is no published guidance at this time, authorizations should remain effective between one and six months after approval.

Bob Dylan probably didn’t have durable medical equipment (DME) in mind when he sang “The times they are a-Changin.” But that memorable refrain could easily apply to Medicare’s DME competitive bidding program (CBP), which will implement a brand new process for bidding this June.
 
With big changes to the competitive bidding program fast approaching, it is vital for medical equipment providers and suppliers to understand how the new process works so they can prepare to place bids that promote both maximum patient access and industry sustainability.
 
What’s changed

It is well known that the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires Medicare to replace the current fee schedule payment methodology for selected DMEPOS items with a competitive bid process. In early March, the CMS announced plans to consolidate the competitive bidding areas (CBAs) included in the Round 2 Re-compete and Round 1 2017 DMEPOS CBP into a single round of competition named “Round 2021.”
 
Key changes include:

  • Use of the “clearing price” to set rates: The single payment amount (SPA) for a lead item will be equal to the maximum bid submitted for that item by bidders whose lead item bids for the product category are equal to or below the pivotal bid for that product category in a CBA.
  • Lead-item pricing: To allow for the use of what is essentially a “clearing price” methodology, suppliers will submit a single bid for a lead item in the product category. The SPA will be calculated for that lead item in the CBA based on the highest amount bid within the winning bids. The SPAs for non-lead items will be based on the relative difference in the fee schedule amounts for the lead and non-lead items.
  • Bid surety bonds: Bidders must obtain a $50,000 bid surety bond for each CBA for which they submit a bid.
  • Use of SPAs to set rates in non-CBAs: CMS also uses the SPAs to set the rates in non-CBAs that are not rural but will set the rural non-CBA rates at what is essentially the SPA plus 10% in rural areas. This means the bids for CBAs will have a direct impact on the rates in non-CBAs.

 
Resources

To help providers get up to speed, a group of industry leaders collaborated to launch an online educational resource: www.dmecbpeducation.com. The website—the product of a collaboration between the American Association for Homecare, the Council for Quality Respiratory Care, the Healthcare Nutrition Council and the VGM Group—serves as a complementary resource to the Competitive Bidding Implementation Contractor (CBIC) website.
 
Suppliers and prospective bidders nationwide can use the website’s powerful calculators to estimate how lead item pricing may impact costs and compare them to an approximation of how the SPAs compare to the current 2019 Medicare rates. The calculator will also show how a bid would affect the rates in non-CBAs if it became the SPA. Moreover, the website will also serve as a platform for webinars and events intended to educate prospective bidders about the CBP in the lead-up to the bidding round.
 
Since bidding is no longer business as usual, all providers who plan to compete should visit www.dmecbpeducation.com and the CBIC website to learn more about how these changes will impact them. And with the bidding period set to launch in June, time is of the essence.
 
So, DME providers, get ready. As Bob Dylan famously sang, “If your time to you / Is worth savin' / Then you better start swimmin' […] for the times, they are a-changin’.”
 
Cara Bachenheimer is Head of the Government Affairs Practice at Brown & Fortunato and General Counsel for the American Association for Homecare. Mark J. Higley is Vice President of Regulatory Affairs for VGM Group, Inc. Robert Rankin is Executive Director of the Healthcare Nutrition Council. Dan Starck is Chair of the Council for Quality Respiratory Care.

Several million Americans rely on Medicare as their main source of health insurance coverage, particularly those over the age of 65. Through Medicare, several options are available for how medical bills for things like prescriptions, exams, tests and medical equipment are paid for by the federal government or the individual insured under the plan. When it comes to durable medical equipment, such as blood sugar monitors, canes, wheelchairs and nebulizers, individuals covered under a Medicare plan often work with special suppliers to get the items they need to remain healthy.

Individuals or companies that work as durable medical equipment suppliers must meet specific requirements to comply with Medicare laws and regulations. One of these requirements, a durable medical equipment surety bond, relates to the prevention of fraud against patients. Here’s what you need to know as a durable medical equipment supplier and your surety bond requirements.

What is a durable medical equipment surety bond?

A durable medical equipment surety bond is a federal surety bond required under CMS. Any supplier of durable medical equipment, including orthotics, supplies, and prosthetics, must have a bond for each location in which they utilize Medicare billing. The purpose of this surety bond is to reduce fraudulent billing of Medicare, protecting the system as well as its patients.

When a supplier has a durable medical equipment surety bond, a claim against a billing practice is submitted to the bond or surety company to help cover financial losses or other damages. The bond helps create a foundation of legitimacy for suppliers while safeguarding the Medicare system from erroneous charges or billing over time.

How much is required?

The surety bond requirement for durable medical equipment suppliers went into effect on a federal level in 2009, as published in the Federal Register. The amount of the bond is no less than $50,000 per location where billing to Medicare takes place. Each supplier is required to have this amount of a surety bond to ensure it complies with the law.

Some medical equipment suppliers are exempt from the surety bond requirement, however. Those that are government-owned, state-licensed personnel operating private practices with custom orders, and some physicians and non-physician providers are not required to have the same federal surety bond.

How to get it and cost

Securing a durable medical equipment surety bond for your supplier business is not a difficult task. However, it does require you to work with a reputable surety agency that understands the requirements set forth for suppliers that bill through Medicare. Each surety agency will have its own process for getting a surety bond, but they all begin with an application that includes details about the business, the amount of the bond, the state in which the business operates, and your credit history.

Surety agencies look into your financial track record because the bond itself is a form of extended credit. If you have less than ideal credit, you can still get a durable medical equipment bond, but the cost of that bond may be higher. Regardless of your financial history, a durable medical equipment surety bond is priced as a percentage of the total bond amount, so the expense is often minimal to suppliers.

Getting a surety bond for your durable medical equipment supplier business is a crucial component of operating legally. The process is simple, but it is necessary to understand this requirement before working with Medicare patients to meet their medical equipment needs.

Eric Weisbrot is the chief marketing officer of JW Surety Bonds.

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