Impact of Medicare DME Reprocessing Claims due to 21st Century Cures Act
By: Rebecca Ingalls, Mediware Reimbursement Services
As if billing for DME supplies and services was not already challenging enough, providers need to be aware of the massive change that CMS has implemented that impacts 36,000 claims each day for 24 weeks total. The 21st Century Cures Act (CR9968) is now responsible for CMS conducting adjustments to fee amounts for certain DME competitive bid items with claim dates of services July 1,2016-December 31, 2016. During this six month period, providers were paid less for their services, and now are being reimbursed slightly more based on the new fee schedule amounts. Depending on the jurisdiction you fall under will depend on how fast the claims are being reprocessed. For jurisdiction D, all claims were reprocessed within 9 weeks. This sounds great to be paid more money for your services, but this creates many new issues that the provider now has to manage. See below for several things the provider needs to be aware of during this transition period.
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- How do I know if the claim is reprocessed? Claims that are reprocessed will have a code of N689. At this point the provider will need to look at their A/R, it will no show a negative balance on your records, so you will need to adjust this claim so that it doesn’t make your DSO grow higher.
- Evaluate options for secondary insurance and patient pay: With the claims being well over one-year old at this point, it is likely that the balance is paid off and the claim is resolved. Now with the new fee schedule amounts, this will create the issue of claims being sent to secondary insurance or if the patient doesn’t have a secondary insurance, it will show the patient has a balance now with a low dollar amount or even pennies remaining they owe you. Since these amounts are low, it may be in the best interest of the provider to not bill the patient for the meager balance and keep this balance on file, and when the balance gets to $5.00 or higher they can send an invoice. If you send an invoice now for a small balance, this will cause further confusion with the patient when they won’t recall the services that were provided one year ago.
- Look closely at oxygen claims: When CMS is reprocessing the claims, it can create an issue with the CMN, where they are processed with the corrected amount but they are also adding in another unit against the CMN, which impacts your number of CAPPED units used. The provider will need to look at the amount of units in the Medicare system compared to what you billed to ensure the correct number is in fact showing with Medicare.
- Caution on overpayment concerns: CMS has mentioned on their website that when they are reprocessing the claims, there is a likeliness of an overpayment. This is due to patients that are in a SNF, HHH, etc. for the date of service on the claim. In this case the provider will receive an overpayment demand letter. Even though this is time-consuming, it is in the best interest of the provider to send any overpayment amount back to CMS to avoid further issues down the road.
- KE Modifier: if your claims required a KE modifier, you have to appeal your claim with specific guidelines. Use a reopening request form to submit for these specific claims.
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