DME Billing Solution
It is a known fact that DME providers are already facing a lot of problems with the increasing confusion in insurance benefits and medical claims. A synchronized effort with the right design, transformation process with the help of intelligent revenue cycle management processes that adapt well with the market realities is the need of the hour!
Impact of Medicare DME Reprocessing Claims
DME providers need to be more aware of the massive change that CMS has implemented impacting over 36,000 claims each day for a total of 24 weeks. The 21st century Cures Act (CR9968) is now responsible for the CMS conducting adjustments for fee amounts for certain DME competitive bid items with claim dates of services July 1 2016- December 31st 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.
How do I know if the claim is reprocessed?
DME claims that are getting reprocessed will have a code of N689. At this point of time, the provider will need to look at their A/R and it will show a negative balance on your records. You will need to adjust this claim so that is higher your DSO!
The key areas with the Physician signature, documentation, coding practices, dispensing of the DME equipment, eligibility verification and authorization process with the patients has to be a streamlined effort.
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.
Caution on over payment concerns
CMS has mentioned on their website that when they are reprocessing the claims, there is a likeliness of an over payment. 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 over payment demand letter. Even though this is time-consuming, it is in the best interest of the provider to send any over payment 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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