We have an oxygen patient whose doctor, for whatever reason, will not complete the recert CMN. This was not an issue for a few months when the patient moved to a Medicare HMO, but he is back on FFS Medicare and we are not getting paid. One of my bosses insists that we can bill the patient since he signed our service agreement. I know this isn't true, but I can't find it in simple enough language to prove him wrong. Can anyone help me?
As DME is subject to MANDATORY CLAIMS SUBMISSION the Medicare beneficiary is protected from owing any monies for certain denials such as "not medically necessary". These are the "CO" denials. Show your boss the definitions of these denials, from the Medicare Remittences, along with the penalties that go with not doing these correctly. Then have your boss read this from the CMS manual:
For an ABN to be acceptable, it must:
• Be on the approved CMS-R-131 form;
• Clearly identify the particular item and/or service;
• State that the supplier believes Medicare is likely (or certain) to deny payment for the particular item and/or service; and
• Give the reason(s) for belief that Medicare is likely (or certain) to deny payment for the item and/or service.
The purpose of the ABN is to inform the beneficiary that Medicare will probably not pay for a certain item and/or service in a specific situation, even if Medicare might pay for the item and/or service under different circumstances. This allows the beneficiary to make an informed consumer decision about whether or not to receive the item and/or service for which they may have to pay out of pocket or through other insurance.
ABNs apply to assigned and nonassigned claims, as there are financial liability provisions under Medicare law for both claim types.
If a supplier renders a service which Medicare considers not medically necessary to a beneficiary, the supplier should notify the beneficiary in writing, before rendering the service, that Medicare is likely to deny the claim and that the beneficiary will be responsible for payment. Modifier GA (Waiver of Liability statement on file) should be appended to the claim with the appropriate Healthcare Common Procedure Coding System (HCPCS) code when filed.
The following statements are examples of reasons for belief that Medicare is likely to deny payment:
• Medicare does not usually pay for this many treatments or services
• Medicare usually does not pay for this service
• Medicare does not pay for this because it is a treatment that has yet to be proved effective (experimental)
• Medicare does not pay for this many services within this period of time
• Medicare does not pay for such an extensive treatment
General statements such as "Medicare may not pay" are not acceptable.
The beneficiary or his/her representative has the right to appeal a claim decision if there is dissatisfaction with the amount of payment, denial of coverage for services or supplies, or if the original claim was not acted upon within a reasonable time. The supplier has the right to appeal a claim decision when assignment has been accepted.
Before submitting a claim to the DME MAC, the supplier must have on file:
• A verbal/dispensing/preliminary order,
• Detailed written order,
• Certificate of Medical Necessity (CMN) (if applicable),
• DME Information Form (DIF) (if applicable),
• Proof of delivery,
• Beneficiary authorization,
• Advance Beneficiary Notice of Noncoverage (ABN) (if applicable),
• Information from the treating physician concerning the patient's diagnosis (if an ICD-9-CM code is required on the claim), and
• Any information required for the use of specific modifiers or attestation statements as defined in certain DME policies.
The documentation in the patient's medical record does not have to be routinely sent to the supplier or to the DME MACs, DME PSCs, or ZPICs. However, they may request this information in selected cases. If they do not receive the information when requested or if the information in the patient's medical record does not adequately support the medical necessity for the item, then for assigned claims the supplier is liable for the dollar amount involved unless a properly executed ABN for possible denial has been obtained. See the chapter entitled "Claim Submission" (Limitation on Liability section) for information on ABNs.
We have found that the beneficiary is much more likely to get results from the physician than we are. If you 1) have the beneficiary sign the ABN (stating that the reason for expected non-coverage is the lack of medical necessity documentation required for Medicare coverage); 2) explain that the beneficiary will be expected to pay the entire bill monthly (you will submit unassigned claims with ABN); and 3) hand the beneficiary the forms that need completed and tell him that all of this can be avoided if he brings them back properly completed by his physician, you will probably have better luck than you will badgering the physician's office.
ABN issue
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