A payment authorization that allows a supplier to submit monthly claims. rentals...what does the patient have to sign monthly?

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1 s and s: Billing Non-Assigned Brown & Fortunato presented several webinars, in the summer and fall of 2016, on billing non-assigned. During the course of the webinars, a number of questions were posed by webinar attendees. Set out below are the questions and Brown & Fortunato's answers. This report is for informational purposes only. This report is not intended to be legal advice and should not be relied upon by the reader without consulting his/ her health care attorney. If you have questions, contact Jeffrey S. Baird, Esq., (806) , jbaird@bflaw.com. Question Being a provider in a rural, non CBA area, do you have any advice or suggestions regarding home oxygen? Can you accept assignment on the concentrator and not accept assignment for the portable gaseous system? If so, could you then have a price of "x" dollars per tank, applicable to all payors? We trans fill our own tanks, but it still does not seem feasible for any patient to be allowed an unlimited number of tanks, especially with the new fee schedule. if you set up a company without ptan and just do retail sales can it be in the same building as your business that has a ptan and does bill insurance?? It is my understanding the requirement for monthly signature from the bene for non assigned claims was found in Jurisdiction C? Does this then apply to all Jurisdictions if it is not included in their guidelines? If we do not have to get an ABN monthly for billing nonassigned rentals...what does the patient have to sign monthly? If the client agrees to purchase a neb from a CBA provider as cash/carry (ABN) etc. Is the client able to receive covered Neb medications from a pharmacy? If the client resides in a CBA and obtains the neb as cash/carry with ABN from a NON CBA winner is the client able to receive Medicare covered neb medications from a pharmacy? During the rental period the content for the portable is included in the payment for the concentrator. It may be better to provide nonassigned on the concentrator and assigned on the portable equipment. After the 36 month, there is concern with adjusting the price on the non assigned portable contents based on tanks used and then whether this would apply to all payers. CMS has issued no guidance on what suppliers can do in this instance. It could be perceived as unbundling as Medicare requires oxygen content to be paid at a bundled rate. Yes, but the operations of the two companies should still be physically segregated so it is clear which inventory, employees, etc. belongs to each operation. The monthly signature authorization requirement for non assigned rental claims is also set out in federal regulations, so is applicable to all Jurisdictions. A payment authorization that allows a supplier to submit monthly claims. The nebulizer medications should be covered if all of the following information is submitted with the initial claim in Item 19 on the CMS 1500 claim form or in the NTE segment for electronic claims: HCPCS code of base equipment,a notation that this equipment is beneficiary owned and the date the patient obtained the equipment. Is the Medicare fee schedule (on capped rental items) still going to be reduced by 25% after the 3rd month? [note: asked similar question during webinar] If we don t accept assignment for an item and charge above Medicare s allowable, may secondary (non supplemental) pick up the extra? Is there a modifier that will trigger this? [note: asked a similar but shorter version of this during webinar] So if we are a Medicare participating provider, are we able to bill unassigned? Yes If you do not accept assignment on an item, the billed amount will be whatever amount you choose to set. The secondary would not typically pay the difference between your billed and allowed charge. This is typically disallowed by secondary payers. There is no modifier to trigger this. No, Medicare participating suppliers are required to accept assignment for all items or services provided to a Medicare FFS patient. Questions and s: Billing Non Assigned 1 of 14

2 If all non assigned claims have the signed ABN, is there still a risk for the provider to have to pay back prepayments? If you are PAR provider with commercial insurance can you bill items non assigned to reimburse prepayments to patient. Also does the signed ABN apply to commercial insurances? There is virtually no published information from Medicare on the risk of liability for non assigned claims. I would be sure that the intake process is the same for assigned and non assigned items. If the patient does not meet medical necessity criteria and you choose to provide and bill non assigned, an ABN should be issued and assuming the ABN is valid, you should not have liability. If the patient did meet medical necessity criteria and you choose to file non assigned claims, you may be liable if the claim is audited. The supplier should not routinely be obtaining an ABN for all nonassigned claims. An ABN should be issued only when the supplier reasonably believes that the claim will be denied. In the instance that a non assigned claim is reviewed and payment denied, the supplier will usually be required to refund the amount collected back to the Medicare beneficiary unless a valid ABN was obtained. ABNs do not apply to commercial payers, refer to your contract with the payer to determine what your options are related to nonassigned billing. If you are a PAR (which I assume to mean contracted supplier) with a commercial payer, refer to your contract. Typically a supplier cannot do non assigned billing to a contracted payer. Can we continue to sell CPAP supplies to our current patients non assigned if we stop taking any new Medicare patients? If you are not a contracted supplier in a CBA, you can choose to provide CPAP supplies non assigned and not take any new Medicare patients. We would like continue to service our oxygen patients through the 5 year mark and then recommend that they find another supplier at that point, because I doubt any company would take them in the middle of their rental period. If we do this, do we also have to stop taking the Medicaid patients? Would we lose our Medicare supplier number if we do this? Do we need a Medicare supplier number to bill Private Insurance? You can choose not to service Medicare beneficiaries oxygen after the 5 years. Suppliers are obligated to provide oxygen equipment once they submit the first rental claim through the 5 year mark, unless the patient chooses to change suppliers. You cannot force patients to go to another supplier mid rental. Each state Medicaid has their own rules, if you have a Medicaid supplier number you can choose to accept or non accept these patients. Suppliers who do not bill the Medicare program at all will lose their supplier number after 12 months of no billing. Private insurance decides what their criteria are to be able to participate with that insurance. Some do require suppliers to be able to bill Medicare. Refer to your payer requirements. Many Medicaid programs require you to be enrolled with Medicare. Questions and s: Billing Non Assigned 2 of 14

3 Our question is can we stop doing all categories of DME for Medicare except oxygen? We would not bill assignment or non assignment, but we would sell these items on a cash basis. Would we have to get a signed ABN if someone wanted to cash purchase a covered item? Could we still bill other insurances for the same categories we stopped doing for Medicare? Or would we have to stop accepting Medicare all together? [note: asked a similar but shorter version of this during webinar] If supplier has Medicare PTAN, it is required to submit claim for any Medicare covered item provided to patient, either assigned or non assigned. It cannot refuse to submit claim if item if potentially covered by Medicare. Would need to get an ABN signed if supplier believed Medicare would deny claim. A supplier can refuse to take care of a Medicare patient if not in a CBA. Are we obligated to get all the same paperwork, medical necessity, face to face etc. if we are going to file non assigned? Do you have to have an ABN for items you are going to bill non assigned? A supplier should evaluate all patients against the LCD and policy article requirements. If a patient meets all Medicare requirements, an ABN cannot be used. A non assigned claim can be filed with appropriate notification to the patient. A supplier is required to determine if the patient meets criteria. An ABN can only be used when it is expected that the patient noes not meet medical necessity criteria. All non assigned claims do not require an ABN. An ABN is required only when the supplier expects Medicare to deny the claim. If we don't have the Face to Face because the beneficiary doesn't want to do that, do we file it with the modifier that we don't have medical necessity and then the bene will not get reimbursed? My question is based on slides 47 50, Paying Cash for a Capped Rental Item : Assume we sell a capped rental item as a purchase (cash sale) and get a signed ABN and the beneficiary checks Option 1. We would have to file a nonassigned claim, right? How do you get the claim past CEDI with the NU modifier since the HCPC only has a rental option? If it got past, it will be denied for an invalid modifier. How does that work? What should the denial be and what will happen if the patient appeals? Depends on what the item is and what the LCD requires. If this is a CPAP and the patient did not have a face to face, then the KX modifier would not be applied. Neither the supplier or the patient would receive any reimbursement. The supplier should also have the patient sign an ABN if they expect the claim to deny for lack of medical necessity. A supplier can only use an ABN and sell a capped rental item if the patient chooses option 2 on the ABN to NOT have the claim submitted to Medicare. A claim with a capped rental HCPCS code and the NU modifier will reject and never be processed by Medicare. If a patient chooses to have the claim filed to Medicare then the supplier cannot sell it and must follow Medicare rules. This must be based on the beneficiaries initiative to purchase the item. Will a non assigned claim crossover to secondary/supplement and will they pay their 20%? Please clarify, if we get a brand new 02 referral needing concentrator and portable can I elect to bill concentrator assigned and portable non assigned? If not, how can we restrict the amount of cylinders a patient receives? Non assigned claims process the same way as assigned. If it is a non assigned claim, the supplier has no obligation to file secondary claims. There is no guarantee the payer will pay the patient as Medicare did. A supplier would be obligated to send any secondary payments to the patient. A supplier cannot restrict the number of cylinders a patient receives per month. Portable contents are reimbursed in the amount paid for the concentrator. Suppliers have the ability to bill equipment assigned or non assigned subject to some issue if provided on the same date of service/fragmented claim. Questions and s: Billing Non Assigned 3 of 14

4 If a Dr. orders, say wound supplies, and has a brand name on the rx for the supplies can we provide a generic brand? Or do we need to get a new RX w/the generic name? If a patient pays "all" his copayments up front can I then bill the Recurring Rental each month and do I have to get a signature each month? I do not currently get a signature each month for recurring rentals. A new order would be required to supply something other than the brand ordered. A new order that does not specify any brand should be obtained. The supplier cannot collect all rental "copayments" up front because a copayment is tied to the monthly rental charge. A supplier can charge their regular charge for the equipment and collect the full amount from the patient on a non assigned basis for the first month, and then take assignment for all subsequent month rentals. A one time claim authorization is effective for future month rentals when assignment is accepted. A separate authorization is required for each month rental billed on a nonassigned basis. I m trying to come up with a model where the Medicare beneficiary does not pay up front. We want to send them a bill after Medicare pays them the Medicare portion. What does the panel think of that model? Taking opinions! If the supplier chooses to file claim non assigned, it's their decision when/how to collect from the patient. If they want to wait to collect from patient until after Medicare pays patient, they can do so. However,it may be unwise to do so since the supplier's best opportunity to collect from the patient is before you hand them the product. You may or may not be able to get your money from the patient after they have the product (as suppliers are well aware when trying to collect copays). We have 3 pharmacies. Our main pharmacy is accredited and we do DME through it. Am I able to provide DME through my other two pharmacies and bill under my main pharmacy or do I have to do separate PTAN numbers, Medicare numbers, accreditation, etc.? Can I treat the other two pharmacies like satellites of the main pharmacy? [note: asked similar question in webinar] Jeff, the majority of our other payors do not allow nonassigned claims. If I decide to make the item non assigned for Medicare, am I in violation of anti discrimination rule Do we file the non assigned claim with a KX modifier? If not, the claim will never pay to the bene. I am assuming we don't ever get the medical necessity since we aren't working the claim as usual. when you do a Medicare rental item, but client has a Medicaid as secondary insurance, can you do non assign to Medicare and bill Medicaid for the purchase of the item instead of a rental A PTAN is specific to a location. If you don't want to obtain accreditation, PTANs for additional pharmacy locations, you can have those pharmacies refer Medicare patients needing DME to the pharmacy that has the PTAN. You cannot bill for DME provided by the other pharmacy locations through the main pharmacy's PTAN. We believe that you will not be discriminating against a Medicare patient so long as you only make that product available to patients for whom you are paid the threshold price set, whether that payment amount is collected from the patient on a non assigned claim, or from the payor (with patient co pay) for assigned claims. A supplier should evaluate all patients against the LCD and policy article requirements. If a patient meets all Medicare requirements, a KX modifier should be placed on the HCPCS if it is required to indicate the patient qualifies. This applies to assigned and non assigned claims. No Questions and s: Billing Non Assigned 4 of 14

5 Do you have any advice on what we should do if our competition continues to bill assigned? I would like to bill non assigned but I'm almost positive the competition will continue to bill assigned in order to get all the referrals. If will bill non assigned I'm almost sure the competition would use this as a selling point as to why they need to send the patients to them (our competition). Please let me know if you have any advice or ideas of what we can do. [note: asked similar question in webinar] How do you bill Non Par on rental Items? If a client zip code is listed with Medicare eligible is not listed in CBA area, can the DME provider deliver t patient in a CBA location? The provider is not a contract winner. Every supplier must make business decisions for themselves. Suppliers cannot consult with other suppliers in determining best business practices. Participating and non participating are supplier status with Medicare enrollment. Participating suppliers are required to accept assignment on all items/services provided to Medicare FFS patient, while non participating supplier can choose whether or not to accept assignment on a claim by claim basis. Therefore, a non participating supplier can bill a rental item on an assigned or non assigned basis. If the patient is temporarily in a CBA even if they do not live in the CBA, they must use a contract supplier in the CBA. Can you set a percentage above cost as your threshold for accepting non assignment rather than a specific $ amount? Does a cbic contract vendor have to offer the complete product selection to Medicare bene's regarding the hcpcs number that they stock? Can ABN's apply to Medicare Advantage plans? A supplier can setup any pricing they want as long as it is the same for all. Suppliers can make decisions on what to take assignment on based on any algorithm as long as it is the same for all payers. A contracted supplier is required to be able to provide products in every HCPCS code in the product category. If a physician orders a particular brand of an item within a HCPCS code, a contracted ABNs are specific to Medicare FFS. Whether a Medicare Advantage plan requires an ABN or something equivalent to an ABN to hold the patient responsible if the plan denies coverage for the claim is dependent on the particular plan. If non participating, won bid for mobility, can I take O2 and bill non assigned? If we are billing a non assigned capped rental item can we collect all 13 months at time of initial set up? No, if you are not contracted you cannot provide oxygen unless a patient chooses to get from you, signs an ABN and understands Medicare will not pay anything. No. Are we allowed to bill non assigned for patients with medical assistance secondary? How do we handle that? This is a state by state issue. Some states allow suppliers to bill patients as long as they do not bill the Medicaid program. If the patient is a QMB Medicaid eligible, a supplier must take assignment. Other Medicaid programs may allow a supplier to not take assignment. Check with your state association Questions and s: Billing Non Assigned 5 of 14

6 Can we bill non assigned for Items that require prior auth. through Medicare? If so, must we obtain the prior auth? would obtaining the prior auth mean we must accept assignment? Yes you can bill non assigned on an item that requires prior approval. Obtaining prior approval does not mean you have to take assignment. A supplier is required to follow Medicare guidelines for coverage regardless of assignment of claim. You referred to a form allowing us to bill non assigned and bill for the patient. What form is this and where can it be found? Can I put in policy across the board that I will only be selling nebulizers, rollators, etc cash bases? Wondering if that will be okay from not discriminating? If you choose you aren't going to bill any insurance for an item because the reimbursement is too low, do we have to get an ABN signed at all? How do you handle sales tax on non assigned If you are in network with a commercial insurance can you still accept an item unassigned due to low reimbursement? Is it true that if we do a abn nebulizer, the patient would need to prove to Medicare or the pharmacy their purchase of the neb to have the medications covered? Would they need proof of delivery or just the tell the pharmacy the purchased and the purchase date? If we want to implement the model where we accept assignment only if it reaches a certain dollar amount, can we use a percentage about cost instead? You must have a signed authorization for submission of the claim. There is no "set" form for this authorization, and could be language included as part of the delivery ticket, or for monthly rentals on a non assigned basis, a separate form could be signed. Use language from the 1500 form on document created by supplier as follows: Patients authorized person s signature: I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to myself. As long as any policy is applied to patients of all payors, it should not be considered to be discriminatory. However, Medicare enrolled suppliers should not adopt an across the board policy to only sell capped rental items. ABNs are only for fee for service Medicare. If you are providing equipment to Medicare patients and you have a PTAN you are required to file a claim with Medicare. The only time you don't have to bill Medicare is when the patient signs an ABN requesting that Medicare not be billed. Status of assigned vs non assigned has nothing to do with sales tax. Taxes are paid by suppliers based on state laws regardless of what Medicare allows. Refer to your contract with the payer. Many contracts do not allow non assigned billing by a contracted supplier. The nebulizer medications should be covered if all of the following information is submitted with the initial claim in Item 19 on the CMS 1500 claim form or in the NTE segment for electronic claims: HCPCS code of base equipment,a notation that this equipment is beneficiary owned and the date the patient obtained the equipment. A supplier can setup any pricing they want as long as it is the same for all. Suppliers can make decisions on what to take assignment on based on any algorithm as long as it is the same for all payers. Questions and s: Billing Non Assigned 6 of 14

7 If we were to start a retail company with no PTAN or billing of insurance whatsoever, would we be allowed to sell items such as CPAP machines that are RX only items? If so would we be required to maintain charts or records of patients so we can prove we received an RX prior to dispensing. Currently we do file the RX with the sales ticket but I wasn t sure how it would work for a retail establishment. Will Medicare accept an electronic signature from a patient for monthly rentals? If we usually charge all insurances (for example) $400/month for E1390, but are unwilling to accept Medicare s rates and charge a patient $200/month as nonassigned. Are we essentially saying that we would take $200/month? Would we be obligated to changing our E1390 price to $200/month? [note: asked a similar but shorter version of this during webinar] Items which require a prescription prior to dispensing should be labeled as such. Any item labeled as a prescription device or supply requires a prescription prior to dispensing, regardless of whether being sold by a Medicare supplier, "retail" company or online company with no PTAN. State licensing requirements govern who can/cannot sell RX items. The seller of a prescriptiononly item should retain the RX in its records. If the supplier is not a Medicare supplier, they do not need to meet Medicare requirements, these are different than state licensure requirements. Medicare should accept an electronic signature that meets the requirements of the Uniform Electronic Transactions Act ( UETA ). In the past, CMS has taken the approach that electronic signatures are not sufficient for AOBs and have attempted to require blue ink documents. We believe that as long as the UETA is followed, CMS should be required to accept electronic documentation. However, you should be aware that there is some risk that CMS may still question the use of an electronic signature. This question is being posed to CMS for clarification. Yes, by charging a non assigned price of $200/month, you are stating that you will accept $200/month as adequate payment. The price you charge for a non assigned claim should be your usual charge, and not a reduced amount, as other payers could claim you are charging them an excess amount. In your opinion how many providers are just going to drop their PTAN and all insurance contracts and just become a retail supplier. Can't answer this question, unpublished information. I have a few questions that I hope you can help me with. On pap supplies like full face mask, headgears, tubing and etc. we carry both brand and generic products and we currently offer both brand and generic to all payer's. With reimbursement cuts we are paying more for brand products like Resmed, Respironics, Fisher Paykel than we are getting reimbursed, but I have heard that you can do an upcharge for brands products that cost more than our reimbursement. Is this true, if it is offered on brand products to all patients regardless of payers? If not could you please advise how we can offer brand products that are written by physician RX for brand product to cover cost, and would this be billed assigned or non assigned. There is no way to upcharge a patient a difference in price within the same HCPCS code. If you aren't in a CBA as a contracted supplier, you can file the claim non assigned and charge your usual rate to the patient. They can pay you upfront and they will receive 80% of the allowable if the claim is paid by Medicare. Managed care would depend on your contract terms. Questions and s: Billing Non Assigned 7 of 14

8 Slide # 84 Monthly signature: Does this apply to Oxygen? Is this for a capped rental only? Does this apply only in the case of a change in status when a supplier chooses to go non assigned mid rental (slide not clear says probably)? Would a monthly signature need to be obtained if a rental claim is non assigned from day 1 on a new patient? Can a supplier (non CBA, not CBA patient) have the patient pay a purchase price for a capped rental item and then bill to Medicare as a rental non assigned? What does the billing authorization need to state for monthly rentals? How much can a dme provider bill for 02 after the 36 months? When we bill unassigned to Medicare will we still get the Medicare Remitance Notice or will that only go to the patient? Can separate CC be run from same location i.e. Retail vs. PTAN CC...? Do we need to draw up written policy for items we will bill as unassigned for threshold payment? We do vacation rentals, do we need an ABN signed by each client to protect ourselves should the patient try to get reimbursed by Medicare? Oxygen with Medicare if we are accepting assignment Medicare says we have to continue to take care of the patients for the 5 year term can we switch to non assigned in the middle of the 5 year term? If Medicare pays then denies the non assigned claim is the supplier going to get a charge back or will the patient be asked to pay it back. [note: asked similar question during webinar] Is there any scenario where you would not need to obtain an ABN from a Medicare beneficiary if they are paying cash on a non assigned basis? This monthly signature requirement applies to all non assigned rental claims. No, if the supplier sells the equipment as a purchase to the patient, it cannot bill Medicare as a non assigned capped rental. Use language from the 1500 form on document created by supplier as follows: Patients authorized person s signature: I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. A supplier cannot bill any amount, either to Medicare or the patient, for rental of oxygen equipment beyond the 36th month. After the 36th month rental, the supplier can only bill for oxygen contents (if applicable), and maintenance and servicing (if performed). Both the supplier and the patient will receive a copy of the remittance. Need more information in question to provide answer. It is up to the supplier whether to reduce the policy to a written form, but doing so would help demonstrate that it is a formal adopted policy, and not just something made up on the spot. An ABN is only needed when the supplier has a reasonable basis to believe that Medicare will deny the claim. Not enough information in the question to provide more specific response. Yes, a supplier can make a different decision on each claim. Recommend that supplier provide at least 30 days advance notice to patient of decision to change to non assigned If claim is denied in post pay audit and supplier did not have signed ABN for reason of denial, supplier will have to refund amounts collected from patient. An ABN is only needed when the supplier has a reasonable basis to believe that Medicare will deny the claim. A supplier should still vet the order to see if the patient qualifies. If the patient will not meet medical necessity criteria, then an ABN should be used. Questions and s: Billing Non Assigned 8 of 14

9 Did you say that you can't have the customer pay for the entire purchase of a unit up front and then bill each month to Medicare when it is a capped rental? When a non contracted CBA supplier sells CBA covered DME to a beneficiary who lives within a competitive bidding area I know an ABN is required and that the noncontracted supplier cannot bill Medicare (for payment or for denial). In this case can the non contracted CBA vendor pre check the ABN to box 2 ONLY in this case? Has CMS given guidance to this? Can you have the retail business in the same location as MCR billing business? If you sell a nebulizer for cash price to a Medicare patient, do you have to do the same with a BCBS patient If the supplier is in a CBA but does not have the Bid for general DME, can that supplier supply a Full Electric Hospital Bed, with an ABN, as it is NOT a Medicare Benefit not that the supplier is NOT a Bid winner? [note: asked similar question during webinar] During the Q&A segment Jeff made a point that I want to pass on to my coworkers but I missed an important detail. I was hoping that you may be able to fill in the blank for me. Jeff stated: If a supplier sells a product non assigned and the claim is ultimately denied for the following reasons:,,. The supplier will be held financially responsible NOT the beneficiary and would need to refund to the beneficiary the amount they paid. If you have an AOB on file (i.e...signature on File documentation)... would you still need the bene to sign an authorization for every month of a non assigned capped rental claim? It was stated that we can bill non assigned after 36 months for o2. Can we bill the patient after 36 months because Medicare only pays for 36 month rental of o2? I didn t know we could bill the patient after 36 months. Is it mandatory to bill assignment for a beneficiary who has Medicare and state Medicaid as a secondary insurance? Is the supplier on a non assigned claim responsible to bill the beneficiary secondary insurance? That is correct. If an item is sold to the patient as a "purchase" it cannot be billed to Medicare as a capped rental. See attached guidance on obtaining an ABN in this scenario. Supplier cannot precheck the ABN box, however a claim can be filed for the item and it will deny as the supplier is not contracted in that CBA. Yes, but the operations of the two companies should still be physically segregated so it is clear which inventory, employees, etc. belongs to each operation. No, but if you are contracted with BCBS you need to follow your contract provisions which may not allow you to sell to a BCBS patient privately. The ABN should state that Medicare will not pay for a fully electric bed as not medically necessary, but will pay for rental of a semielectric bed if obtained from a Medicare competitive bid contract winner. Applicable reasons for denial requiring an ABN are denials for lack of medical necessity, failure to have a Medicare supplier number, violation of telephone solicitation prohibition, denial of an Advanced Determination of Medicare Coverage (ADMC) request, and noncontracted suppliers for competitive bid items in a CBA Yes. An AOB is when the supplier is accepting assignment. A supplier can only bill oxygen content and maintenance after the 36 months up to 60. These items can be billed non assigned or assigned. This is a state by state issue. Some states allow suppliers to bill patients as long as they do not bill the Medicaid program. If the patient is a QMB Medicaid eligible, a supplier must take assignment. Other Medicaid programs may allow a supplier to not take assignment. Check with your state association No, a supplier is not required to bill secondary insurance on nonassigned claim. Questions and s: Billing Non Assigned 9 of 14

10 When we bill non assignment with coverage criteria met and the remit shows a denial on the claim, who is responsible to appeal for payment? [note: asked similar question during webinar] I was informed by our Medicare contractor that even if we billed non assigned, if this claim was denied in a post pay audit that the $$ would be recouped from us and not the patient because we submitted the claim. Is this correct? Do we need an ABN if we are billing a standard wheelchair unassigned and Medicare only pays $22 and if we charge $55 If we decided to be non assigned, do we still need an ABN for capped rental or purchase item? Is there examples for ABN wording? Could have a standing ABN for monthly rental signature requirement? In the event we could charge a card on file for months a signature was not obtained. Can you switch an oxygen patient to non assigned anytime in the first 36 months and if the patient declines how will Medicare handle patient switching suppliers? Jeff regarding your suggestion of setting up a separate cash business how would that affect the CMS measure of increasing non assigned claims vs CB success? Are we allowed to have ABC and ABC retail sales inc in the same building as far as instore Medicare visits and or accreditation visits? According to CGS, either the patient or the supplier can file the appeal. If claim is denied in post pay audit and supplier did not have signed ABN for reason of denial, supplier will have to refund amounts collected from patient. This question has been posed to CMS. An ABN is needed only when the supplier has a reasonable basis to believe that Medicare will deny the claim. The ABN has nothing to do with amount charged on unassigned claims. An ABN is needed when the supplier has a reasonable basis to believe that Medicare will deny the claim, regardless of whether the claim is filed assigned or non assigned. The wording on the ABN is dependent on the reason that the supplier anticipates that Medicare will deny the claim. There are no CMS Medicare published examples. If the patient won't sign an authorization, then the suppliers does not have authorization to submit a claim to Medicare. It would seem the patients would be incentivized to sign authorization so that they can receive reimbursement from Medicare. Yes, the supplier can change from assigned to non assigned during the 36 month rental period. The supplier should give the patient at least 30 days advance notice so that the patient can try to find another supplier that will accept assignment if they choose to. There maybe an issue as the supplier who is paid the first month is required to furnish the entire 36 months and then oxygen needs through the 60th month. However if a patient chooses to leave, it may take the supplier off the hook. Medicare will not care about the switch if it is the patient's choice. Since a separate cash business would not have a Medicare PTAN number, sales by that entity would not be included in CMS measurements of assigned/non assigned claims. Yes, but the two operations should still be physically segregated so it is clear which inventory, etc. belongs to each operation. If we have a Medicare customer walk in with all the medical documentation and the diagnosis qualifies for an item (walker) but Medicare allowable is low and we do not want to accept assignment. what reason do we state on the ABN for not accepting assignment? An ABN is not required for a non assigned claim unless the supplier has a reasonable basis to believe that Medicare will deny the claim. Questions and s: Billing Non Assigned 10 of 14

11 Here is an idea after listening to the webinar: Our manufactures start making items that are cash only? Pride Mobility was able to make the Jazzy Air which is a Cash Only item and does not have a HCPCS code. Just a thought that maybe manufactures should start doing this. Manufacturers cannot determine what are cash sale items or not. Since the majority of HCPCS codes do not require code verification it is up to the supplier to determine if an item meeting a HCPCS definition and if it does, as a Medicare supplier, they are required to submit the claim assigned or non assigned. How does a Non Par supplier collect directly on a Medicare rental item? If we decide to drop certain equipment, such as bed and not do it anymore, If a patient already has one will we still be able to bill for that patient until the end of their 13 months If we have a rental item can you collect all the coinsurance upfront? If you have an NPI can you sell an Oxygen Conc. as a cash item? If the cash price for a used wheelchair can be less than Bairds recommendation of 17% less than the Medicare fee schedule? Used wheel chair, not billing Medicare, cash up front for purchase [note: asked similar question during webinar] If we have to go non assigned on rental equipment can we collect a signature up front on a form that states that the patient understands that they have agreed to go nonassigned for the 13 month capped rental and that they reserve the right to change their mind at any time. Can we collect this up front rather than chasing the bene down each month for the beneficiary claim authorization signature? Can it be simplified up front? ASSUME THE BENE QUALIFIES FOR A RENTAL WHEELCHAIR AND WE RENT NON ASSIGNED FOR EACH MONTH OF THE RENTAL PERIOD WHY WOULD THERE BE A REASON TO OBTAIN AN ABN? A non participating supplier can choose to not accept assignment for a Medicare rental item, and can collect its usual rental charge up front from the patient and submit a claim to Medicare on a nonassigned basis, which results in Medicare paying 80% of the Medicare allowable to the patient. Supplier needs to follow all Medicare requirements when filing non assigned claims as well. Yes as long as you are still a Medicare supplier. The supplier cannot collect all rental coinsurance up front because the coinsurance is tied to the monthly rental charge. A supplier can charge their regular charge for the equipment and collect the full amount from the patient on a non assigned basis for the first month, and then take assignment for all subsequent month rentals. Supplier can obtain credit card information and authorization to charge the card monthly for the copay. All medical professionals/providers/suppliers have an NPI, so it would depend on the type of professional/provider. Need more information to provide additional guidance. Suppliers who have a PTAN must follow Medicare requirements to bill. The cash price can be any price set by the supplier, it is not limited to 17% of anything. It is up to the supplier to determined pricing, the 17% is not a hard fast rule. If the patient refuses to sign an authorization then a supplier cannot submit the claim to Medicare. Supplier should notify the patient it is not in their best interest as they will be billed and receive no money from Medicare for the unassigned claim. The patient would still be billed. CMS has not issued any guidance on what needs to be on whether a supplier can get something signed upfront for all months of rental. An ABN is not required for a non assigned claim unless the supplier has a reasonable basis to believe that Medicare will deny the claim. Questions and s: Billing Non Assigned 11 of 14

12 Does a non participating provider need to post a notice today that they are changing their policy on collecting upfront? If I have contracts with insurance companies and my U &C is already established can I still do a discount price to the Medicare patient and bill non assigned? A non participating supplier can choose to not accept assignment on a claim by claim basis. We anticipate that suppliers will continue to accept assignment on some items, and not on others. Therefore, the supplier should notify the patient in advance any time it will not accept assignment for an item. A supplier should not reduce its U&C for non assigned claims to Medicare patients as it could adversely impact the U&C billed to other payers. We are hearing from bene. now that they can buy on amazon. cpap machine. and you say Medicare will pay for future supplies if we put info in the narrative section. how? If we want to get out of the Medicare business completely, can we continue to service the rental patients we have now and just stop taking new patients? The patient would need to meet all Medicare requirements for the CPAP unit and the supplier would need all of this documentation to get paid for the supplies. The supplier could enter an NTE segment indicating patient owns CPAP, the claim would likely deny and would need to be reopened or appealed in order to get paid. Yes you can, however; you are required to continue servicing capped rental patients till the end of the cap rental period, or end of 5 year period for oxygen patients. Failure to do so can be seen as violation of Medicare requirements. The same response applies whether you are participating or non participating? You can continue servicing capped rental patients as required, but stop taking any new Medicare patients. When adopting policies outlining "the allowables must meet X $ amount to be supplied on assignment", can the policy include a statement that says if the patient's insurance policy doesn t allow for the filing of non assigned claims, that it must be purchased out right? No, a supplier is held to the terms of the insurance contract. Most insurance contracts will not let you bill the patient for an item covered by the insurance. In my instance I have a contract with a third party administrator to supply DME for its patients but I must accept assignment. May I still be able to bill non assigned claims to Medicare for the same equipment? Example if I take assignment from the third party administrator can I bill rolling walkers to Medicare non assigned? We believe that you will not be discriminating against a Medicare patient so long as you only make that product available to patients for whom you are paid the threshold price set, whether that payment amount is collected from the patient on a non assigned claim, or from the payor (with patient co pay) for assigned claims. Regarding capped rental items. We do a lot of wheelchairs, so when we bill as a non assigned are we required to have an authorization signed monthly? Any suggestions on how to obtain? [note: asked similar question during webinar] If the patient refuses to sign an authorization then a supplier cannot submit the claim to Medicare. Supplier should notify the patient it is not in their best interest as they will be billed and receive no money from Medicare for the unassigned claim. The patient would still be billed. CMS has not issued any guidance on what needs to be on whether a supplier can get something signed upfront for all months of rental. Should an ABN be used on all of our non assigned claims? This way if the claim is denied we would be able to keep our payment. If not all the time when should the ABN be used? [note: asked similar question during webinar] An ABN is needed when the supplier has a reasonable basis to believe that Medicare will deny the claim. Medicare prohibits the use of routine or blanket ABNs, absent a specific reason why the supplier thinks the claim will be denied. Questions and s: Billing Non Assigned 12 of 14

13 If you choose to provide certain items non assigned to a Medicare beneficiaries with an ABN, is there still an expectation that an attempt to meet Medicare guidelines was made? Was it mentioned as to what wording you would use on the ABN under reason Medicare may not pay"? Can a DME that is a department of a participating hospital become a non participating provider if the DME uses the same tax id as hospital? The DME has a different NPI than the hospital. As a non bid winner for General DME, can I supply a drop arm commode with an ABN as a sale? [note: asked similar question during webinar] Can you do a non assigned claim for dual eligible (Medicare/Medicaid) bene's.? My understanding has always been NO...because Medicaid will not allow a nonassigned claim for Medicaid. If your answer is no...do you have any recommendations on how to handle dual eligible beneficiaries? Can a CB winner deny service(s)? Rumor has it that some suppliers are not wanting to dispense walkers. How does a supplier efficiently collect beneficiary signature each month on a non assigned rental? What if bene, refuses down the road? How far in advance can you get signature authorization for the non assigned capped rental claims each month? Does signature and billing date need to be the same? The supplier should attempt to make sure Medicare guidelines are met for any product dispensed to a Medicare patient, whether assigned or non assigned. If the supplier is aware that Medicare guidelines are not met, then the supplier should have the patient sign an ABN detailing what Medicare requirements are not met as the basis for an expected denial of coverage. The wording on the ABN should reflect the reason that the supplier anticipates that Medicare will deny the claim. The NSC states that If the supplier and the hospital are under the same tax id number, if the hospital is participating then a supplier must be participating as well. If the item is a competitive bid item and the supplier did not get the competitive bid contract, it can only provide that item to a Medicare beneficiary if the patient signs an ABN stating that no payment will be made by Medicare because the item is being provided by a supplier without a competitive bid contract. This is a state by state issue. Some states allow suppliers to bill patients as long as they do not bill the Medicaid program. If the patient is a QMB Medicaid eligible, a supplier must take assignment. Other Medicaid programs may allow a supplier to not take assignment. Check with your state association A contracted winner cannot refuse to provide services for which they are contracted. If a complaint is filed with CMS, they will follow up with the contracted supplier. If the patient refuses to sign an authorization then a supplier cannot submit the claim to Medicare. Supplier should notify the patient it is not in their best interest as they will be billed and receive no money from Medicare for the unassigned claim. The patient would still be billed. As this point in time, the question cannot be answered as no guidance has been issued by CMS. This issue has been posed to CMS. Questions and s: Billing Non Assigned 13 of 14

14 We believe that you will not be discriminating against a Medicare I need a clarification on the information regarding billing patient so long as you only make that product available to patients unassigned and the Anti Discrimination rule. We contract for whom you are paid the threshold price set, whether that with a lot of Commercial insurances that we are unable to payment amount is collected from the patient on a non assigned bill unassigned and do not reimburse what we would claim, or from the payor (with patient co pay) for assigned claims. consider and acceptable reimbursement. My question is In the circumstance that a commercial payor requires that you this, using an example of procedure code A7036, can we accept assignment, you can decline to make a particular product state, we can provide this item for a reimbursement of at or available unless the reimbursement meets the threshold amount above $ If a particular insurance company does not established for that item (unless your contract requires otherwise). meet this reimbursement, we would either bill unassigned In your example, if you agreed to a fee schedule for A7036 less or not provide the service? If not, please explain why not or than $36, you will have to provide some A7036 product at that what a more appropriate statement would be. price, but not all products meeting that HCPCS code. Do the Medicare advantage plans require the same paperwork as straight Medicare? do the detailed written order requirements, Face to Face, etc. apply to the Medicare advantage plans as well? [note: asked similar question in webinar] What happens after the non assignment claim is filed? I know you guys were getting back to us on who gets the remit, whether it comes to us and/or just the beneficiary Coverage and documentation requirements are established by the MA plan, which may or may not mirror Medicare FFS requirements. Medicare will pay 80% of the Medicare allowable to the patient. Both the supplier and the patient will receive a copy of the remittance. Can 2 companies bill for Oxygen? For example: A patient is nocturnal and is in month 30 rental. Patient then needs portable O2, current company asks patient to go nonassigned and they refuse finding a company to take them on for portables. Can both companies bill for the 2 different codes? As a non participating provider can we charge over the 17% of the allowed amount? Can you collect all of the rental months upfront How do you document on an ABN the fact that you are billing unassigned based on the understanding that patient meets all coverage criteria? ASIDE FROM AN ABN HOW DO WE AVOID A CO DENIAL? CMS has issued no guidance on this type of situation. There is nothing definitive in the rule, this question has been posed to CMS. Yes, a non participating supplier is not limited on the amount of its "usual and customary" charge collected from a patient for a nonassigned claim. No An ABN is not required for a non assigned claim unless the supplier has a reasonable basis to believe that Medicare will deny the claim. An ABN is the only way to avoid a CO denial. A patient needs to meet Medicare criteria and if not the supplier can obtain an ABN and file claim non assigned. Still having trouble figuring out how to bill tanks after 36th month, could he touch on this again or send me more info on how to do this? E0443 can be billed monthly if they are given a 3 months supply so would we just bill monthly only when we provide tanks and bill after the fact so we know how many tanks they got? and if so what DOS would we use if they got multiple deliveries in a month. This may be too lengthy for this forum; I just can't wrap my brain around how to do it but sure do need to. The LCD and policy article review how to bill the portable content either monthly or for 3 months and what date of service to use when submitting claim. Questions and s: Billing Non Assigned 14 of 14