Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Medicare pricing methodology

Transcription

1 Durable Medical Equipment, Prosthetics, This is an educational component of Burgess Reimbursement System. Thoughtfully designed to help you accomplish more with Medicare reimbursement information. Welcome Orthotics, and Supplies (DMEPOS) Medicare pricing methodology

2 Agenda Payment System Highlights o o o Medicare Pricing Methodologies Competitive Bidding Program Basics National Mail-Order Competitive Bidding Program DMEPOS Competitive Bidding Program Round 1 DMEPOS Competitive Bidding Program Round 2 DMEPOS Competitive Bidding Program Subsequent Rounds Key Payment Policies Common DMEPOS HCPCS Modifiers Learning Objectives Understand the various DMEPOS payment methodologies and key policies under Original Medicare Establish a foundation for understanding the features and functionality in the Burgess Reimbursement System (BRS)

3 Payment System Highlights

4 What is DMEPOS? DMEPOS is a Medicare Part B benefit DMEPOS Criteria: o Be able to withstand repeated use o Be primarily and customarily used to serve a medical purpose o Not be useful by a person in the absence of an illness or injury; and o Be appropriate for use in the home

5 Medicare Payment Methodologies National Mail-Order Competitive Bidding (CB) Program DMEPOS Competitive Bidding (CB) Program DMEPOS Fee Schedule

6 Competitive Bidding Program Basics Mandated by the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) Requires Medicare to replace the fee schedule methodology for select DMEPOS with competitive bid Single Payment Amounts (SPAs) Contracts must be rebid at least every 3 years

7 Competitive Bidding Program Basics Program Goals: o To reduce beneficiary costs o To continue beneficiary access to quality DMEPOS o To establish overall Medicare Program cost savings

8 Competitive Bidding Program Basics Suppliers: o Compete to become Medicare contract suppliers o Submit bids to provide certain DMEPOS items in a Competitive Bidding Area (CBA) Suppliers include: o DMEPOS Suppliers o Physicians o Skilled Nursing Facilities o Home Health Agencies o Hospital Outpatient Facilities

9 Competitive Bidding Program Basics Competitive Bidding Implementation Contractor (CBIC): o Evaluate bids o Select qualified suppliers o Set a Single Payment Amount (SPA) for each item based on the median of all winning bids o Assist CMS and DME Medicare Administrative Contractors (MACs) to monitor the program s effectiveness, access, and quality

10 National Mail-Order Competitive Bidding Program Effective July 1, 2013 Applies to all parts of the United States: o All 50 states o District of Columbia o Puerto Rico o U.S. Virgin Islands o Guam o American Samoa Mail-order means items shipped or delivered to the beneficiary s residence, regardless of the method of delivery Applies to diabetic testing supplies such as: o Lancets o Test strips o Calibrator solution/chips o Replacement batteries Estimated to reduce Medicare expenditures for diabetic testing supplies by 72%

11 DMEPOS Competitive Bidding Program Round 1 Effective January 1, 2011 Applies to 9 Competitive Bidding Areas (CBAs) Applies to the following services: o Hospital beds and related accessories o Walkers and related accessories o Oxygen supplies and equipment o Continuous Positive Airway Pressure (CPAP) and Respiratory Assist Devices (RADs) and related supplies and accessories o Enteral nutrients, equipment and supplies o Standard power wheelchairs, scooters, and related accessories o Complex rehabilitative power wheelchairs and related accessories (Group 2) o Support surfaces (Group 2 mattresses and overlays) in Miami o Mail-order replacement diabetic supplies Estimated to reduce Medicare expenditures for related Round 1 DMEPOS items by 26%

12 DMEPOS Competitive Bidding Program Round 1 Competitive Bidding Areas (CBAs): o Charlotte-Gastonia-Concord, NC-SC o Cincinnati-Middletown, OH-KY-IN o Cleveland-Elyria-Mentor, OH o Dallas-Fort Worth-Arlington, TX o Kansas City, MO-KS o Miami-Fort Lauderdale-Pompano Beach, FL o Orlando-Kissimmee, FL o Pittsburgh, PA o Riverside-San Bernardino-Ontario, CA

13 DMEPOS Competitive Bidding Program Round 2 Effective July 1, 2013 Applies to 91 Competitive Bidding Areas (CBAs) Applies to the following services: o Hospital beds and related accessories o Walkers and related accessories o Oxygen, oxygen equipment, and supplies o Continuous Positive Airway Pressure (CPAP) and Respiratory Assist Devices (RADs) and related supplies and accessories o Enteral nutrients, equipment, and supplies o Standard (Power and Manual) wheelchairs, scooters, and related accessories o Support surfaces (Group 2 mattresses and overlays) o Negative Pressure Wound Therapy pumps and related supplies and accessories Estimated to reduce Medicare expenditures for related Round 2 DMEPOS items by 45%

14 DMEPOS Competitive Bidding Program Round 2 Competitive Bidding Areas (CBAs) - Northeast o Albany-Schenectady-Troy, NY o Allentown-Bethlehem-Easton, PA-NJ o Boston-Cambridge-Quincy, MA-NH o Bridgeport-Stamford-Norwalk, CT o Buffalo-Niagara Falls, NY o Hartford-West Hartford-East Hartford, CT o New Haven-Milford, CT o New York-Northern New Jersey-Long Island, NY-NJ-PA o Philadelphia-Camden-Wilmington, PA-NJ-DE-MD o Poughkeepsie-Newburgh- Middletown, NY o Providence-New Bedford-Fall River, RI-MA o Rochester, NY o Scranton-Wilkes-Barre, PA o Springfield, MA o Syracuse, NY o Worcester, MA

15 DMEPOS Competitive Bidding Program Round 2 Competitive Bidding Areas (CBAs) - Midwest o Akron, OH o Chicago-Joliet-Naperville, IL-IN-WI o Columbus, OH o Dayton, OH o Detroit-Warren-Livonia, MI o Flint, MI o Grand Rapids-Wyoming, MI o Huntington-Ashland, WV-KY-OH o Indianapolis-Carmel, IN o Milwaukee-Waukesha-West Allis, WI o Minneapolis-St. Paul-Bloomington, MN-WI o Omaha-Council Bluffs, NE-IA o St. Louis, MO-IL o Toledo, OH o Wichita, KS o Youngstown-Warren-Boardman, OH-PA

16 DMEPOS Competitive Bidding Program Round 2 Competitive Bidding Areas (CBAs) - South o Asheville, NC o Atlanta-Sandy Springs-Marietta, GA o Augusta-Richmond County, GA-SC o Austin-Round Rock-San Marcos, TX o Baltimore-Towson, MD o Baton Rouge, LA o Beaumont-Port Arthur, TX o Birmingham-Hoover, AL o Cape Coral-Fort Myers, FL o Charleston-North Charleston-Summerville, SC o Chattanooga, TN-GA o Columbia, SC o Deltona-Daytona Beach-Ormond Beach, FL o El Paso, TX o Greensboro-High Point, NC o Greenville-Mauldin-Easley, SC o Houston-Sugar Land-Baytown, TX

17 DMEPOS Competitive Bidding Program Round 2 Competitive Bidding Areas (CBAs) - South (Continued) o Jackson, MS o Jacksonville, FL o Knoxville, TN o Lakeland-Winter Haven, FL o Little Rock-North Little Rock-Conway, AR o Louisville/Jefferson County, KY-IN o McAllen-Edinburg-Mission, TX o Memphis, TN-MS-AR o Nashville-Davidson--Murfreesboro--Franklin, TN o New Orleans-Metairie-Kenner, LA o North Port-Bradenton-Sarasota, FL o Ocala, FL o Oklahoma City, OK o Palm Bay-Melbourne-Titusville, FL o Raleigh-Cary, NC o Richmond, VA o San Antonio-New Braunfels, TX

18 DMEPOS Competitive Bidding Program Round 2 Competitive Bidding Areas (CBAs) - South (Continued) o Tampa-St. Petersburg-Clearwater, FL o Tulsa, OK o Virginia Beach-Norfolk-Newport News, VA-NC o Washington-Arlington-Alexandria, DC-VA-MD-WV

19 DMEPOS Competitive Bidding Program Round 2 Competitive Bidding Areas (CBAs) - West o Albuquerque, NM o Bakersfield-Delano, CA o Boise City-Nampa, ID o Colorado Springs, CO o Denver-Aurora-Broomfield, CO o Fresno, CA o Honolulu, HI o Las Vegas-Paradise, NV o Los Angeles-Long Beach-Santa Ana, CA o Oxnard-Thousand Oaks-Ventura, CA o Phoenix-Mesa-Glendale, AZ o Portland-Vancouver-Hillsboro, OR-WA o Sacramento--Arden-Arcade--Roseville, CA o Salt Lake City, UT o San Diego-Carlsbad-San Marcos, CA o San Francisco-Oakland-Fremont, CA o San Jose-Sunnyvale-Santa Clara, CA

20 DMEPOS Competitive Bidding Program Round 2 Competitive Bidding Areas (CBAs) West (Continued) o Seattle-Tacoma-Bellevue, WA o Stockton, CA o Tucson, AZ o Visalia-Porterville, CA

21 DMEPOS Competitive Bidding Program Subsequent Rounds Further expansion expected No details available to date

22 DMEPOS Fee Schedule Applies to DMEPOS not part of: o National Mail Order Competitive Bidding Program o DMEPOS Competitive Bidding Program Round 1 o DMEPOS Competitive Bidding Program Round 2 o DMEPOS Competitive Bidding Program Subsequent Rounds Rates vary by state Comprises more than 1,800 DMEPOS related HCPCS codes

23 Medicare Payment Methodologies - Summary Type of DMEPOS National Mail-Order Competitive Bidding Competitive Bidding Round 1 or 2 Beneficiary Address Beneficiary Travel Destination Type of Supplier DMEPOS Must Be Purchased Payment Method Any Any Contracted CB Supplier Single Payment Amount* CBA Same CBA Contracted CB Supplier Single Payment Amount* CBA Different CBA Contracted CB Supplier Single Payment Amount* CBA Non-CBA Any Medicare Supplier Single Payment Amount* Non-CBA CBA Contracted CB Supplier Fee Schedule* Non-CBA Non-CBA Any Medicare Supplier Fee Schedule* All Other Any Any Any Medicare Supplier Fee Schedule* * Based on the beneficiary s permanent address (i.e. ZIP code) on file with the Social Security Administration (SSA)

24 DMEPOS Pricing Florida July 1, 2013 State subject to mix of SPA and Fee Schedule rates HCPCS: E0250-RR HCPCS Description: Hospital bed, with mattress Payment Method Location Rate DMEPOS Round 1 SPA Miami-Fort Lauderdale-Pompano Beach $61.93 Orlando-Kissimmee $ different rates in effect for the same DMEPOS item Rates range $55.53 to $91.33 DMEPOS Round 2 SPA DMEPOS Fee Schedule Cape Coral-Fort Myers $68.43 Deltona-Daytona Beach-Ormond Beach $55.53 Jacksonville $55.53 Lakeland-Winter Haven $56.52 North Port-Bradenton-Sarasota $68.43 Ocala $68.43 Palm Bay-Melbourne-Titusville $55.53 Tampa-St. Petersburg-Clearwater $59.18 Florida $91.33

25 Key Payment Policies DMEPOS Categories Category CR Description Capped Rental Items in this category are generally rented for a specified amount of time (e.g. 01/01/2006 and after for up to 13 months, Prior to 01/01/2006 for up to 15 months). Once the maximum rental period is reached, the rental is capped with no further payments with the exception of payments for reasonable/ necessary service and maintenance. FS Frequently Serviced Items Items in this category require frequent/substantial servicing and are rented for as long they are medically necessary for the beneficiary. IN Inexpensive & Other Routinely Purchased Items Items in this category generally: Have a purchase price of $150 or less, Are purchased 75% or more of the time, or Are accessories used in conjunction with certain nebulizers, aspirators, and ventilators Items in this category can be purchased new or used.

26 Key Payment Policies DMEPOS Categories Category OS OX PO SD SU TE TS Description Ostomy, Tracheostomy, Urological Items Oxygen & Oxygen Equipment Prosthetics & Orthotics Surgical Dressings Supplies Transcutaneous Electrical Nerve Stimulators Therapeutic Shoes

27 Key Payment Policies Walkers Provided by certain physicians, other treating practitioners, or hospitals who are not required to submit a bid under the competitive bidding program Grandfathered suppliers Suppliers who are not awarded a bid, but choose to continue to provide competitively bid DMEPOS or oxygen/supplies to beneficiaries Beneficiary changes supplier

28 Common DMEPOS HCPCS Modifiers Modifier NU RR UE KH KI KJ MS Description New equipment Rental Used durable medical equipment DMEPOS item, initial claim, purchase or first month rental DMEPOS item, second or third month rental DMEPOS item, parenteral enteral nutrition (pen) pump or capped rental, months four to fifteen Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty

29 Common DMEPOS HCPCS Modifiers Modifier AU AV AW KC KF KM KN Description Item furnished in conjunction with a urological, ostomy, or tracheostomy supply Item furnished in conjunction with a prosthetic device, prosthetic or orthotic Item furnished in conjunction with a surgical dressing Replacement of special power wheelchair interface Item designated by FDA as class III device Replacement of facial prosthesis including new impression/moulage Replacement of facial prosthesis using previous master model

30 Common DMEPOS HCPCS Modifiers - Competitive Bidding Modifier J4 KE Description DMEPOS item subject to DMEPOS competitive bidding program that is furnished by a hospital upon discharge Bid under round one of the DEMPOS competitive bidding program for use with non-competitive bid base equipment KG DMEPOS item subject to DMEPOS competitive bidding program (Round 1) KK DMEPOS item subject to DMEPOS competitive bidding program (Round 2) KL KT KV DMEPOS item delivered via mail Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item DMEPOS item subject to DMEPOS competitive bidding program that is furnished as part of a professional service

31 Common DMEPOS HCPCS Modifiers - Competitive Bidding Modifier Description KU DMEPOS item subject to DMEPOS competitive bidding program (Round 3) KW DMEPOS item subject to DMEPOS competitive bidding program (Round 4) KY DMEPOS item subject to DMEPOS competitive bidding program (Round 5)

32 Learning Objectives Recap Understand the various DMEPOS payment methodologies and key policies under Original Medicare Establish a foundation for understanding the features and functionality in the Burgess Reimbursement System (BRS)

33 QUESTIONS? Contact BRS Support at: p e.