From enrollment screening to new payment oversight, it's all part of the law.
by Jeffrey S. Baird, Esq.

This is the second of a 4-part series on the provisions of
the Patient Protection and Affordable Care Act (PPACA) and how the
health reform law affects DME providers.
Series: Part
1 | Part 2 |
Part 3

At presstime for this issue, Republicans were lining up for a
run at repeal of the Patient Protection and Affordable Care Act
(PPACA), which was signed into law on March 23, 2010. Here's a
refresher on some provisions in the health reform law with serious
effects for DME suppliers.

  • Power Wheelchairs: The purchase option is available only
    to complex rehabilitation power wheelchairs and not to other power
    wheelchairs. Additionally, the rental payment amounts change to 15
    percent for the first three months and 6 percent for the remaining
    rental months.

  • Provider Screening and Enrollment: Providers and
    suppliers enrolling or re-enrolling in Medicare, Medicaid or CHIP
    will be subject to screening measures established by the HHS
    Secretary. All providers and suppliers will be subject to licensure
    checks and, if the Secretary determines, additional screening
    measures such as criminal background checks, fingerprinting and
    unscheduled and unannounced site visits.

    Applicants will also be required to disclose any current or
    previous affiliations with any provider or supplier that has
    uncollected debt, been subject to payment suspension under a
    federal health care program, excluded from a federal health care
    program or has had billing privileges denied or revoked. The
    Secretary may deny enrollment if such affiliations pose an undue
    risk of fraud, waste or abuse.

    In determining the size of a surety bond, the Secretary must
    take into account the volume of billing for a DME supplier. As
    well, the Secretary may impose a temporary moratorium on the
    enrollment of new providers and suppliers if it is determined such
    action is necessary to prevent or combat fraud, waste or abuse.

    The Secretary may adjust payments to a provider or supplier that
    has the same tax ID number as a provider or supplier that owes
    past-due obligations under Medicare, Medicaid or CHIP, regardless
    of such provider's or supplier's Medicare billing number or

  • Enhanced Program Integrity: Any provider or supplier that
    receives an overpayment must report the overpayment and provide
    written notice of the reason for the overpayment. An overpayment
    must be reported and returned no later than 60 days after it is
    identified or the date of any corresponding cost report (if
    applicable). Failure to do so may result in civil money penalties.
    Additionally, a claim that includes items or services resulting
    from a violation of the Medicare/Medicaid anti-kickback statute
    constitutes a false or fraudulent claim under the Civil False
    Claims Act.

  • Orders and Documentation: On or after July 1, 2010, DME
    or home health services must be ordered by a Medicare-enrolled
    physician or eligible professional. As a condition of Medicare
    payment, the patient notes must document that a physician,
    physician assistant, nurse practitioner, or clinical nurse
    specialist has had a face-to-face encounter with the patient during
    the six months prior to the written order for the DME, although the
    Secretary may determine another reasonable timeframe. (The July 1
    deadline has since been delayed.)

    The Secretary may revoke enrollment of a supplier for various
    reasons, including failure to maintain and provide access to
    documentation relating to written orders or requests for payment
    for DME. Such revocation may be for no longer than one year per

  • DMEPOS Competitive Bidding Program: The competitive
    bidding program will be expanded in Round 2 to 100 metropolitan
    statistical areas (i.e., Round 2 will include the nine MSAs from
    Round 1 plus 91 additional MSAs). The Secretary will be required to
    apply competitively bid prices to adjust payments for
    non-competitive bid areas nationwide by 2016.

  • Prepayment Review, Oversight of Initial Claims: The
    Health Care and Education Reconciliation Act of 2010 was signed
    into law on March 30, 2010, and modified PPACA.

Under this law, the limits on when a Medicare Administrative
Contractor can conduct a prepayment review have been removed. Also
under the Reconciliation Act, if the Secretary determines that
there is a significant risk of fraudulent activity among DME
suppliers, then the Secretary will withhold Medicare payment of any
claims submitted by a supplier that is initially enrolling in

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Jeffrey S. Baird, Esq. is chairman of the Health Care Group
at Brown &
Fortunato, P.C.
, a law firm based in Amarillo, Texas. He
represents pharmacies, infusion companies, home medical equipment
companies and other health care providers throughout the United
States. Baird is board-certified in health law by the Texas Board
of Legal Specialization. He can be reached at 806/345-6320 or