Round One Providers Get Adjustments; Collecting Copays Could Be Tough
BOCA RATON, Fla.–Sylvia Toscano, president of Professional Medical Administrators in Boca Raton, Fla., told members of the Accredited Medical Equipment Providers Association last week that Cigna Government Services, the Jurisdiction C DME MAC, had issued remittances reflecting adjustments for underpaid claims based on the two-week implementation of the DMEPOS competitive bidding program, which began July 1 and was halted July 15.
Toscano said she discovered the adjustments while reviewing new Explanation of Medical Benefit (EOMB) statements for her round one clients.
According to Toscano, the notices carried the following remark codes:
–M112, The approved amount is based on the maximum allowance for this item under the DMEPOS Competitive Bidding Demonstration;
–M113, Our records indicate that this patient began using this service(s) prior to the current round of DMEPOS Competitive Bidding Demonstration. Therefore, the approved amount is based on the allowance in effect prior to this round of bidding for this item; and
–M114, This service was processed in accordance with rules and guidelines under the Competitive Bidding Demonstration Project.
Though the adjustment will bring over 26 percent of the revenue back to providers who billed in the first half of July, they may not be able to collect everything they are owed, according to AMEPA. Toscano believes collecting the copayments from beneficiaries and secondary insurance companies will be very difficult. She also noted that patients may be confused after already paying the prior coinsurance amounts when they receive an additional bill for the adjusted difference.
Walt Gorski, vice president, government relations, for the American Association for Homecare, agreed. “While CMS is paying the claims at the full 80 percent as if the competitive bidding program didn’t go into effect, collecting the additional copays from the beneficiaries is going to be the more difficult aspect [for providers],” he said. “It will be difficult for the beneficiaries to understand.”
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