Q&A: Meeting Post-Delivery Obligations

AMARILLO, Texas — “Out of necessity, HME providers are
looking at ways to cut costs,” notes heath care attorney Jeff
Baird, chairman of the Health Care Group at Brown & Fortunato. “In doing
so, however, it is important for the provider to continue to
fulfill the post-delivery obligations that are imposed by the
Supplier Standards.”

Here are some of the commonly asked questions about
post-delivery obligations, and Baird’s answers.

Q: What do the Quality Standards say about follow-up
services?

A: Medicare’s Quality Standards (also referred
to as Accreditation Standards) generally require that the supplier
provide follow-up services consistent with the type of equipment,
items and services provided. The follow-up services also need to be
consistent with any recommendations from the patient’s physician or
other health care professional.

Q: What are Medicare’s specific requirements for
handling patient complaints and equipment repairs?

A: Under Medicare’s Supplier Standards, a
supplier must answer questions and respond to complaints a patient
has about the Medicare-covered item, regardless of whether the item
was sold or rented to the patient. The supplier must have a
complaint resolution protocol in place to address patient
complaints. The Supplier Standards require a supplier to record and
keep certain information on all complaints, regardless of whether
the complaint is written or oral.

First, the supplier must document the name, address, telephone
number and health insurance claim number of the patient making the
complaint. The supplier must record or summarize the complaint, the
date the complaint was received, the name of the person receiving
the complaint and any actions taken to resolve the complaint. The
supplier must keep written complaints, related correspondence and
notes of any actions taken in response to written or oral
complaints. The information must be kept at the supplier’s physical
facility and made available to the CMS upon request.

Q: What are the guidelines for notification to the
patient filing the complaint?

A: The Quality Standards require that a
supplier notify the patient that it has received the patient’s
complaint and is investigating the complaint. The supplier may give
notice through email, telephone, fax or letter. Such notice must be
given within five calendar days from receiving the patient’s
complaint. The supplier then has 14 calendar days to provide
written — not oral (such as telephone)- — notification
to the patient of the results of the investigation. If an
investigation is not conducted, the supplier must record the name
of the person making the decision not to conduct an investigation
and the reason for the decision.

Q: Are there requirements imposed on the supplier
regarding an incident, injury or infection?

A: The Quality Standards require that a
supplier investigate any incident, injury or infection, known to
the supplier, in which DME may have contributed to the incident,
injury or infection. A supplier should initiate an investigation
within 24 hours of becoming aware of a patient’s hospitalization or
death due to an incident, injury or infection in which DME may have
been a contributing factor.

In cases not involving a patient’s death or hospitalization,
Medicare expects a supplier to begin an investigation within 72
hours of becoming aware of the incident, injury or infection. The
record of the investigation should include all pertinent
information and conclusions about the incident, and whether the
supplier believes that changes in systems or processes are needed
in response.

Q: What maintenance and repair obligations are imposed
on the supplier after delivery of an item?

A: Under the Supplier Standards, a supplier
must honor all warranties and not charge the patient or Medicare
for the repair or replacement of Medicare-covered items or services
covered under warranty. Generally, for Medicare-covered items
furnished on a rental basis, the supplier must maintain, repair and
replace the item at no charge. Medicare does not cover routine
servicing, such as testing, cleaning and checking the equipment
because Medicare expects the patient to perform such routine
maintenance.

Maintenance that needs to be performed by authorized technicians
is usually covered as a repair to the equipment. Such maintenance
includes, for example, performing tests requiring specialized
testing equipment. Medicare does not cover any maintenance for
items considered to require frequent and substantial servicing. For
capped rental items, such as power wheelchairs, furnished prior to
Jan. 1, 2006, Medicare will pay for maintenance and servicing the
equipment once every six months when either the 15-month rental cap
has been reached and six months have passed from the end of the
final paid rental month or when the item is no longer covered under
warranty, whichever is later.

Medicare’s policies regarding repair and maintenance of oxygen
equipment are different.

Q: What happens when Medicare denies payment for an item
or service provided to the patient?

A: If the supplier is not a participating
supplier and did not accept assignment on the claim, then the
supplier may seek payment directly from the patient. If the patient
fails to make payment, then the supplier may repossess the
equipment (subject to applicable laws on repossession). If the
supplier is a participating supplier or otherwise accepted
assignment on the claim, then the supplier may not seek payment
from the patient (other than the applicable copayment or
deductible) unless the supplier gave the patient an ABN prior to
furnishing the item or service.

The supplier is required to submit assigned and non-assigned
claims for patients. That is, even if the supplier does not accept
assignment on the claim and gives the patient an ABN, the supplier
must submit the claim to Medicare for the patient, if the patient
requests that the supplier do so. However, there is no similar
requirement for the supplier to appeal denied claims for
patients.

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
[email protected].