DME by the Numbers

Re-enrollment in Medicare is often one of those activities conducted during the fall. The industry has been told that CMS is revising the 855-S form that suppliers use for Medicare program enrollment and re-enrollment in order to better align the accreditation product categories that list the DME items pharmacies and suppliers provide. We have not seen the revised form yet, but we are expecting it to be released at any time.

Prescribers and PECOS Enrollment

It has been three years since the first prescribers were enrolled in PECOS and the system went live. Now it is time for PECOS re-enrollment. Many suppliers across the country found themselves in a quagmire this summer when their routine prescribers were no longer listed in PECOS. As it turns out, prescribers have been very slow to complete their re-enrollment over the past months and as suppliers are checking that their prescriber is active in PECOS, they are finding that those that have always been listed are now not. This is happening because many of the previously enrolled prescribers have either completed their re-enrollment, incorrectly or in an untimely manner. When this happens to you, contact the prescriber’s office and explain to the management staff that they are now not listed and you are unable to provide DME until they are re-enrolled. You might also remind them that this affects all of their other referrals for Medicare services, as well as their invoices for visits and procedures. You will not be able to process any referrals from them until their re-enrollment is complete.

Number of DME Suppliers

Speaking of enrollment, now we have some numbers from CMS:

In the early months of 2007, there were roughly 111,750 DME suppliers. This number was at the start of the accreditation requirement, although the mandatory compliance date of October 1, 2009, had not been announced and Round 1 of Competitive Bidding was set to begin in July of that year. Now that we have mandatory accreditation for all DME suppliers, limited accreditation requirements for pharmacies, Competitive Bidding Rounds 1 and 2, and several years of consolidation, we had 91,339 DME suppliers in 2014. That’s a 13 percent reduction over seven years. With the proposed application competitive bidding rates to rural areas starting on January 1, 2016, we are going to see a much more dramatic drop in suppliers as more and more will no longer be able to afford to participate in Medicare with the terribly low reimbursement rates and increased audit activity.

And Medicaid Too

Driven by financial necessity, CMS seeks to move Medicaid Managed Care in line with Medicare.

State Medicaid reforms generally are being more quickly adopted than federal pilot projects. In innovating states, one can find widespread use of such things as patient-centered medical homes and bundled payments.

And relative enrollment has increased greatly, including the more traditional versions of managed care. In 1992, only 8 percent of Medicaid beneficiaries accessed at least some of their benefits via capitated health plans. In 2011, the participation rate was 58 percent, according to a CMS fact sheet.

The numbers do not tell us anything we did not already know, but they remind us to stay nimble, remain compliant with all of our requirements and continue to think outside the box for new programs and opportunities as they become available in the community. It is critical for your survival!