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 jbaird@bf-law.com.