Our industry faces new challenges daily, such as the new resupply regulations and contacting patients by the Centers for Medicare & Medicaid Services (CMS). Let’s look at the A4377, ostomy pouch, drainable, for use on faceplate, plastic, each. RemitDATA has provided great denial information regarding this item. The A4377 has an overall denial rate of 15.9 percent, and the number-one reason is the 150 denial code (payer deems the information submitted does not support this level of service).
This denial often occurs when providers have supplied too many of the A4377 or other supply items to patients within a specified period. Medicare beneficiaries are allowed 10 every month. Providers should train intake teams to understand the limits assigned to supply items in all categories. When a patient calls in a request, providers should examine the invoice/transaction/claim history to see if they’ve previously received items, when and in what quantity. If the patient has already received the item(s) and it is not within the timeframe dictated by Medicare, the claim will be denied due to “overutilization.” If the patient doesn’t meet the requirements, then an Advanced Beneficiary Notice (ABN) must be sent.
New resupply requirements also impact PAP, diabetic, ostomy and urological, etc. The documentation requirements redefined how providers are to follow up with patients. This means that providers of IVR technology need to change their systems to meet these requirements as well. The listserves were sent by the DME MACs on June 7, 2012 announcing the change, but CMS revised the requirements for refills effective for dates of service on or after August 2, 2011.
For items that the patient obtains in person at a retail store, the signed delivery slip or copy of itemized sales receipt is sufficient documentation of a request for refill.
For delivered items, documentation of a request for refill must be either a written document received from the beneficiary or a contemporaneous written record of a phone conversation/contact between the supplier and beneficiary.
The refill request must occur and be documented before shipment. A retrospective attestation statement by the supplier or beneficiary is not sufficient. The refill record must include the beneficiary’s name or authorized representative if different than the beneficiary, a description of each item being requested and the date of refill request.
For consumable supplies such as surgical dressings, etc., the supplier should assess the quantity of each item that the beneficiary still has remaining to document that the amount remaining will be nearly exhausted on or about the supply anniversary date.
For non-consumable supplies such as Positive Airway Pressure and Respiratory Assist Device supplies, the supplier should assess whether the supplies remain functional, providing replacement only when the item is no longer able to function. Document the functional condition of the item in sufficient detail to demonstrate the cause of the dysfunction that necessitates replacement/refill.
This information must be kept on file and be available upon request to ensure that the refilled item remains reasonable and necessary, that existing supplies are approaching exhaustion and to confirm any changes/modifications to the order.
Contact with the beneficiary or designee must take place no sooner than 14 calendar days prior to the delivery/shipping date, and the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product.
For all DMEPOS items that are provided on a recurring basis, suppliers must have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a request from a beneficiary. Items delivered without a valid, documented refill request will be denied. Suppliers must not dispense a quantity of supplies exceeding a beneficiary’s expected utilization, and they must stay attuned to changed or atypical utilization patterns.
These changes need to be implemented whether you call patients yourself, outsource the personal contact to a qualified business affiliate, or utilize a supplemental IVR program through a vendor partner. Prevent denials and post-payment monetary takebacks by reviewing your resupply program to ensure that you are following the most recent updates.