durable medical equipment, prosthetics, orthotics and supplies (dmepos ) assisting medicare...

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

Assisting Medicare Beneficiaries

Renee RichardCMS Boston Regional OfficeEdward McGuire, LiaisonPalmetto GBA

DefinitionDefinition

Durable medical equipment (DME) is furnished to a beneficiary for use in the patient’s home, covered under the Part B program, whether furnished on a rental basis or purchased.

Definition: DME is equipment that: (1) can withstand repeated use, (2) is primarily and customarily used to serve a medical purpose, (3) generally is not useful to a person in the absence of illness or injury, and (4) is appropriate for use in the home.

September 2015 National Training- DMEPOS 2

Major Categories of DMEPOSMajor Categories of DMEPOS

DME – equipment used in the home which can withstand repeated use, is primarily and customarily used to serve a medical purpose and is generally not useful in the absence of an illness or injury;

Prosthetic Devices – devices that replace all or part of an internal body organ, including ostomy, tracheostomy and urological supplies, parenteral and enteral nutrients, equipment and supplies (PEN), intraocular lenses (IOLs), and one pair of conventional eyeglasses or contact lenses after each cataract surgery;

Prosthetics – artificial legs, arms, and eyes; Orthotics – rigid or semi-rigid leg, arm, back, and neck braces; Surgical Dressings Therapeutic Shoes and Inserts


Non-covered DMENon-covered DME

Other devices and equipment used for environmental control or to enhance the environmental setting in which a bene resides are not considered covered DME.

These include items such as room heaters, air conditioners, humidifiers, dehumidifiers, elevators, posture chairs, physical fitness equipment, self-help devices and training equipment.


Coverage CriteriaCoverage Criteria

Medicare requires a physician’s prescription for DMEPOS items. A supplier must have an order signed and dated by the bene’s doctor before dispensing any DMEPOS item to a bene.


Face-to-Face Exam RequirementsFace-to-Face Exam Requirements

Effective July 01, 2013–– As a condition for payment, Section 6407 of the

Affordable Care Act (ACA) requires a physician to document that the physician, PA, NP or CNS has had a face-to-face encounter examination with a beneficiary in the six (6) months prior to the written order for certain items of DME

• This includes encounters conducted via CMS approved telehealth services

• PMD bases are not affected by these changes


Replacement - Basic Payment RulesReplacement - Basic Payment Rules

Defined– Substitute an item for another that is broken, inefficient, lost

or no longer working or yielding what is expected Replacement of DME may occur in cases of loss,

irreparable damage, or a change in patient’s condition– Loss/stolen– Irreparable Damage

• Specific accident or a natural disaster• Equipment may be replaced in cases of loss or irreparable damage• New order/CMN required

Patient’s condition changes to necessitate a different type of equipment



Replacement of DME may occur in cases of irreparable wear after the reasonable useful lifetime has expire– Irreparable Wear

• Deterioration sustained from day-to-day usage over time• Replacement due to irreparable wear takes into

consideration the reasonable useful lifetime of the equipment

• New order/CMN required

Note: Replacement due to wear and tear before the reasonable useful lifetime is not covered



Useful Lifetime– Determined through program instructions– In absence of instructions, contractors may determine

the reasonable useful lifetime of equipment– In no case can it be less than five years– Computation is based on when the equipment was

delivered– Replacement due to wear is not covered during the

reasonable useful lifetime


Competitive BiddingCompetitive Bidding


Competitive Bidding– A Better Way to Pay Competitive Bidding– A Better Way to Pay

Program will help people with Medicare− Save money− Get quality equipment, supplies and services

Program strengthens protections against Medicare fraud

September 2015 11National Training- DMEPOS

How the Program WorksHow the Program Works

DMEPOS suppliers submit bids– Suppliers must submit a bid to be awarded a

contract Medicare uses bids to determine payments Contracts will be awarded to sell/rent DMEPOS “Contract suppliers” will be those who

– Offer the most competitive price– Meet eligibility, quality, and financial standards– Are accredited by an independent organization


How the Program WorksHow the Program Works

Only contract suppliers will be able to– Provide competitively bid DMEPOS items – File claims with Medicare for payment of

competitively bid items and services Contract supplier charge cannot exceed

– Single payment amount based on bids received for an item

– Medicare fee schedule allowed amount


Round 2Round 2

Competitive Bidding Program expanded– Round 2

• 91 Metropolitan Statistical Areas (MSAs)• Effective date July 1, 2013

– National Mail-Order Program


Products Included in Round 2*Products Included in Round 2*

Products Included in Round 2

Oxygen, oxygen equipment, and supplies

Enteral nutrients, equipment, and supplies

Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs), and related supplies and accessories

Hospital beds and related accessories

Walkers and related accessories

Support surfaces (Group 2 mattresses and overlays)

Standard (power and manual) wheelchairs, scooters, and related accessories

Negative pressure wound therapy pumps and related supplies and accessories


*Changes from Round 1 to Round 2 in Bold Italics

National Mail Order Program for Diabetic Testing Supplies

National Mail Order Program for Diabetic Testing Supplies

Targeted to go into effect at the same time as Round 2

Includes all parts of the United States:− The 50 States− The District of Columbia− Puerto Rico− The US Virgin Islands− Guam− American Samoa


Who is Affected? Who is Affected?

Beneficiaries who have Original Medicare and– Permanently reside in a ZIP Code in a CBA– Obtain competitive bid items while visiting a CBA

To find out if a ZIP Code is in a Competitive Bidding Area (CBA)– Call 1-800-MEDICARE (1-800-633-4227)

• TTY users call 1-877-486-2048

Medicare Advantage enrollees can use suppliers designated by their plan



Region I: Round 2 MSAsConnecticut

• Bridgeport-Stamford-Norwalk, CT• Hartford-West Hartford-East Hartford, CT• New Haven-Milford, CT

Maine: None

Massachusetts • Boston-Cambridge-Quincy, MA-NH • Providence-New Bedford-Fall River, RI-MA • Springfield, MA • Worcester, MA

New Hampshire• Boston-Cambridge-Quincy, MA-NH

Rhode Island• Providence-New Bedford-Fall River, RI-MA

Vermont: None

Using Contract SuppliersUsing Contract Suppliers

Must almost always use contract supplier if– Items and services are included in Competitive

Bidding Program where a beneficiary lives in a CBA– Traveling to or visiting a CBA

Doctors, treating practitioners, and hospitals can supply certain items (ex: walkers or folding manual wheelchairs)

Nursing Facility can only supply directly if it becomes a contract supplier

September 2015 19 National Training- DMEPOS

Identifying Contract SuppliersIdentifying Contract Suppliers

Visit the DMEPOS Supplier Locator tool– www.medicare.gov/supplier

Call 1-800-MEDICARE (1-800-633-4227)– TTY users call 1-877-486-2048


http://www.medicare.gov/supplier

Non-contract SupplierNon-contract Supplier

If in CBA, a non-contract supplier may not furnish bid items

If non-contract supplier used, supplier must issue Advance Beneficiary Notice (ABN)– Says Medicare will not pay– By signing, beneficiary agrees to pay entire

amount– If no ABN signed, beneficiary not responsible for

payment


Specific BrandsSpecific Brands

Doctor must prescribe in writing Medical record must reflect need Contract supplier must

– Furnish the specific brand or form as prescribed OR

– Work with doctor or treating practitioner to find suitable alternative OR

– Help locate another contract supplier that can furnish the specific brand or form as prescribed


Equipment Repair & ReplacementEquipment Repair & Replacement

For owned medical equipment– Any Medicare-enrolled supplier can make

necessary repairs– For replacement must use contract supplier – For warranty repairs, follow the warranty rules

For rented equipment– Repairs are included in rental payment – the

supplier must fix at no charge


Hot TopicsHot Topics

Repairs to Power Mobility Devices: many suppliers unwilling to do repairs because the PMDs were purchased from now out of business suppliers. – Bankruptcy– Closed

Benes are paying out of pocket for equipment from non-enrolled suppliers. – Eye glasses (post cataract surgery)(Now in the

Medicare handbook)


Other Inquiries/CasesOther Inquiries/Cases

Other inquiries/cases

Open Discussion for common or problematic inquiries


Questions?Questions?

Visit www.medicare.gov/supplier– DMEPOS Supplier Locator Tool

Visit www.medicare.gov website – Consumer information

Call 1-800-MEDICARE (1-800-633-4227) –TTY users should call 1-877-486-2048

Beneficiary’s physician or supplier Medicare’s local information resources

(SHIPs, ACL, etc)September 2015 26National Training- DMEPOS

http://www.medicare.gov/suppliers

http://www.medicare.gov/

Thank youThank you

Renee Richard, CMS617-565-1256

Edward McGuire, Palmetto GBA803-763-5774


durable medical equipment, prosthetics, orthotics and supplies (dmepos ) assisting medicare...

Documents

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national training dmepos3non

national training dmepos5face

physical fitness equipment

expectedreplacement

medical purpose

repeated use

covered dmeother devices