DMEPOS Provider Educational Session: Policy Review and Provider Impact

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DMEPOSProvider Educational Session Policy
Review and Provider Impact

• Web-Cast Presentation
• Tuesday, February 10th and 24th, 2009
• 200 pm to 330 pm

Margie Preston, Director, Medical Policy Unit
Lindsay Ryan, Program Specialist 2, DME, OP
Services
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DCH Mission
RESPONSIBLE
HEALTHY
ACCESS
Access to affordable, quality health care in our
communities
Responsible health planning and use of health
care resources
Healthy behaviors and improved health outcomes
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DCH InitiativesFY 2008 and FY 2009
FY 2009
FY 2008
Medicaid Transformation Health Care
Consumerism Financial Program Integrity Health
Improvement Solutions for the Uninsured Workforce
Development PeachCare for KidsTM Program
Stability Customer Service
Medicaid Transformation Health Care
Consumerism Financial Integrity Health
Improvement Solutions for the Uninsured Medicaid
Program Integrity Workforce Development PeachCare
for KidsTM Program Stability SHBP Evolution
Customer Service and Communication
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OBJECTIVES

• To provide a basic understanding and
  clarification of recent updates to the Part II
  Policy and Procedure Manuals for Durable Medical
  Equipment (DME) and Othodics and Prosthetics
  (OP)
• To solicit provider feedback/input for increased
  collaboration

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PROVIDER FEEDBACK

• Request consideration for notification period
  from 30 to 90 days
• Reimbursement methodology
• Setting rates
• Budget/Savings
• Provider participation

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INTENT OF THE POLICY UPDATES

• To clarify policy with regards to coding and
  pricing parameters for accurate and timely prior
  approval review and claims processingwhile
  ensuring adequate benefit coverage of DME and OP
  services/supplies

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WHAT ARE THE POLICY CHANGES?

• To apply CMS rates to HCPCS codes being submitted
  w/BR
• Delete K0108
• Updated ATP ATS Certification policy

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RATIONALE Applying CMS Rates

• To adhere to the Departments State Plan and DME
  reimbursement policy (Section 1001)
• To comply with CMS requirements to guard against
  claim overpayment
• To ensure a standard and consistent reimbursement
  methodology for all services and across all
  providers

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RATIONALE Deleting K0108

• The Department requires the use of unique
  HCPCS/CPT codes to bill services/supplies
• The use unique codes allows for consistent rate
  establishment, accurate claim payment, and
  effective expenditure and audit tracking
• Minimizes reimbursement for non-covered services

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RATIONALE Consolidating ATP ATS

• The change is in accordance with the Centers for
  Medicare and Medicaid Services (CMS) Durable
  Medical Equipment, Prosthetics, Orthodics, and
  Supplies (DMEPOS) Quality Standards, Section
  IIIComplex Rehabilitative Wheelchairs and
  Assistive Technology (October 2008)

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OVERALL IMPACT

• Increased efficiency of prior approval and claim
  processing
• Consistent fair and equitable application of the
  benefits and claim reimbursement
• Increased reliability of expenditure and audit
  tracking
• Allows for PA exceptions for aberrant care needs,
  where applicable

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COLLABORATION

• DCH solicits providers input to identify and
  submit unique HCPCS code that best defines the
  services/supplies
• DCH staff will review, price, and open unique
  HCPCS codeused to report covered services
• DCH staff will update DME and OP manuals and
  notify providers within the described period of
  time prior to implementation of the proposed
  change(s)

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REIMBURSEMENT METHODOLOGY

• In accordance with the Part II Policy and
  Procedure Manual for DMEPOS, Section 1001 the
  maximum reimbursement for providers of medical
  equipment is limited to the lower of a) the
  actual charges for the item or b. the statewide
  rate in effect on the dates of service
• The standard statewide rate is calculated using a
  CMS rate

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Q and A

• THANK YOU FOR YOUR PARTICIPATION