Suppliers of Durable Medical Equipment, Prosthetics and Orthotics, and Supplies (“DMEPOS”) have historically faced scrutinous review from the Centers for Medicare & Medicaid Services (“CMS”) with respect to Medicare enrollment. While Medicare fee-for-service improper payment rates for DMEPOS have been trending downward in recent years, DMEPOS claims still have the highest percentage of improper payment rates when compared to other Medicare claim types. See 2023 Medicare Fee-For-Service Supplemental Improper Payment Data (for claims submitted July 1, 2021 – June 30, 2022). Suppliers must ensure full compliance with regulations to avoid repayment risks to both CMS and beneficiaries, as well as revocation of billing privileges.
Depending on supplier type, DMEPOS suppliers can be subject to state licensure, accreditation, and various Medicare rules to obtain and maintain billing privileges (e.g., 42 CFR 424.57; DMEPOS Quality Standards; Medicare enrollment standards, etc.). Outside of routine audits, DMEPOS suppliers are most frequently assessed for compliance through accreditation surveys and site visits resulting from Medicare enrollment updates (e.g., revalidation, relocation, etc.). Medicare contractor site visits are extremely important to maintaining Medicare billing privileges. Failed site visits can result in revocation of Medicare billing privileges, which can lead to reimbursement interruptions.
Included below are five tips for DMEPOS suppliers to maintain compliance with Medicare enrollment requirements.
- Adopt a holistic approach to Medicare enrollment, which includes all relevant stakeholders.
Medicare enrollment impacts many parts of an organization, including legal, compliance, finance/revenue cycle, operations, etc. Individuals should be trained on events triggering Medicare enrollment updates and that information should flow to those responsible for executing such updates. When updates are required, the operational team on-site should be aware of the enrollment submission and responsibilities related to the site visit. Communication across the organization through planning, execution, and approval are critical to maintaining Medicare billing privileges.
- Ensure all necessary documentation is organized and readily available for a site visit.
DMEPOS suppliers should maintain continuous compliance with all relevant regulatory requirements. Oftentimes, DMEPOS suppliers will receive written correspondence from the Medicare Administrative Contractor (“MAC”) that it will conduct an unannounced site visit as part of an enrollment application. Pay close attention to the content of the letter and communicate the same to all individuals who may be on-site during an unannounced site visit.
To commence a site visit, the surveyor should provide identifying information upon request. Documents to show compliance with regulatory requirements should be maintained in a centrally located area that is known to individuals at the facility who may be responsible during the site visit. Examples of documents frequently asked for during a site visit include, as applicable:
- Licensure
- Insurance Certificate of General Liability (with appropriate limits of coverage and certificate holder)
- Inventory
- Complaint resolution protocol and complaint log/form
- Warranty coverage notification
- Rent/purchase option notification
- Surety bond agreement
- Accreditation certificate/information
- Documentation for written instruction/information on beneficiary use/maintenance of supplies
All the above-referenced documents should be current and not expired. These are frequently documents that are uploaded to the Medicare enrollment system and they should be updated therein before expiration. Failure to provide a document requested by the surveyor can result in revocation of Medicare billing privileges.
- Take notes during or immediately after the site visit and debrief with leadership team.
It is important for staff to take notes during or immediately after the site visit. Notes should include documents requested and provided. If the surveyor identifies compliance issues warranting revocation, a letter from the MAC/CMS will follow. However, that letter may not arrive for a few weeks or even months. Preparing notes during the site visit or immediately after allows staff to refresh their recollection of the site visit and is useful if there is staff turnover. These materials will be beneficial in formulating a corrective action plan (“CAP”) or reconsideration request, if necessary (see number 4 below). Staff present at the site visit should debrief with leadership after the site visit.
- Have a plan if the site visit is failed and execute plan immediately with all relevant stakeholders.
If a site visit is failed, it will take, at minimum, a few weeks to receive a letter from the MAC. In some cases, it can take a few months for this to happen. The letter will identify the regulatory sections that were deficient and a revocation date for Medicare billing privileges. Contact persons receiving this letter should immediately notify the leadership, compliance, legal, and other teams to begin gathering details from the site visit. It is important to assemble the team of stakeholders quickly as billing privileges have been or will be revoked and there is a timeline to respond – 35 calendar days from the date on the letter for a CAP and 65 days for a reconsideration request.
Letters from the MAC/CMS frequently do not include much factual detail. Therefore, it is important to have the site visit notes as mentioned above. The MAC/CMS letter should be reviewed carefully for procedural guidance and that should be confirmed in the relevant Medicare regulations. Once a response strategy is determined, either CAP, reconsideration request, or both, that plan should be executed as soon as possible.
- Conduct routine audits and maintain an accurate enrollment record.
Accurate maintenance of Medicare enrollment records requires a responsible individual or individuals, good communication, and organization. For example, insurance certificates typically expire after one year. Organizations should set calendar reminders to update and upload to the Medicare enrollment system new insurance certificates every 11 months. Premiums for surety bonds should continue to be paid and periodically reviewed to confirm the bond is still active. State licensure should be maintained, timely renewed, and updated with Medicare. Staff should receive regular training on policies and procedures and be well-versed in DMEPOS requirements from accrediting organizations, 42 CFR 424.57, and DMEPOS Quality Standards.
Top performing organizations prioritize and conduct routine internal audits of these standards. It is much easier to correct deficiencies when they are identified internally, rather than in response to a MAC/CMS letter revoking billing privileges and for which a response is time constrained.
Advis helps organizations across the spectrum of providers and suppliers maintain a current and accurate Medicare enrollment record. Suppliers are well advised to seek expert advice and guidance in this regard.
