Chiropractors and the changing Medicare DME provider rules

New competitive regional DME bidding on patient care is coming – how to minimize the impact on chiropractic practices and qualify to...

New competitive regional DME provider bidding on patient care is coming – how to minimize the impact

BY CHIROPRACTIC ECONOMICS STAFF

Chiropractors work tirelessly to promote not only spine and musculoskeletal health, but overall health, wellbeing and quality of life for patients in their care. Chiropractors with a Medicare durable medical equipment (DME) PTAN number (which allows for supplying and reimbursement by Medicare DME) can currently deliver DME provider supplies such as lumbar and knee braces. But The Centers for Medicare & Medicaid Services (CMS) DMEPOS Competitive Bidding Round 2021 will drastically impact this business model. ¹

“Business as usual” for some practices, but not all

Many chiropractic practices will be impacted by the CMS reimbursement changes resulting from Round 2021. In particular, braces that fall under Product Category OR03 will be subject to competitive bidding – and, if a practice traditionally supplies these braces, one may no longer be able to supply under Product Category OR03.

The CMS defines Product Category OR03 as off-the-shelf (OTS) prefabricated items requiring minimal self-adjustment for appropriate use that do not require custom-fitting expertise.

“Unless you placed a bid by the Sept. 18, 2019 deadline, after Jan. 1, 2021, your billable options via CMS for supplying Product Category OR03 OTS prefabricated braces are limited and will end on Dec. 31, 2020,” says James C. Antos, D.C., DABCO, owner of Antos & Associates, LLC. Antos serves as a consultant in the areas of DME provider applications, documentation and clinical appropriateness, and has been licensed for chiropractic practice in Florida since 1978.

But there are options to mitigate the impact of Round 2021 on a chiropractic practice.

Bid options

Once CMS awards bids by competitive bid area (based on proposed fee, geographic region and patient volume capability), only bid-winning suppliers will be eligible for Medicare reimbursement for this specific subset of OTS braces. However, as Antos notes, there are two options that will allow practices that currently have Medicare DME provider status to continue doing so under Round 2021.

“Chiropractors whose practices have at least 5% ownership by an MD, DO, PA, or nurse practitioner will be allowed to continue as exempt from the competitive bid process,” Antos says. “As long as the practice is listed as a medical (MD, DO, PA, or nurse practitioner) ownership of at least 5%, those offices will continue to enjoy the privilege of being able to supply, bill for, and be reimbursed at the approved values for DME supplies.”

Besides meeting the 5% ownership criteria using Product Category OR02, there is another pathway to consider to continue as a Medicare DME provider. The competitive bidding does not have to result in a service gap for non-exempt providers, and there is a significant opportunity to expand the service a practice provides while enhancing reputation for providing comprehensive patient care. A practice can provide items in CMS’s Product Category OR02, custom-fit prefabricated orthotic braces. This category is not impacted by competitive bidding, and chiropractors can easily obtain this accreditation.

CMS defines Product Category OR02 as prefabricated orthotics that all require custom-fitting and adjustment (for example, the item must be trimmed, bent, molded [with or without heat], or otherwise modified by an individual with expertise in customizing the fit for use by a specific patient). A custom-fitted orthotic requires modification of the item to provide an individualized fit.

A patient-centered solution and opportunity

Matthew Gruskin, MBA, BOCO, BOCPD, credentialing director at the Board of Certification/Accreditation (BOC), works with a large variety of DME suppliers and notes the opportunity to provide items in Product Category OR02 is attainable for any chiropractic office.

“By following a simple, three-part process, you can establish your business as an accredited supplier that is recognized by CMS; then you can continue delivering and fitting braces as a valued service to your Medicare beneficiaries,” Gruskin says of becoming or maintaining status as a DME provider.

Here are the three parts of the process Gruskin references. He notes that they can be completed in any order (or simultaneously), but all three are required to be reimbursed by CMS for items in Product Category OR02:

Part 1: Apply for DMEPOS Accreditation — In order to apply for Product Category OR02, a business must earn accreditation from a CMS-deemed accrediting organization. ²

If a practice is not already accredited, review the CMS DMEPOS Supplier Standards and CMS DMEPOS Quality Standards and contact an accrediting organization to begin the process. ^{3, 4}

Part 2: Employ or Contract with a Professional with Education and Training as an Orthotic Fitter — In addition to DMEPOS Accreditation, to bill CMS under Product Category OR02, a practice’s staff must include at least one employee with verified education as an orthotic fitter, such as a certified orthotic fitter. A chiropractor can earn this designation, or contract with a certified orthotic fitter professional, or hire an employee who holds this certification.

The requirements to become a certified orthotic fitter include but are not limited to successful completion (within the last five years) of an entry-level course through a fitter education provider and documentation of supervised patient care experience.

Once a DC or team member meets the prerequisites, the next step is to take and pass a certified orthotic fitter exam to earn the necessary credentials to satisfy the CMS billing requirement. Two national certification bodies offer this exam: BOC (Board of Certification/Accreditation) and ABC (American Board for Certification); only the BOC exam is nationally accredited.

Next steps

By earning DMEPOS accreditation for a practice and enlisting a certified orthotic fitter, once can provide the full spectrum of specialized patient care, including OR02 custom-fit prefabricated braces.

Reminder: Patients will need a prescription for a custom fit brace, and DCs can work directly with referring physicians, physician assistants or nurse practitioners. The accrediting organization or a consultant will guide DCs to additional resources about the documentation required to bill CMS, as well as state’s guidelines.

JAMES C. ANTOS, DC, DABCO, of Antos & Associates, LLC, can be contacted at antosdmebrace.com, Antsjm@hotmail.com, or 386-212-0007.

MATTHEW GRUSKIN, MBA, BOCO, BOCPD, Board of Certification/Accreditation (BOC), can be contacted at www.bocusa.org, matt.gruskin@bocusa.org, or 410-753-8721.

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