This year has shaken up durable medical equipment suppliers for chiropractic, Medicare and competitive bidding
MEDICARE DME, as of Jan. 1 of this year, changed to a new status for all Medicare durable medical equipment suppliers and providers. To be put very simply, unless your chiropractic office has been awarded a competitive bid contract for Medicare DME for your geographical area, you will not be able to supply, bill for, and be paid for off-the-shelf lumbar spinal bracing and off-the-shelf knee bracing.
You still can supply, bill for, and be paid for all other Medicare DME supplies in your category of certification. Denial responses to bills not in compliance of the new “Competitive Bid” changes are already being received by chiropractic offices that are not in an excluded category.
There are common exceptions to this new status:
- If your geographical location is not included in the locations published. These are most commonly rural, and most large city areas are included in competitive bid jurisdictions.
- If your practice certification is considered a “Group Medical” practice that includes as a partner a licensed medical physician such as an MD or DO and they own at least 5% of the group practice.
- If your practice includes personnel who are certified orthotic fitters and are recognized as so by one of the Medicare-approved accrediting organizations for orthotic fitters.
Durable medical equipment suppliers and competitive bid areas
Concerning point No. 1 above, you can find out if your geographical location is considered a part of the competitive areas included by checking the website at dmecompetitivebid.com.
If your practice location is not included in a competitive bid area, you will be able to supply off-the-shelf lumbar and knee braces, along with all other orthotics in your category, but the dollar amount that Medicare DME approves for reimbursement may have changed significantly. You can check the current payout amount by going to dmecompetitivebid.com. A telephone number that might be helpful is 877-577-5331 if you want to try to talk with a person about your particular situation.
In some areas the reimbursement has gone down slightly; in some areas the reimbursement has gone down significantly, and in a few areas the reimbursement has actually gone up. Also, there are a few areas where the competitive bid status is only for lumbar braces and not knee braces, or only for knee braces and not for lumbar.
Now for some information on point No. 2 — all medical practices are excluded for the new competitive bid changes. That means a medically-owned practice in any location that is certified for Medicare durable medical equipment suppliers reimbursement may continue to provide off-the-shelf DME supplies such as lumbar and knee braces and be reimbursed from Medicare DME payers. The only new change for medical practices is that the off-the-shelf reimbursement values have changed and the medical practice must accept the new levels of reimbursement.
It is important that medical exemption practices must now add a modifier to the bill for reimbursement of KV to identify to Medicare DME that the provider/supplier is part of the medical exemption category for Medicare DME competitive bid. Also, if the practice is a group practice and has a medical provider as an owner of at least 5% or more, that practice is considered a group medical practice and, therefore, is also excluded from the competitive bid area restrictions.
In my experience over the years, ownership in a group practice by a physician’s assistant and/or nurse practitioner have also been accepted as qualifying the practice as a group medical practice and have qualified as an exemption to the Medicare durable medical equipment suppliers competitive bid changes now in place. Another possible exclusion for chiropractic practices wishing to continue or become a new certified provider for Medicare DME is to add the status of having a certified orthotic fitter on staff or in ownership. I really like this as it allows for a chiropractor to retain 100% control of the practice, yet still participate in Medical DME reimbursement under competitive bid.
The requirements for a chiropractor to become certified as an orthotic fitter acceptable to Medicare DME are very straightforward at this time and can be accomplished with online education. Certified orthotic fitter suppliers must also have their facility accredited, purchase a surety bond, and have in place a compliance, policy, and procedural manual specific for Medicare durable medical equipment suppliers and the individual practice location.
Medicare DME remains strong
Changes are upon us and those practices that continue to update their qualifications and education, and provide multiple services to their patients, will continue to thrive and have every opportunity to excel and prosper in today’s marketplace and the future.
After all, the Medicare population is a strong one and their need for clinically-necessary DME supplies is strong and proven.
JAMES C. ANTOS, DC, DABCO, lives in Windermere, Fla. He serves as a consultant helping chiropractors, medical doctors and others to become certified to be reimbursed under Medicare for DME supplies. He can be reached through his website at antosdmebrace.com, 386-212-0007 or firstname.lastname@example.org.
Addendum: Credentials that support your clinic’s continuity of care
Many chiropractic practices that previously supplied prefabricated, off-the-shelf orthoses (CMS product category OR03) have been impacted by durable medical equipment suppliers competitive bidding. However, prefabricated custom-fitted orthoses (category OR02) have not been impacted by competitive bidding, and chiropractors across the country have continued providing this valuable care to patients with OR02 orthoses. Preparing to provide these custom-fitted orthoses is a two-part process:
First, if your practice is not already accredited, you will need to obtain DMEPOS accreditation from a CMS-deemed Accrediting Organization (AO). To begin the process, review the CMS DMEPOS Supplier Standards and CMS DMEPOS Quality Standards, and contact a CMS-deemed AO such as the Board of Certification/Accreditation (BOC).
OR02 requires custom fitting and adjustment; for example, these items must be trimmed, bent or otherwise modified by an individual with expertise in customizing the fit for use by a specific patient. Therefore, the second part of the process is to employ or contract with an “individual with expertise,” like a Certified Orthotic Fitter (COF). A chiropractor or other staff member can earn the COF designation, contract with a COF, or hire a new employee who holds this certification.
The primary requirements to become a COF include documentation of supervised patient care experience and successful completion of an entry-level course through an approved fitter education provider. In some cases, the education may be completed virtually.
Once a chiropractor or team member meets the prerequisites, the next steps are to apply for certification and then pass the required exam. Two national certification bodies offer this exam: BOC (Board of Certification/Accreditation) and ABC (American Board for Certification). BOC offers live, remote-proctored testing so candidates may take exams online in any convenient and quiet space.
After earning DMEPOS durable medical equipment suppliers accreditation for a practice and adding the services of a COF or other CMS-recognized “individual with expertise,” chiropractors can provide patients with the full spectrum of custom-fitted orthoses and complement the care they already are providing.
To learn more, reach out to your AO or a consultant who can provide you with additional resources about the documentation required to bill CMS, as well as other relevant guidelines.
MATTHEW GRUSKIN, MBA, BOCO, BOCPD, CDME, is credentialing director for the Board of Certification/Accreditation (BOC).