It is possible to participate at the current high levels of reimbursement for Medicare DME if your facility and practice is eligible to be classified for exemption
As the year 2020 slowly comes to an end, Medicare DME is preparing for significant changes to the way chiropractors can participate in the Medicare DME reimbursement program. As of Jan. 1, 2021, Medicare DME is planning on two major changes to the program, both of which involve the concept called “competitive bidding.”
Competitive bidding means that Medicare DME has decided to only allow and reimburse those facilities that have been awarded a “competitive bid” for the regional area they are in under the Medicare DME program for certain supplies such as lumbar braces. This impacts currently certified suppliers such as chiropractic offices in two ways:
First, it means that unless you are in an area of the country that is not covered under competitive bidding (mainly rural mildly populated areas), you will not be able to continue to participate in the Medicare DME reimbursement program. Let me be very clear about this: your business as a Medicare DME provider/supplier will be over as of Jan. 1, 2021, and end. You will not be able to bill for and be reimbursed for DME supplies such as lumbar braces.
Second, if you are either an exempted entity (more on this further on in this article) or in an area that is not included in the competitive bid program, you will experience a reduction in the reimbursement amount as much as 50-75%. While the official amount for approved reimbursement has not yet been published, the “word on the street” from insiders is saying this.
Medicare DME exemptions
There is good news, however, and it is possible to be participating at the current high levels of reimbursement in the Medicare DME program if your facility and practice is eligible to be classified for exemption. There are two possible ways to accomplish this if your practice meets certain criteria. Both are reasonable and attainable for any chiropractic practice. You just have to know about the criteria and follow the basic rules.
The first exempt pathway is for what are classified as Group Medical Practices. This pathway has a number of very good advantages. A group medical practice is one in which at least one of the members with 5% or more ownership is a MD or DO. Nurse practitioners and physician assistants have also been accepted in the past as meeting these criteria.
Another advantage besides being exempt from the competitive bidding changes is that group medical practices do not need office facility accreditation and do not need to carry surety bond coverage. Also, group medical offices can continue to do both “off the shelf” and customized or modification of braces.
Certified Orthotic Fitter status
For those chiropractic offices that cannot or do not participate in the entity of a group medical practice there is another option. That option involves adding a Certified Orthotic Fitter to the office staff and having your office on record with Medicare DME as having Certified Orthotic Fitter personnel. For a chiropractor who owns his own office this can be done by passing an online course of instruction and then passing an online certification test approved by a Medicare Accrediting Organization (AO).
The advantage of this is that the chiropractor keeps 100% ownership. The disadvantages are that the chiropractic facility must achieve and keep approved accreditation, keep appropriate surety bond coverage in place at all times, and achieve and stay current with being a Certified Orthotic Fitter.
Medicare DME advantages
For those chiropractors who have been in the Medicare DME program, some for many years, you are aware of the advantages to participating. For chiropractic offices that are integrated with medical procedures and have at least a 5% or greater medical partner, the only change with the Competitive Bidding program that will affect you is the reduction of the “off the shelf” pricing. The reimbursements for customization or modification is not scheduled to change.
For those chiropractors who are 100% owners of your facility and practice, whether you have medical employees or not, your participation will end come Jan. 1, 2021, unless you make changes to become and one of the exempt entities and are registered so under the Medicare DME program.
Medicare reserves the right to delay the upcoming program but, as of now, the rumors of delay do not appear to be true. Therefore, be aware and make any necessary changes to stay in the program or become deactivated from the program come Jan. 1, 2021. It is up to you to decide what is best for your situation and to act or not. Working within the Medicare DME program for properly credentialed offices, in spite of the changes coming, a chiropractor still has options that can be both viable and very rewarding.
JAMES C. ANTOS, DC, DABCO, lives in Windermere, Fla. He serves as a consultant helping chiropractors, medical doctors and others 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.