Major Medicare durable medical equipment (DME) change coming

Most physicians will be exempt, but current chiropractic Medicare durable medical equipment providers will face new rules

Medicare will implement a new Competitive Bid Program for durable medical equipment (DME) on Jan. 1, 2021, for a category of Medicare DME that includes supplies such as lumbar and knee braces. 

For chiropractors currently certified to bill Medicare DME, the program will undergo a major and significant change that will, in all probability, end the program for those chiropractors who currently enjoy Medicare DME PTAN certification.

New bidding process

In 2020 all current DME suppliers will have an opportunity to bid to become a supplier for a geographical region. After extensive investigation from numerous reliable sources, it is my opinion that offices wholly owned by chiropractors that are now certified to participate in supplying products and billing Medicare durable medical equipment will not be accepted as a “winner” in the competitive bidding process. Chiropractic offices are just not substantial enough in their business to handle the volume of demand that a selected DME supplier will have to be able to handle for a geographical region.

While chiropractors can bid a lower fee, that is not as important as the ability to handle a large volume in a region, which is bad news for chiropractors retailing DME.

The good news

But there is good news — those chiropractic-certified suppliers who have a MD, DO, PA, or nurse practitioner as a 5% or greater owner of that practice, and that practice is listed as a medically- (physician) exempt certified supplier, will continue as exempt from the Competitive Bid Program process. There chiropractic-certified suppliers will continue to enjoy the privilege of being able to supply, bill for, and be reimbursed at the approved values on their patients. 

Let me repeat — physician practices will be exempt from the Competitive Bid Program process. The physician exemption applies to medical physicians, osteopathic physicians, physician assistants, and nurse practitioners. Chiropractors are not considered physicians that are exempt under Medicare DME rulings. This attitude and treatment of chiropractors first started in 2012 when chiropractors had to undergo the accreditation process on their facilities before being able to apply for Medicare durable medical equipment certification. Before 2012 chiropractors were treated as physicians with a limited status.

Exempt status

So if the practice is integrated and has an exempt-status owner of at least 5% of the practice, that practice will be considered exempt. Business will go on as before. For those practices that are integrated but the exempt persons are employees, that practice will not be exempt, and that practice’s ability to supply, bill, and be reimbursed will end.

Consulting on this issue, more than 50% of those practices I have helped are already integrated and I now believe have no need to be concerned. It would be wise, however, to double-check your status. The real concern exists for those chiropractic-owned practices that do not have a 5% or greater ownership by one of the exempt-status persons.  

For those practices in jeopardy of losing their ability to participate in Medicare DME, they will have four options:

1. Do nothing and wait and see what happens.
2. Remain the same and try to participate (win) in the Competitive Bid Program process.
3. Rearrange the ownership to include at least 5% of the exempt-professional category persons, and clarify that status with Medicare DME.
4. Be aware that current status will end on January 1, 2021, and resign to that fact.

How this came about

Why is this change occurring?  Based on my experience over many years in this field of health care and the “back alley” sources that I have developed relationships with over the years, the following is my opinion. Chiropractors, when they accepted their status in Medicare back in the 1970s as being able to only be reimbursed for chiropractic adjustments, sealed their fate. While a consultation, an examination, x-rays, and any other appropriate actions must be performed and documented at length, only the adjustment would be reimbursed.

Today we now live with the fact that chiropractic is significantly impacted in performing health care to Medicare enrollees, which are a large and growing segment of the population in the United States. This status now leaves chiropractors out of the loop in the physician-exemption certification concerning competitive bidding in Medicare durable medical equipment. 

FBI raids and the DME future

Recently a large FBI police action arrested a number of individuals involved in criminal activity concerning the Medicare DME reimbursement of DME supplies such as lumbar braces and knee braces. You may have seen their advertisements on television.  I have been advising my clients for years to stay away from these people and their business promises of lead generation. This criminal activity hurt those certified in a similar category and lead to, I believe, a “throwing out the baby with the bath water.”

Chiropractors have always been participating in the health care arena in helping sick and injured people get well, and helping well people stay well. Chiropractic can even succeed in “supercharging” patient’s health, wellbeing, performance, and enjoyment of a great quality of life. 

While this upcoming change will be a challenge for many participating chiropractic offices, it can also be a real chance to modify business models to stay certified in DME and find even greater financial success in 2021 and beyond.

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 antsjm@hotmail.com.