Medicare claims for DME (Items that have a medical purpose and repeated use) are suitable for coverage, and appeal if they have been denied, if they meet specific criteria.
Topic: Durable Medical Equipment
he Bulletin addresses a serious and persistent obstacle to obtaining DME faced by people dually eligible for Medicare and Medicaid in many states because of the mismatch of processing rules in the two programs.
On Friday August 19, 2016, the Center for Medicare Advocacy submitted comments in response to a June 30 request from the Centers for Medicare & Medicaid Services (CMS) for information regarding Durable Medical Equipment (DME) access issues faced by individuals who are dually eligible for Medicare and Medicaid.
We continue to observe that the misalignment of payment procedures in Medicare and Medicaid results in denials, delays, and higher than appropriate health care costs for essential DME among dually eligible beneficiaries.
On June 30, 2016 the Centers for Medicare & Medicaid Services (CMS) published a proposed rule about the difficulties of dually eligible people (individuals eligible for both Medicare and Medicaid) to obtain Durable Medical Equipment (DME).
The GAO report, released on June 1, 2016, provides information on utilization, expenditures, and how the 2016 CBP adjusted payment rates for accessories compare to the 2016 unadjusted fee schedule payment rates for the same items.
On January 4, 2016, The Centers for Medicare and Medicaid Services (CMS) awarded the administration of the Jurisdiction B Durable Medicare Equipment Administrative Contractor (DME MAC) serving Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin to CGS Administrators, LLC (CGS)—an organization that is headquartered in Nashville, Tennessee.
Effective February 20, 2016, CMS has created a prior authorization process for certain identified DMEPOS before they can be approved for Medicare payment.
On October 8, 2015 the Center for Medicare Advocacy filed a complaint with the Office of Civil Rights regarding Proposed Local Coverage Determination (LCD) DL 33787. This proposed LCD would unfairly and illegally restrict Medicare coverage for beneficiaries in need of lower limb prostheses.
Beneficiaries who seek Medicare coverage for expanded types and features of Speech Generating Devices (SGDs) have reason to be optimistic. Electronic devices that meet the definition of a Speech Generating Device will be coverable. This could include a tablet, computer, or smart phone.
CMS Rescinds Restrictive Policy and Will Reconsider Technological Advances
Ultimately, the billions of dollars to be saved by the Medicare program through reducing unnecessary expenditures and the preservation of beneficiary access to necessary DMEPOS should be paramount.