Lymphedema Therapy Source

  

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Cash Pay for Medicare Compression?

Medicare will now pay for lymphedema compression supplies, aids & garments. But there may be an occasion when a patient wants to pay cash for an item. Simple, right? Well (as noted in last month’s post), government complicates things. (Next month, we’ll resume our normal educational blog about lymphedema.)

Disclaimer: Information is not garanteed to be comprehensive or accurate. Consult a healthcare law attorney for guidance.

Image by Andrew Patrick / Pexels

In this post, “provider” will be used interchangeably with “supplier” except where noted.

Billing Medicare 1,2

Most patients will want to bill Medicare for anything Medicare will cover. In such cases, providers (i.e. therapists who add a DME supplier aspect to their provider therapy business for their own patients) must have a PTAN (provider transaction access number). This is obtained when enrolling with Medicare. There are three classifications: “participating,” “non participating,” & those who “opt out”.

Participating Providers 3, 4

A participating provider is an individual who contracts with Medicare. They have agreed to accept what Medicare will pay. They are required (by law) to submit a claim on behalf of a Medicare beneficiary for any service or item that’s a covered benefit. This now includes lymphedema compression (thanks to Heather Ferguson & team – see also the Lymphedema Treatment Act). Because they contract with Medicare, these providers cannot accept cash for an item sold to a Medicare beneficiary (other than the deductible, 20% coinsurance or upgrades). They also have other rules (such as issuing an ABN – advanced beneficiary notice – when certain services or items are not expected to be covered.) Some commercial insurance companies require therapists to be Medicare participants in order to become an in-network provider with them.

A Participating Provider can become a Non Participating Provider by notifying their regional national provider enrollment contractor during the enrollment period (mid-Nov to Dec 31 each year). There are currently two regional enrollment providers (NPE East & NPE West) that took the place of the prior National Supplier Clearing House (“NSC”).

Non Participating Providers 5-8

Non participating providers are individuals who accept Medicare payment but not necessarily in full. (They are still “contracted” providers & must have a PTAN in order to bill Medicare – whether they accept or do not accept Medicare’s payment amount in full.) If they choose not to accept Medicare’s payment in full, they can charge more than Medicare’s payment amount (similar to out-of-network providers), but they have a limit (by law) on what amount they can charge. However, this limit only applies to providers, not suppliers.

Non participating providers can require payment upfront but must still issue an ABN (like participating providers). They’re supposed to submit a claim to Medicare on behalf of a patient in order to collect any billed amount. (If a patient submits a claim, a “CMS 1490S” form can be used.) Can a “non participating provider” sell an item for cash to a Medicare beneficiary? Possibly – if a patient specifically states they don’t want Medicare to be billed. (see image below)

Opting Out 9,10

The Social Security Act Title 18 amendment (of the Balanced Budget Act of 1997, §4507) has a provision allowing a provider to opt out of Medicare. Opt-out providers have chosen not to work with Medicare at all. Instead, they privately contract with patients. This decision is valid for two years at a time. Opting out means a provider can legally bill a Medicare patient directly for services that would be covered. This is not an option for therapists or suppliers.

Non-Contracted Providers (Cash Practices or “retail”) 11,12

Can cash-only practices (without a PTAN) choose to sell compression to Medicare patients? According to CFR 42, section 1395m (j)(4)(A), no. One exception may be if the supplier informed the patient before any transaction took place that the supplier did not bill Medicare & the patient agreed to pay cash. And an ABN should be issued for signature as well.

What about internet sales? 12

Can a Medicare patient pay cash for an item now covered by Medicare? Not without the supplier having liability. According to one legal source, a supplier needs to ensure they have an obvious notice on their website (& at checkout) for all Medicare beneficiaries informing the buyer that the supplier does not have a PTAN & does not bill Medicare. They might even consider having an ABN form signed by each Medicare buyer.

Competitive Bidding

Items covered under the LTA are not currently subject to Competitive Bidding according to 42 U.S. Code § 1395m – Special payment rules for particular items and services.

References
1 Title 42 USC section 1395 m(j), https://www.cgsmedicare.com/jc/pubs/pdf/chpt2.pdf
2 https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c10.pdf
3 (Upgrades) CFR 1395m (19) Certain Upgraded Items https://www.law.cornell.edu/uscode/text/42/1395m
4 (Enrollment Providers) https://www.achc.org/blog/cms-replacing-nsc/)(https://www.cms.gov/medicare/provider-enrollment-and-certification/medicareprovidersupenroll/downloads/contact_list.pdf
5 (Limit not for Suppliers) https://www.medicareinteractive.org/get-answers/medicare-covered-services/outpatient-provider-services/participating-non-participating-and-opt-out-providers#:~:text=Non%2Dparticipating%20providers%20accept%20Medicare,care%20services%20as%20full%20payment
6 (CMS 1490S) https://www.cms.gov/medicare/cms-forms/cms-forms/cms-forms-items/cms012949
7 (paying cash) https://www.webpt.com/blog/times-a-medicare-patient-cant-pay-cash#:~:text=As%20a%20non%2Dparticipating%20provider,may%20reimburse%20the%20patient%20directly
8 https://www.medicareinteractive.org/get-answers/medicare-covered-services/outpatient-provider-services/participating-non-participating-and-opt-out-providers#:~:text=Non%2Dparticipating%20providers%20accept%20Medicare,care%20services%20as%20full%20payment
9 (opting out) https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00093112#P22_1451
10 (opting out) https://www.congress.gov/bill/105th-congress/house-bill/2015#:~:text=were%20not%20notified.-,(Sec.,shall%20receive%20no%20Medicare%20reimbursement
11 (CFR 42, subch 18, part B, section 1395m, (j)(4)(A)) https://www.law.cornell.edu/uscode/text/42/1395m
12 https://medtrade.com/news/billing-reimbursement/selling-dme-by-a-supplier-without-a-ptan/#:~:text=AMARILLO%2C%20TX%20%2D%20Certain%20disclaimers%20must%20be,does%20not%20have%20a%20Medicare%20supplier%20number%2C

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Billing for Compression (part 3)

We’ve been talking about how a therapist can bill for compression in light of the passage of the Lymphedema Treatment Act. Last month, we noted there were (3) models. The third model involved:

  • a therapist billing Medicare for compression as a supplier & for service as a provider for their own patients, and
  • the same therapist also billing for compression for people who are not their patients.

This gets tricky because the model gives rise to unique ownership concerns related to Medicare & Medicaid payments. (Government complicates things.) These concerns revolve around federal statutes & criminal liability. That’s the focus of this month’s blog.

Disclaimer: Information is not guaranteed to be comprehensive or accurate. Consult a healthcare law attorney for guidance.

Model 3

You would think billing for other people’s patients could be done in your therapy business. But that’s not the case – unless the individual is your patient. And would another therapist want to refer their patients to you – a competitor? Of course, there are several people seeking compression that aren’t wanting treatment. They just need someone who can bill insurance. But does billing for a supply item constitute someone becoming a patient?  Besides that, the 42 CFR has special considerations for therapists billing for compression for their own patients that doesn’t apply to therapists billing for individuals who are not their patients. (See April’s blog update.) A seemingly easy solution is to have a second business.

If you have a second business for DME, why not simplify things? Keep your therapy services in the therapy business & the DME in a DME business. You could have both businesses in the same location & save on costs (like rent). Additional benefits could include having a different taxonomy code (for potential better reimbursement rates), less confusion among insurance payors, & legal protection from financial losses.  You could refer your therapy patients to the DME business. Right? Wrong. (Why not? Well, government complicates things.)

Medicare Supplier Standards2

Anyone who plans to bill federal healthcare programs for DME must be mindful of the 42 CFR Supplier Standards. One of those standards states a supplier is prohibited from sharing a practice location with another Medicare provider or supplier. But there are a few exceptions. Two of these include:

  • a therapist (i.e. provider) who is billing DME for their own patients only
  • a DME supplier can be co-located with & owned by a Medicare provider (e.g. therapist), but the businesses must operate separately (separate phone lines, separate computers, separate staff, etc.). You must also meet the definition of a Medicare provider.7,8

It would seem you actually could separate the therapy business & refer your patients to your DME company. But that’s not the case. (Did I mention government complicates things?)

The Anti-Kickback Statute

The Anti-Kickback Statute is one of the fraud & abuse laws mentioned last month. It was an amendment added to the Social Security Act & first passed by Congress in 1972 as an effort to prevent fraud & abuse of federal healthcare programs (i.e. Medicare & Medicaid).6 It can be found in Title 42 of the U.S. code which covers public health & welfare. (These laws are broken down into titles, chapters, subchapters, parts & sections.)3,4 Specifically, Section 1320a-7b talks about the Anti-Kickback Statute. This amendment prevents giving or receiving anything of value (e.g. money, free rent or other perks) for generating healthcare business paid for by federal programs.

In other words, if you had two businesses that billed Medicare or Medicaid, & you wanted to refer patients from one to the other, you can’t. (Unless, of course, you don’t mind jail time & hefty monetary penalties. Most therapists try to avoid these.) There are a few “safe harbor” exclusions that will allow such business transactions.5 But all elements of a safe harbor must be met. (And these have pros & cons.)

Two notes: First, this only applies to providers/suppliers billing federal healthcare programs (clarification is needed as to whether the non-direct plans like the exchange programs provided by commercial plans are included in this). Second, you can still have a therapy business providing therapy services & DME to your own patients. You can also have a separate DME business for other people’s patients in addition. But these must operate entirely separately & cannot refer business between them if you bill federal healthcare programs unless you fall within one of the safe harbor exclusions. You would also be wise to consider other mitigating factors to prevent implication of Anti-Kickback Statute violation.

There’s one more question that comes to mind regarding billing. What if a Medicare patient wants to pay cash for an item? We’ll look at that next month.

References
1 https://oig.hhs.gov/compliance/physician-education/fraud-abuse-laws/
2 (supplier standards) https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-424/subpart-D/section-424.57
3 https://www.govinfo.gov/app/details/USCODE-2010-title42/USCODE-2010-title42-chap7-subchapXI-partA-sec1320a-7b
4 https://uscode.house.gov/
5 (safe harbors) https://www.ecfr.gov/current/title-42/chapter-V/subchapter-B/part-1001/subpart-C/section-1001.952
6 https://www.whistleblowerllc.com/anti-kickback-statute/#:~:text=Congress%20first%20enacted%20the%20AKS,physicians%20corrupt%20medical%20decision%2Dmaking.
7 (clinic definition) https://www.govinfo.gov/content/pkg/USCODE-2011-title42/html/USCODE-2011-title42-chap7-subchapXVIII-partE-sec1395x.htm, https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R5BP.pdf & https://www.ssa.gov/OP_Home/ssact/title18/1861.htm
8 (OTPP definition) https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R5BP.pdf

Attribution
Photo by Olia Danilevich Pexels

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Compression Garments & Insurance (part 4)

Requirements for Medicare Coverage of Lymphedema Compression, Supplies & Accessories

The last post on the Lymphedema Treatment Act (LTA) passage was in December. (The LTA passed December, 2022, & became effective Jan 1, 2024, providing coverage to Medicare beneficiaries for lymphedema compression garments, supplies & accessories.) Since my last post on the topic, I’ve had questions about what’s needed for Medicare coverage. The following are required:

  • DMEPOS Enrolled Supplier – a supplier can be a DME supplier or a medical professional providing items to their own patients after enrolling with Medicare to do so. (To learn about becoming a supplier or how a medical professional can become a supplier for their own patients, click here.)

    Note: A therapist cannot be a provider & a DME supplier in the same space unless solely providing these items to their own patients. They must still become an enrolled supplier & meet certain requirements to bill for items provided to their own patients. (Such therapists cannot bill items for people who are not their own patients. They can fit patients, however. See below.) (CFR, Title 42)

    Note: A trained, experienced fitter is recommended to measure lymphedema compression (particularly custom) & to recommend appropriate accessories. If measurements have been obtained from a therapist who is not enrolled as a DMEPOS supplier, a 3rd party supplier can be used for ordering & billing Medicare. However, payment for the fitting itself is included in the garment payment amount. So, therapists fitting patients & submitting an order to a 3rd party must get payment for their service from that supplier (if payment is desired). Fitting Medicare patients is not a separate, billable service under this law.
  • Script – there are specific items that must be on the physician’s order (i.e. script).2

    Note: A physician, nurse practitioner, or clinical nurse specialist is considered a “treating practitioner.”

    Note: A supplier must have additional information such as supportive documentation. They will likely ask for medical records (such as progress notes, therapist notes, etc.) verifying medical necessity.

    Items Needed on Order:
    – Beneficiary’s name or Medicare beneficiary identifier (i.e. Medicare number)
    – Order date
    – A lymphedema diagnosis (acceptable ICD-10 diagnosis codes include: I89.0, Q82.0, I97.2, I97.89)
    – Item description (the HCPCS billing code). For a list of lymphedema compression HCPCS codes, click here.
    – Quantity of item to be dispensed (i.e. how many are being ordered)
    – Treating practitioner’s name or NPI
    – Treating practitioner’s signature (no signature stamp is allowed)

Next month, we’ll review what Medicare covers, the frequency & allowable amounts.

************UPDATE 02/19/24**********

The Lymphedema Treatment Act recently published an article summarizing the above. Here’s that pdf.

Coverage-for-Lymphedema-Compression-Supplies-copyDownload

References
1 https://med.noridianmedicare.com/web/jddme/dmepos/lymphedema-compression-treatment
2 https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55426
3 https://www.cgsmedicare.com/jc/pubs/news/2023/12/cope147943.html
4 https://lymphedematreatmentact.org/final-coverage-rules/

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Compression Garments & Insurance (part 3)

This post will wrap up (for now) Medicare’s recent passage of the Lymphedema Treatment Act (LTA) requiring coverage of lymphedema compression & supplies. (Included will be pictures of a few examples.) One concern I cited last month was the competency of the typical DME supplier to fit compression garments. I will expand on that in this post.

Bill Coverage summary

You can read last month’s post for a more comprehensive overview of what will be covered in the LTA. You can find the final Medicare rule here.

Swell spot (by JoViPak) – use to break up fibrosis or fluid pocketing on the chest wall & under the armpit typically related to breast cancer & mastectomy.

In short, compression garments (readymade or custom) & treatment supplies will be covered. Additionally, accessories like donning or doffing aids will be included in the coverage (items which help you put compression on or take it off).5 These will be covered at 80% (with 20% being your responsibility depending on what coinsurance you have). Garments are subject to the Medicare deductible.

Regarding frequency, as noted on p. 58 & 60 of the above final rule link:

  • Medicare has increased the frequency limitations to (3) sets of daytime compression garments every 6 months & (2) nighttime garments every two years.
  • Medicare doesn’t propose a specific frequency for bandaging systems & supplies (including accessories). The DME company will have to determine what is “medically necessary.”

Swell spot for the neck such as may be needed after head/neck cancer.

DME supplier requirements

Anyone providing DME-covered items must be a licensed DME supplier. That means a company must be enrolled with Medicare as a DME supplier & meet supplier standard requirements. There are several steps (& expense) to this process.

What is not highlighted is how important the knowledge & competency of a fitter is. A fitter should have a broad understanding of lymphedema & related pathology. Under this heading I would include an understanding & awareness of the following (non-comprehensive) list:

  • causes & complications of lymphedema
  • the disease process of the above lymphedema causes
    • for example, lipedema compression tolerance in stage 1 vs stage 3
    • for example, cancer precautions
  • complications of common comorbidities such as
    • weakness due to arthritis
    • restrictions due to arterial disease
    • restrictions due to fragile, thinning skin
    • limited mobility, back precautions & safety donning/doffing compression (or modification of tools)
    • edema-causes of swelling (like heart failure or venous reflux) which may not tolerate circular-knit hose
    • adaptive devices for assisting donning/doffing compression
  • recognizing & knowing how to address pressure spots caused by garments
  • textile properties & how they affect tissue containment
    • for example, gradient pressure or working pressure vs resting pressure

Farrow Velcro sleeve & readymade glove (readymade means it’s not custom).

DME supplier recommendations

While standard DME companies can address basic DME items like walkers, canes, wheelchairs, etc., fitting compression garments requires a more nuanced knowledge. Ideally, the fitter would also be an experienced lymphedema-certified therapist. An experienced therapist will have a working knowledge of lymphedema, comorbidities, problems with donning/doffing & creative solutions. They will have an idea of long-term outcomes associated with particular garments & lymphedema or related conditions. A therapist would also be an ideal person to educate patients on topics listed in the prior section.

But just because a therapist has experience treating lymphedema doesn’t mean they have experience fitting patients with compression. For example, fitting custom garments is a developed skill, & measuring technique can vary between manufacturers. In addition, an experienced lymphedema therapist may not have a good knowledge of billing practices. For example, they may not know how to verify copays, deductibles, prior authorization & pre-certifications or when to apply modifiers to HCPCS billing codes.

Thuasne chipped foam, Velcro lower leg garment. (Typically, a nighttime garment.)

DME fitters

Ideally, a DME fitter would be an experienced lymphedema therapist familiar with (& practiced in) fitting compression – including custom. They would also have a working knowledge of billing practices.

In cases where the DME fitter is not an experienced therapist, the next best scenario would be for the fitter to work closely with a lymphedema therapist. As noted above, unfortunately, many therapists don’t have a comprehensive knowledge of compression products. Their specialty is treating lymphedema. Hopefully, lymphedema training schools will add more compression training to their curriculum. But until then, most manufacturers offer free educational classes. A therapist only needs to contact them. Well-known manufacturers of lymphedema compression include:

  • Lohmann Rauscher (includes Solaris)
  • Essity (formerly BSN Medical – includes Jobst, Farrow, & JoViPak)
  • Juzo
  • Sigvaris (including Biacare)
  • Medi
  • Thuasne
  • LympheDIVAs

LympheDIVAs readymade sleeve & glove

For therapists who want to be fitters

From my experience, I’d recommend a therapist who wants to fit compression start by learning one manufacturer’s products well.  Lohman Rauscher, for example, offers both treatment supplies & compression garments. They would be a good manufacturer to start with. Once that manufacturer’s products are mastered, another manufacturer such as Essity (BSN Medical) could be learned. And so on.

Conclusion

The good news is compression garments & supplies will now be covered by Medicare. The bad news is lymphedema is a specialty field. Compression garments (& fitting them) are a niche within that specialty which many people do not have a good working knowledge of.

Jobst Readymade nighttime leg garment

P.S. If you don’t have traditional Medicare…

The Lymphedema Treatment Act team has requested you contact your insurance company (if it’s not traditional Medicare as your primary insurance) & request the company modify their coverage of lymphedema compression coverage (following Medicare’s new policy).  If you have private insurance plans (whether employer-based or purchased separately), supplemental and secondary plans, Medicare Advantage, Medicaid, TriCare, & VA health care, the LTA team provides a template you can print here.

Juzo readymade sleeve

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Little Elm, Texas 75068-5196
214-422-8265 | 469-579-5034
214-614-9352 fax
info@LTStherapy.com

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