ANSWERS TO YOUR INDUSTRY QUESTIONS How long must a patient have equipment before billing for replacement and/or upgrade?

What type of hospital bed may be delivered and billed to a patient who weighs 360 pounds?

I have submitted a number of reviews that have never been received by the durable medical equipment regional carrier, but I have never had a fair hearing that was lost. Do reviews go through a different process upon receipt?

Does Medicare plan to cover long-term care?

EQUIPMENT MAY BE replaced or upgraded if (a) the patient's medical necessity has changed (weight gain, physical deterioration, etc.) and/or (b) the cost to repair the equipment exceeds the cost of replacement; the equipment is not repairable and the manufacturer's warranty has expired. Thorough documentation should be obtained to justify need for upgrade and/or replacement if the patient has had the equipment for less than five-eight years, as determined by the individual carrier's guidelines.

A patient who exceeds 350 pounds may be delivered a heavy-duty, extra-wide hospital bed. The reimbursement code for this item is K0456. The patient's height and weight must be documented on the original certificate of medical necessity.

- Answered by Jane Wilkinson-Bunch, a member of the Medicare Region C Advisory Council and president of Jane's Billing and Consultation Services, 4001 Canton Road, Suite 6, Marietta, GA 30066; 678/445-1221; fax: 678/445-1222

A LARGE NUMBER of claims submitted to the review department are not accompanied by a formal review request. Suppliers often submit only a copy of the Health Care Financing Administration 1500 form with no comment or instruction. The review department has a screening process for incoming claims, which includes identifying the status of claims that contain no specific review request. Review requests are also received for claims that should be resubmitted instead. The review department does not inform the supplier of receipt of a request for review. The supplier is informed of the result of a review by a remittance notice if the denial is overturned or by letter if the denial is upheld.

- Answered by Administar Federal Region B DMERC provider relations team, P.O. Box 7078, Indianapolis, IN 46207-7078; 317/577-5722; Web site: www.astar-federal.com

MEDICARE DOES NOT even begin to address the needs of a society that is living longer and longer. When Medicare was developed in the mid-1900s, we had only limited knowledge regarding the special needs of elderly people, including chronic care needs. Currently, 69 percent of nursing home residents rely on Medicaid to pay for their care. Another 24 percent pay for home health care or nursing care through private funding sources.

- Answered by officials at the American Health Care Association, 1201 L. St. N.W., Washington, DC 20005; 202/842-4444; fax: 202/842-3860