Working Down Denials
Our industry faces new challenges daily, such as the new resupply regulations and contacting patients by the Centers for Medicare & Medicaid Services (CMS). Let’s look at the A4377, ostomy pouch, drainable, for use on faceplate, plastic, each. RemitDATA has provided great denial information regarding this item. The A4377 has an overall denial rate of 15.9 percent, and the number-one reason is the 150 denial code (payer deems the information submitted does not support this level of service).
This denial often occurs when providers have supplied too many of the A4377 or other supply items to patients within a specified period. Medicare beneficiaries are allowed 10 every month. Providers should train intake teams to understand the limits assigned to supply items in all categories. When a patient calls in a request, providers should examine the invoice/transaction/claim history to see if they’ve previously received items, when and in what quantity. If the patient has already received the item(s) and it is not within the timeframe dictated by Medicare, the claim will be denied due to “overutilization.” If the patient doesn’t meet the requirements, then an Advanced Beneficiary Notice (ABN) must be sent.
New resupply requirements also impact PAP, diabetic, ostomy and urological, etc. The documentation requirements redefined how providers are to follow up with patients. This means that providers of IVR technology need to change their systems to meet these requirements as well. The listserves were sent by the DME MACs on June 7, 2012 announcing the change, but CMS revised the requirements for refills effective for dates of service on or after August 2, 2011.
For items that the patient obtains in person at a retail store, the signed delivery slip or copy of itemized sales receipt is sufficient documentation of a request for refill.
For delivered items, documentation of a request for refill must be either a written document received from the beneficiary or a contemporaneous written record of a phone conversation/contact between the supplier and beneficiary.
The refill request must occur and be documented before shipment. A retrospective attestation statement by the supplier or beneficiary is not sufficient. The refill record must include the beneficiary’s name or authorized representative if different than the beneficiary, a description of each item being requested and the date of refill request.