Greenvale Pharmacy & Homecare Bills DME To
Medicare Non-Assigned (Patient Reimbursement) Only.
Reimbursement Is Usually Less Than the Out Of Pocket Price Paid.
Durable Medical Equipment (DME) Defined
- For any item to be covered under Medicare, it must meet the test of durability. Medicare will pay for medical equipment when the item:
- Withstands repeated use (excludes many disposable items such as underpads)
- Is used for a medical purpose (meaning there is an underlying condition which the item should improve)
- Is useless in the absence of illness or injury (thus excluding any item preventive in nature such as bathroom safety items used to prevent injuries)
- Used in the home This excludes all items needed only when leaving the confines of the home setting.
Understanding Assignment and Non-Assignment
- When providers accept assignment, they agree to accept Medicare's approved amount as payment in full.
- You will be responsible for 20 percent of that approved amount. This is called your coinsurance.
- This does not include any Medicare part B yearly deductible you may have
- If a provider does not accept assignment, (a non-assigned claim) with Medicare, you will be responsible for paying the full amount upfront. The provider will still file a claim on your behalf and any reimbursement made by Medicare will be paid to you directly. You will receive the Medicare allowable which may be less than the full amount. (Providers must still notify you in advance, using the Advance Beneficiary Notice, if they do not believe Medicare will pay for your claim.)
- Every provider is required to submit a claim for covered services within one year from the date of service
How does Medicare pay for and allow you to use the equipment?
Typically, there are 2 ways we can bill Medicare for a covered item:
- Purchase it outright; then the equipment belongs to you,
- Rent it continuously until it is no longer needed or consider it a "capped rental” meaning Medicare will pay rent the item for a total of 13 months and consider the item purchased such time. Capped rentals can not be billed Non-assigned.
This protects the Medicare program from paying too much should your needs change earlier than the 13-month total payout. Medicare will not allow you to purchase these items outright.
Medicare expects your equipment to last 5 years and will not pay for a replacement prior to that
The role of your physician with respect to home medical equipment:
- Every item billed to Medicare requires a physician's order along with additional documentation showing patient medical condition determined at an office visit within the last 90 days.
- Nurse Practitioners, Physician Assistants, Interns, Residents and Clinical Nurse Specialists can also order medical equipment. The same documentation is required.
- All physicians have the right to refuse to complete documentation for equipment they did not order, so make sure you consult with your physician before requesting an item from a provider.
Prescriptions Before Delivery:
- Any assigned claim must have a prescription and all needed documentation before the item is dispensed.
- For non-assigned claims, (claims paid up front and then patient is reimbursed by Medicare) prescriptions and documentation can be obtained after dispensing the product so as to bill the claim for patient to be reimbursement
Greenvale Pharmacy & Homecare
Diabetic Testing Supplies
- For diabetics, Medicare covers the glucose monitor, lancets, spring-powered lancing devices, test strips, control solution, and replacement batteries for the meter.
- Medicare will approve up to one test per day for non-insulin-dependent diabetics and three tests per day for insulin-dependent diabetics without additional verification.
Diabetic shoes are covered when the patient meets the following criteria
- The patient has diabetes mellitus: Type II or Type I:
- The patient has one or more of the following conditions (check all that apply):
* History of partial or complete amputation of the foot.
* History of previous foot ulceration.
* History of pre-ulcerative callus.
* Peripheral neuropathy w/evidence of callus formation.
* Foot deformity.
* Poor circulation:
Braces and Supports
Back, Knee, Neck, Wrist, Ankle:
These supports are covered with a Dr's prescription that includes a valid Diagnosis as pertains to the style and need of the product, along with chart notes from the last visit denoting the same condition prescribed for the brace
Braces like a soft cervical collar or elastic back brace with no structural support or motion control are not covered.
Ostomy supplies are covered for people with a:
- Urinary catheters and external urinary collection devices are covered to drain or collect urine for a patient who has permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in that patient within 3 months.
Seat Lift Mechanisms
- In order for Medicare to pay for a seat lift mechanism, patients must be suffering from severe arthritis of the hip or knee or have a severe neuromuscular disease. In addition, they must be completely incapable of standing up from any chair, but once standing they can walk either independently or with the aid of a walker or cane. The physician must believe that the mechanism will improve, slow down, or stop the deterioration of the patient's condition.
- Transferring directly into a wheelchair will prevent Medicare from paying for the device.
- Medicare will only pay for the lift mechanism portion. The chair portion of the package is not covered, and you will be responsible for paying the full amount for the furniture component of the chair..
- A commode is only covered when the patient is physically incapable of utilizing regular toilet facilities. For example:
- The patient is confined to a single room, or
- The patient is confined to one level of the home environment and there is no toilet on that level, or
- The patient is confined to the home and there are no toilet facilities in the home.
- Heavy-duty commodes are covered for patients weighing over 300 pounds.
- Mobility equipment is covered by Medicare specifically for:
- Mobility needs for daily activities within the home
- Least costly alternative/lowest level of equipment to accomplish these tasks.
- Most medically appropriate equipment (to meet the needs, not the wants)
- Medicare requires that your physician and provider evaluate your needs and expected use of the mobility product you will qualify for.
- They must determine which the least level of equipment is needed to help you be mobile within your home to accomplish daily activities by asking the following questions:
- Canes, Crutches,Walkers
- Will a cane or crutches allow you to perform these activities in the home?
- If not, will a walker allow you to accomplish these activities in the home?
- Wheelchairs (CAPPED RENTAL)
- If not, is there any type of manual wheelchair that will allow you to accomplish these activities in the home?
- If not, will a scooter allow you to accomplish these activities in the home?
- If not, will a power chair allow you to accomplish these activities in the home?
Hospital Beds (CAPPED RENTAL)
- A hospital bed is covered if one or more of the following criteria (1-4) are met:
- The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed, or
- The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or
- The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out, or the patient requires traction equipment which can only be attached to a hospital bed.
- Specialty beds that allow the height of the bed to vary are covered for patients that require this feature to permit transfers to a chair, wheelchair, or standing position.
- A semi-electric bed is covered for a patient who requires frequent changes in body position and/or has an immediate need for a change in body position.
- Heavy-duty/extra-wide beds can be covered for patients who weigh over 350 pounds.
- The fully electric bed is not covered because it is considered a convenience feature. If the patient prefers the fully electric feature, the provider usually can apply the cost of the semi-electric bed toward the monthly rental price of the total electric model by using an Advance Beneficiary Notice (ABN).
Hospital Beds Specialty Support Surfaces
- Group 1 products are designed to be placed on top of a standard hospital or home mattress. They can utilize gel, foam, water, or air, and are covered for patients who are:
- Completely immobile OR
- Have limited mobility with any stage ulcer on the trunk or pelvis (and one of the following):
- impaired nutritional status
- fecal or urinary incontinence
- altered sensory perception
- compromised circulatory status
- Group 2 products are typically powered pressure reducing mattresses or overlays. They are covered for patients with one of three conditions:
- Multiple stage II ulcers on the pelvis or trunk while on a comprehensive treatment program for at least a month using a Group 1 product, and at the close of that month, the ulcers worsened or remained the same. (Monthly follow-up is required by a clinician and the product is only covered while ulcers are still present.) OR Large or multiple Stage III or IV ulcers on the trunk or pelvis (Monthly follow-up is required.) This product is only covered while ulcers are still present, OR a recent myocutaneous flap or skin graft for an ulcer on the trunk or pelvis within the last 60 days who were immediately placed on Group 2 or 3 support surface prior to discharge from the hospital and the patient has been discharged within last 30 days
Patient Lifts (CAPPED RENTAL)
- A lift is covered if transfer between bed and a chair, wheelchair, or commode requires the assistance of more than one person and, without the use of a lift, the patient would be bed confined.
- An electric lift mechanism is not covered because it is considered a convenience feature. If you prefer to have the electric mechanism, your provider can usually apply the cost of the manual lift toward the purchase price of the electric model by using an Advance Beneficiary Notice (ABN). You would be responsible to pay the difference in the retail charges between the two items.
Non-covered items (partial listing):
- Adult diapers
- Bathroom safety equipment
- Grab bars
- Raised toilet seats
- Hearing aids
- Stair lifts
- Van lifts
- Exercise equipment
- Humidifiers/Air Purifiers
- Massage devices
- Emergency communicators
- Low Vision aids