The unwritten policy called the "improvement standard" used by Medicare Contractors to deny any therapy that does not result in measurable functional improvement has been thrown out by a Federal Judge. This means that Medicare beneficiaries who require skilled maintenance services cannot be denied those services in the home health, nursing home or outpatient setting. This settlement becomes effective today, January 24, with the signing of the Settlement Agreement in the Jimmo v. Sebelius Medicare Improvement Standard case.
CMS has been tasked to educate its contractors and to change its documentation, policies, guidelines and instructions. In the meantime, if medically required therapy that has been prescribed by your physician in treatment of your lymphedema has been denied on the basis that there is no expected functional improvement, file an appeal.
It will be very interesting to see how this law will affect the implementation of the new therapy reimbursement policies scheduled for 2014, which are based on demonstration of functional improvement.
January
23, 2012
PECOS Warning Edit Change (CEDI Message)
Effective
January 01, 2012 the durable medical equipment Medicare administrative
contractors (DME
MACs) began to return warning messages if the
ordering or referring provider on the claim is not eligible to
order or refer DME supplies as determined from Provider Enrollment
Chain & Ownership System
(PECOS). These messages are returned
on the electronic remittance advice (ERA) or standard paper remit
(SPR) with the following remittance advice remark code (RARC) and will
apply to both 4010A1 and
5010A1 formatted claims:
N544 - Alert:
Although this was paid, you have billed with a referring/ordering provider that
does not match
our system record. Unless, corrected, this will not
be paid in the future.
Through January 29, 2012 the Common Electronic Data
Interchange (CEDI) will continue to return the
PECOS warning edits
for 4010A1 claims on the GenResponse Report.
The Centers for Medicare &
Medicaid Services (CMS) and the DME MACs will communicate when the
edits will become denials when that date is determined.
President
Obama Signs the Temporary Payroll Tax Cut Continuation Act of 2011
(TPTCCA)Section 304
of the TPTCCA extends the exceptions process
for outpatient therapy
caps. Outpatient therapy service providers may
continue to submit claims with
the KX modifier, when an exception is
appropriate, for services furnished on or
after January 1, 2012, through
February 29, 2012.
The therapy caps are determined on a calendar year
basis, so all patients begin
a new cap year on January 1, 2012. For
physical therapy and speech language
pathology services combined, the limit
on incurred expenses is $1,880. For
occupational therapy services, the
limit is $1,880. Deductible and coinsurance
amounts applied to therapy
services count toward the amount accrued before a cap
is reached, and also
apply for services above the cap where the KX modifier
is
used.
Robert Weiss, M.S.
Lymphedema Patient
Advocate
National Lymphedema Network
-----------------------
The
official medicare website is located at :
http://www.medicare.gov/
How to find a
prescription plan under medicare:
http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/MPDPFIntro.asp?version=default&browser=IE%7C6%
7CWinXP&language=English&defaultstatus=0&pagelist=Home&View&PDPYear=2006&MAPDYear=2006&MPDPF%5FMPPF%
5FIntegrate=N
From the looks
of it there are 2 types of plans you can join:
Plans include HMOs, PPOs,
and Private-Fee-for-Service plans. They offer complete Medicare-
covered health care, including drug coverage, through a single plan.
Most of these plans generally
offer extra benefits and lower
copayments than the Original Medicare Plan. However, you may
have
to see doctors that belong to the plan or go to certain hospitals to get
services.
FROM NORD again:
Knowing Your Health History Could Save
Your Life
Most Americans believe that knowing their family health
history can be beneficial, but only about
one-third have actually
tried to gather and record information about family health, according to a
recent study by the U.S. Centers for Disease Control and Prevention
(CDC).
Furthermore, the discussion of family history between physician
and patient typically lasts just a
few minutes.
"But knowing
your family history can save your life," US Surgeon General Richard H. Carmona
said at a press conference in November to launch a project known as
the Family History
Initiative. As part of this project, the
Department of Health and Human Services has created a
new
computerized tool, called "My Family Health Portrait," that can be downloaded
at www.hhs.
gov/familyhistory/ to help in the
process.
Francis S. Collins, MD, PhD, director of the National Human
Genome Research Institute, noted
that all people have genetic
abnormalities that make them more susceptible to certain illnesses.
Tracking illnesses from one generation of a family to the next can help
identify illnesses for which
the family is at risk. This may allow
family members, working with their physicians, to take steps
to
reduce their risk.
The tool guides users through a series of screens to
record information for each family member
about six common
diseases. Other conditions may also be added. After the information has been
collected, a diagram can be printed and shared with a
physician.
All personal information is maintained on the user's
computer. No information is given to the
government. Eventually, the
tool will be available in both English and Spanish. Also, a print
version will be provided to those who call the Federal Citizen
Information Center at (888) 878-
3256.
The federal employees
who have worked on this project, from the National Institutes of Health,
Surgeon General's office and CDC, hope families will take advantage of
being together over the
holidays to compile a health history. "It
is our hope as families gather this holiday season, they'll
take the
time to learn-and record-their families' health histories so that they can
continue to have
years of family gatherings together," said Muin
Khoury, MD, director of CDC's Office of
Genomics and Disease
Prevention.
MEDICAID ALERT:
Medicare/Medicaid Information
regarding insurance with medicare:
You automatically qualify for extra
help and don't need to apply if you:
have Medicare and full coverage
from a state Medicaid program that currently pays for your
prescriptions. You should join a plan that meets your needs by December
31, 2005 because
Medicaid will no longer pay for prescription drugs.
If you don't, Medicare will enroll you in a plan
effective January
1, 2006 so you don't miss a day of coverage. You can drop the plan or switch to
another any time.
get help from your state Medicaid
program paying your Medicare premiums (belong to a
Medicare Savings
Program). You should join a plan that meets your needs by December 31, 2005.
If you haven't signed up by May 15, 2006, Medicare will enroll you
in a plan effective June 1,
2006 so you don't have to pay a
penalty. You can drop the plan or switch to another any time.
get
Supplemental Security Income. You should join a plan that meets your needs by
December 31,
2005. If you haven't signed up by May 15, 2006,
Medicare will enroll you in a plan effective June
1, 2006 so you
don't have to pay a penalty. If Medicare enrolled you in a prescription drug
plan,
you can switch to another plan one time before December 31,
2006.
---------------------
What To Do
When Medicare Says
'No'
http://www.elderlawanswers.com/resources/article.asp?id=2334&Section=4&state=
Your
doctor suggested you have a minor operation or procedure, you went ahead and
had it done, and now
Medicare won't pay for it. What should you do?
Appeal.
Your provider tells you that your lymphedema compression garments
are not covered. What should you
do? Appeal. [Added by Bob
Weiss]
Medicare covers procedures that are deemed medically necessary.
"Appealing is easy and most people win
so it is worth your while to
challenge a Medicare denial," says the Medicare Rights Center, a national
nonprofit organization. The denial of coverage may be due, for example,
to a simple coding error in your
doctor's office.
People
have a strong chance of winning their Medicare appeal. According to Center, 80
percent of
Medicare Part A appeals and 92 percent of Part B appeals
turn out in favor of the person appealing.
The Medicare Rights Center
offers the following tips to maximize your success when appealing your
denial:
a.. Write "Please Review" on the bottom of your Medicare Summary
Notice (MSN), sign the back and
send the original to the address
listed on your MSN by certified mail or with delivery confirmation.
b..
Include a letter explaining why the claim should be covered.
c.. When possible, get a letter of support from your doctor or other health care provider explaining why the
service was "medically
necessary."
d.. Save photocopies and records of all communications, whether
written or oral, with Medicare concerning
your denial.
e.. Keep
in mind that you only have up to 120 days from the date on the MSN to submit an
appeal.
The Center notes that the appeals process is slightly different if
you are in a private Medicare plan, like an
HMO or a PPO. One
difference is that you have only 60 days from the date on the denial notice to
file an
appeal.
Resources:
For information on how to
fight a hospital discharge, click here.
For more on the Medicare Rights
Center, visit its Web site at http://www.medicarerights.org
To download
Medicare appeal forms from the government's Medicare website, click
here.
--------------------------------------------------------------------------------------------
FILING
A CLAIM FOR REIMBURSEMENT FOR COMPRESSION GARMENTS
* Garment supplier fills out an ABN and gives Beneficiary a copy. Beneficiary pays garment fitter and gets a
receipt. Make sure that this is the
latest version of Form CMS-R-131. I have the version dated (03/08).
This is important since the Section (G) Options were in reverse order
from earlier versions. The option to be
chosen is the only one
which states in bold "I can appeal to Medicare".
* If the Supplier should choose to file the claim for the beneficiary, they will file on a Form 1500. Ask that
they fill out Item 27 Acceptance of Assignment with
a "NO", and further place the note "Beneficiary refuses
to assign
benefits" in Item 19. (see note below why Supplier may not be motivated to file
for the beneficiary).
* Beneficiary submits CMS form 1490 Patient's
Request for Medical Payment to Medicare requesting
reimbursement for
the garment listed on the ABN, and attaches receipt. Block 6 Authorization says
"... and
request payment of medical insurance benefits to me." just
above beneficiary's signature.
* Medicare sends a denial directly to the
Beneficiary. Denial appears on the quarterly Medicare Summary
Notice (MSN). After the headers on this form, the sentence "This is a
summary of claims processed from ...
to ...". Following this there
should be a section labeled "Part B Medical Insurance-Unassigned Claims". In
the last column "See Notes Section" there will be a series of code
letters denoting the reason for the denial.
There will also be
detailed instructions for appealing the decision. There is a 120-day appeal
period after
which no appeal will be allowed.
* Beneficiary
consults Bob Weiss [LymphActivist@aol.com] to proceed further, i.e., several
more denials
will come down the pike before it goes to an
administrative law judge... At this point I will need a copy of
the
MSN and I will either guide the beneficiary in the first appeal, or I will file
it on behalf of the beneficiary.
This first appeal to an
"independent" Medicare Contractor is called a "Redetermination", the next
appeal to a
"Medicare Quality Independent Contractor" or a "DME
MAC" is a "Reconsideration", and the next appeal
is to an
Administrative Law Judge (ALJ). None of these appeals costs any more than the
cost of making
copies and postage. There is a 60-80% chance of a
favorable determination by the ALJ. In the event that
the ALJ
renders an unfavorable decision then we will appeal to the Medicare Appeals
Council, where I run
about a 50% favorable rate.
IF the
Beneficiary gets reimbursed after 2 years or so, the ABN states that "If
Medicare does pay, you will
refund any payments I made to you, less
co-pays or deductibles." This puzzles me. Does this mean that
Medicare will reimburse the garment fitter directly? (That's crazy
because it is definintely not in a garment
fitter's interest to go
to the trouble of submitting an ABN for a Beneficiary only to have to refund
their money
at a later time). You are correct that the Supplier has
little incentive to file your complaint. The supplier
receives a
reduced amount of reimbursement from the retail price of the item, and if they
are a Medicare
Supplier they are required to file a claim for
something they know will be denied. So they will ask for
payment in
advance. So as long as they are filing on behalf of the beneficiary it is
important for the
beneficiary to refuse to assign benefits on the
Form 1500. That way there will be no refunds necessary.
(Thanks to
therapist Kevern Hartmann for providing the framework for this piece and
forcing me to
research the appeal process. I would ask any reader
who discovers any errors or changes to the process to
contact me
immediately. Please remember that I am not allowed to provide medical or legal
advice. All I
can do is to read the appropriate regulations and
policies and tell you what my understanding is.)
Robert Weiss,
M.S.
Lymphedema Patient Advocate
LymphActivist@aol.com
--------------------------------------------------------------------------------------------
Abstracted
this from an article in the San Francisco Chronicle. This applies to denials of
compression
bandages, garments and devices, which are medically
required in the treatment of lymphedema.
Bob Weiss
Medical care's
state of denial
Victoria Colliver, Chronicle Staff Writer
Monday,
June 23, 2008
http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/06/22/MNUK11C28G.DTL&tsp=1
What to do if
you are denied medical care
If your health insurance carrier is refusing
to approve treatment recommended by your doctor, you have a
number
of options. First, contact your health plan. You probably will have to go
through the plan's internal
grievance process first. If time is of
the essence, ask for an expedited review through the state.
Tips to help
you get the care you need:
-- Review your health plan policy. Many
are available online.
-- Make sure your doctor is aware of your problem.
Sometimes the initial denial comes from the medical
group, which is
charged with managing costs. In any case, your doctor's support is
important.
-- Request the reason for the denial in writing. Take
detailed notes of all conversations, including the date
and time of
the call and the name of the person you speak with. Save copies of all
paperwork, and keep
these records in chronological order.
--
Act soon. If you wait longer than six months, you could lose the right to file
a complaint, ask for an
independent medical review (also called an
IMR), or take other action against your health plan such as
arbitration or a lawsuit. An IMR decision is binding on the health
plan, but not the
patient.
-------------------------------------------------------------------------------------------
NHIC
Provider Education, Medicare Part B
Expiration of Therapy Cap
Exceptions
The exceptions to outpatient therapy caps expire on June 30,
2008. Outpatient therapy service providers
should not submit
claims with the KX modifier for services furnished on or after July 1, 2008.
To the
extent possible, CMS is working with Congress, health care
providers, and the beneficiary community to
avoid disruption in
the delivery of health care services and payment of outpatient physical
therapy,
occupational therapy and speech-language pathology claims
for services furnished by physicians, non-
physician
practitioners, and therapists paid under the physician fee schedule, beginning
July 1.
For physical therapy and speech language pathology services
combined, the limit on incurred expenses is
$1810. For
occupational therapy services, the limit is $1810. Deductible and coinsurance
amounts
applied to therapy services count toward the amount
accrued before a cap is reached. Therapy cap
accruals began on
January 1, 2008, and some patients may have reached the annual limits by June
30,
2008.
Providers may access the accrued amount or
remaining amount of therapy services from the Medicare
beneficiary
eligibility inquiry and response transactions. Specifically:
o For CWF
users, the system returns the “applied� amount. See CR4115 at
http://www.cms. hhs.
gov/transmit tals/downloads/
/R759CP.pdf
o
For users of the HETS 270/271, the system returns the “remaining� amount.
See the page 18 of
the 270/271 user guide at http://www.cms. hhs.gov/HETSHelp
/Downloads/ HETS%20270- 271%
20User%20Compan ion%20Guide. pdf
o
The Medicare contractors' Interactive Voice Response units (IVR) return either
the remaining or applied
amounts based upon contractor programming.
For those few contractors that do not provide this
information on
their IVRs, providers can call the contractors' customer service
representatives.
For additional information, Providers and Suppliers
should also read the Medicare Claims Processing
Manual, chapter 5,
section 10. 2 at http://www.cms. hhs.gov/manuals/
downloads/ clm104c05TXT. pdf
Patients Who
Have Reached Their Limit(s) on Outpatient Therapy Services:
Note that
patients who have reached their limit(s) on outpatient therapy services, other
than those who
reside in a Medicare-certified part of a skilled
nursing facility, may obtain medically necessary therapy
services
that exceed the caps if the services are furnished and billed by the outpatient
department of a
hospital. In other settings, outpatient therapy
services in excess of the caps are not covered, and the
therapy
provider may charge for those services. An Advance Beneficiary Notice is
recommended, but not
required for services that exceed therapy
caps.
An ABN is available at the following link: http://www.cms.
hhs.gov/BNI/ 02_ABNGABNL.
asp#TopOfPage (click on ABN-CMS-R-131
Form). In the box titled "Reason Medicare will not pay"
the
following language is suggested Medicare will not pay more than $1810 for
expenses incurred for
physical therapy and speech-language
pathology services combined or for occupational services in
2008.
Patients may be referred to this website for further
information:
http://www.medicare
.gov/Publication s/Pubs/pdf/ 10988.pdf which will be activated by July 3,
2008.
We will continue to be in communication with you with further
information about payment of Medicare
physician fee schedule
claims. In addition, be on the alert for more information about other
legislative
provisions which may affect you.
Reference:
JSM/TDL-08387;
7/3/2008
----------------------------------------------------------------------------------
Extension
of Therapy Cap Exceptions
July 16, 2008
The Medicare
Improvements for Patients and Providers Act of 2008 was enacted on July 15,
2008. One
provision of this legislation extends the effective date
of the exceptions process to the therapy caps to
December 31, 2009.
Outpatient therapy service providers may now resume submitting claims with the
KX
modifier for therapy services that exceed the cap furnished on
or after July 1, 2008.
For physical therapy and speech language
pathology services combined, the limit on incurred expenses is
$1810 for calendar year 2008. For occupational therapy services, the
limit is $1810. Deductible and
coinsurance amounts applied to
therapy services count toward the amount accrued before a cap is
reached. Services that meet the exceptions criteria and report the KX
modifier will be paid beyond this
limit.
Before this
legislation was enacted, outpatient therapy service providers were previously
instructed to not
submit the KX modifier on claims for services
furnished on or after July 1, 2008. The extension of the
therapy
cap exceptions is retroactive to July 1, 2008. As a result, providers may have
already submitted
some claims without the KX modifier that would
qualify for an exception.
Providers submitting these claims using the
837 institutional electronic claim format or the UB-04 paper
claim
format would have had these claims rejected for exceeding the cap. These
providers should resubmit
these claims appending the KX modifier so
they may now be processed and paid. Providers submitting
these
claims using the 837 professional electronic claim format or the CMS-1500 paper
claim format would
have had these claims denied for exceeding the
cap. These providers should request to have their claims
adjusted
in order to have the contractor pay the claim.
In all cases, if the
beneficiary was notified of their liability and the beneficiary made payment
for services that
now qualify for exceptions, any such payments
should be refunded to the
beneficiary.
---------------------------------------------------------------------------------------
Seven
Mistakes to Avoid When Seeking Social Security Disability BenefitsAllsup
outlines missteps that can
be obstacles when applying for SSDI
benefits.Belleville, Ill. (Vocus) July 11, 2008 -- People with severe
disabilities
know what it means to wait. They wait medical test results; they wait
doctors’ diagnoses and
they wait for answers to their questions
about the future. Delays are typical for people filing for Social
Security Disability Insurance (http://allsup.com/About-SSDI/Free-SSDI-Evaluation.aspx) (SSDI)
benefits,
but there are ways to avoid common mistakes that make the
process even more difficult to navigate,
according to Allsup
(http://allsup.com/Home.aspx). Founded in 1984 and headquartered near St.
Louis,
Allsup represents people nationwide for their entitled SSDI
benefits.Two-thirds of all SSDI applicants will
have their initial
claim denied. If they appeal, and even if they are successful, they will go
through several
additional steps and may wait two years or longer
before they ev er see a disability payment. There are
some
missteps, however, that can actually add time and increase the delay for an
SSDI award, according to
Allsup.Social Security disability payments
are a significant, and often the sole, income source for millions of
individuals
with disabilities and their families,said Edward Swierczek (http://www.allsup.com/About-
Us/News-Room/Resources-for-Journalists/Allsup-Experts/Edward-Swierczek.aspx), senior
claimant
representative with Allsup. Unfortunately, people with
disabilities often make mistakes in applying for their
SSDI
benefits. This may result in even more delays, which puts more stress on what
could already be a
precarious financial situation.To help educate
claimants, Allsup provides the following information on seven
common mistakes people make when filing for SSDI benefits.Seven Common
Mistakes When Filing for
SSDI1. Going into the process uneducated.
Some people believe i's just a matter of filling out a few forms,
sending them in and waiting for their checks. They would be surprised
to find out just how complicated the
SSDI process really is. The
Social Security Administration follows a five-step sequential evaluation
process
to determine if an individual qualifies for disability
benefits (http://allsup.com/About-SSDI/Why-You-Want-
SSDI.aspx), explained
Swierczek, including:* You must not be gainfully employed, which is defined
as
earning $940 a month or more, * Your condition is severe,
meaning it interferes with basic activities of
work, * Your
condition is on the Social Security Administration's list of disabling
conditions, or medically
equals one of the disabling conditions on
the list, and you will be disabled for more than 12 months, * You
are
not able to do the work you had been doing before the impairment, and, * You
can't perform any
other type of work. You have to meet the first two
criteria before the Social Security Administration will
consider
your claim, said Swierczek, who has more than 30 years of experience helping
individuals through
the complexities of the SSDI application process
(http://allsup.com/About-SSDI/SSDI-Process.aspx). If
you're a 40-year-old ironworker who hurt your back, the Social Security
Administration may find that you
are not disabled if you can do
desk work. You may not think you can, but if you don't provide compelling
evidence20why you can't, they will deny your claim, he said.2. Going
through the SSDI process alone.
Individuals who apply for Social
Security Disability Insurance benefits (http://www.allsup.com/About-
SSDI/Choosing-Representation.aspx) without
representation are more likely to have their claim denied.
Working
with government agencies and understanding the nuances of what's needed to
comply with the
regulation isn't something the average person is
aware of, said Allsup senior claimant representative David
Bueltemann (http://www.allsup.com/About-Us/News-Room/Resources-for-Journalists/Allsup-
Experts/David-Bueltemann.aspx), who has
successfully represented thousands of SSDI applicants.“Just
as
people hire accountants to complete their tax returns and represent them before
the Internal Revenue
Service if the're audited, individuals are
recognizing they need representation when they go into the Social
Security Disability Insurance process, he added.3. Underestimating the
impact of your disability. Sometimes
pride leads people to
underplay the extent of their disabilities because they have endured a
condition so long
that they have learned how to cope with the
stress of daily life. But many people underestima te how much
their
disability affects their day-to-day lives. A good example, Bueltemann
explained, is a 50-year-old
grandmother who tells the state
Disability Determination Service (DDS) that she takes care of her
grandchildren. If the woman doesn't explain that the children are
teen-agers and self-sufficient, the DDS may
deny her claim because
it believes that she is capable of working in a day care center.4. Exaggerating
the
impact of your disability. On the other end of the spectrum are
people who want to make their condition
appear worse than it is.
For example, a man who uses a cane at a hearing before an administrative law
judge
but does't normally use a cane would be over-representing his
condition. “If the judge asks to look at the
cane and sees the
tip is not worn, the claim is immediately suspect, even though the claimant may
have had a
legitimate case if he’d just stuck to the
unexaggerated truth, Swierczek explained. It is important to
elaborate, but not exaggerate.�5. Being vague about your work
history. Knowing what the expectations
are for your work, and
showing accurately from the outset why you can't perform this work any longer,
is an
essential part of qualifying for SSDI benefits
(http://www.allsup.com/About-SSDI/SSDI-Guidelines-by-
Disability.aspx). For example
, Swierczek said, a service technician might be required to drive for extended
periods as part of the job.If your impairment means you can only
drive for 10 minutes without experiencing
extreme pain, yet your
job requires you drive in 60-minute stretches, you need to make it clear on
your
disability application what the work expectations are and what
your limitations are, said Swierczek.
Otherwise, you may end up in
double jeopardy: Your disability claim is rejected because the Social Security
Administration believes you can still perform your work, he said.
But you're out of work because you really
can't meet the
requirements of the job.. Missing the appeals deadline. The Social Security
Administration
denies more than 60 percent of all initial SSDI
applications, but there is a formal appeals process with three
levels. If you are rejected at any level, you have only 60 days to
appeal to the next level. If you miss the
deadline, you need to
start the process from the beginning. If you've applied on your own and
received a
denial, it's not too late to choose an SSDI
representative (http://www.allsup.com/Allsup-
Representation/How-It-Works-At-Allsup.aspx), such as Allsup, to handle
the appeal and continue with
your case. Taking this step may make
the differenc e in experiencing further delays to receiving your SSDI
benefits.7.
Giving up. The process can be excruciatingly long and cumbersome. Nearly
750,000 people are
waiting for a hearing before an administrative
law judge, which is only one level of the SSDI appeals
process. For
individuals already facing significant physical or mental disabilities, this
delay can add to the
difficulty. Bueltemann, however, is quick to
point out that receiving SSDI is a benefit that individuals with
disabilities and their families have earned, if they meet the SSDI
requirements. An SSDI award also is
essential in securing other
forms of financial support, including Medicare benefits (http://www.allsup.
com/Financial-Matters/Managing-Healthcare-Costs/Medicare.aspx) and
retirement protection.It may not be
as easy as it should be to
receive your payments, but do not give up, Bueltemann said.Make sure you have
good representation and don't lose hope that you can secure your
benefits.ABOUT ALLSUPAllsup,
Belleville, Ill., is a leading
nationwide provider of financial and healthcare related services to people with
disabilities. Founded in 1984, Allsup has helped more than 100,000
people receive their entitled Social
Security Disability Insurance
and Medicare benefits. Allsup employs more than 500 professionals who
deliver
services directly to consumers and their families, or through their employers
and long-term disability
insurance carriers. For more information,
visit
www.Allsup.com.Contacts:
Allsup - Rebecca Ray(800) 854-
1418, ext. 5065 Dan Allsup, ext.
5760.
----------------------------------------------------------------------------------------
I
have no idea if this is good or not, cause if the cap is 1810, my
therapy
for less than 2 weeks 3 years ago was almost $9,000 so what
good is 1810?
Well I hope this does help someone out there and that
it is a good
thing.
If you are on Medicare and are provided lymphedema treatment
by a Medicare-approved physical
therapist, you do not pay (except
for deductables and 20% co-pay) for the service up to $1800. The
therapist is not alowed to charge any more, and (s)he is reimbursed by
Medicare. The reimbursement rates
vary from state to state, but run
about $25 per unit, with 3-4 units per visit, that provides about 15-20
visits.
But this annual limit has been suspended for many years by
Congress, but is now back in place. But
Congress has also said that
in cases where there is a medical necessity for more than the capped amount per
year, there would be an exception process for certain conditions.
Last year lymphedema was on the list of
exception conditions, so
the limit did not apply. But starting July 1, the exception process
expired.
This new law just put the exception process back. That's good,
since if you need more than 15-20
treatments in any one year for
your lymphedema, you can have them justified.
I have no idea how your
therapist charged you $9,000 for a course of lymphedema treatment. Did that
cost
include bandages or garments (not covered by
Medicare)?
Bob Weiss
Lymphedema Patient
Advocate
-----------------------------------------------------------------------------------
Bob...
I just got a new prescription for Compression hose... I have never worn any...
I just can't afford them
right now.. I had one RX but did not even
try to get them because I knew that I could not afford them.. I am
on Medicaid.. should I try with this RX and then when I get turned down
then try the appeals process or
should I wait until I can afford a
pair and then try and after I have to pay for them go for an appeal? I really
just can't afford them.. I can't afford my treatment at all.. so I
am just waiting in limbo right now... It is a little
hard to do
when I get fluid in my knees and can't stand up on my own at times... any
advice???? Thanks,
Marbeth :)
Marbeth,
Find a
Medicare approved supplier and give them a copy (you keep the original) of the
doctor's prescrition
and ask them to request an advanced approval to
Medicaid and to Medicare if you are on both. It will be
denied, but
you will then have something to appeal and a claim number that can be tracked.
The prescription
should clearly state that the stocking is
necessary to treat your lymphedema, with the appropriate diagnostic
code.
Bob
Weiss
----------------------------------------------------------------------------------
By
accepting the denial of treatment or a compression garment on the basis of the
the letter of denial which
says it is not covered, we allow this
insurance travesty to continue. Appeal each and every denial of
lymphedema treatment. If you run into what appears to be a brick wall
contact me and I'll see how to
approach an appeal.
Bob
Weiss
Lymphedema Treament
Advocate
=================================================================
San
Francisco Chronicle Examines Health Insurance Claim Denials
The San
Francisco Chronicle on Monday examined how "[e]ach year, thousands of
Californians find
themselves at odds with their health insurers
over whether they, as patients, should get the treatment their
doctors prescribed."
Insurers say that physicians do not always
prescribe the most cost-effective treatments. Anthem Blue Cross
says it follows strict protocols in denying care and relies on medical
evidence to determine what care is
appropriate. Michael Belman,
Anthem's medical director, said, "Even in a dire situation, it is ethically
appropriate to withhold treatment if it's not effective." Alan Sokolow,
chief medical officer for Blue Shield of
California, said, "We
think that is our job -- to help patients and providers apply the benefit
package the
patient has, the dollars they put for insurance
coverage and health care, in the most appropriate and effective
way," adding that patients should appeal denials if they
disagree.
According to the Chronicle, in 2007, the state's HMO Help
Center received about 90,000 calls from
individuals with health
insurance disputes. The majority of disputes involved whether treatment or
procedures prescribed by physicians were "medically necessary" or
considered "experimental" or
"investigational." The state
Department of Insurance, which regulates a smaller number of insurance plans,
received 35,280 complaints and resolved 262 independent medical
review cases in 2007. The Department
of Managed Health Care since
2001 has offered third-party medical reviews and has resolved 1,716 IMRs
since 2007. According to DMHC, roughly 40% of decisions are settled in
favor of the patient.
Jerry Flanagan, health advocate for Consumer
Watchdog, said that issues arise because health insurers "are
going
back to the old strategies of the '90s, when they interrupted care on the front
end by denying or
delaying treatment offered by a doctor." He said
insurers hope patients will not dispute the decisions or
settle for
less, in order to save money -- a statement that insurers dispute.
The
Chronicle also profiled the cases of three individuals whose claims were denied
by insurers (Colliver,
San Francisco Chronicle,
6/23).
------------------------------------------------------------------------------
see
link to upcoming CMS public meeting agenda regarding Durable
Med
http://www.cms. hhs.gov/MedHCPCS
GenInfo/Download s/HCPCS_Meeting_ Agenda_DME_ 052808.
SEE page 11
--
topic 08.71
Garments to be discussed : FLEXITOUCH.
We need
to continue to contact our local politicians to continue to push for
all
lymphedema garments expenses to be covered!
Thanks Lisa for the
heads-up.
This request is for Medicare Codes for the body garments used
with the Flexitouch pneumatic compression
controller. They are
coded as "durable medical equipment" since they are used in conjunction with a
piece of
durable medical equipment. This ruling will in no way
affect coverage of compression bandages or garments,
which are a
different Medicare benefit category (i.e. "prosthetic devices").
I'm
afraid that while contacting our local politicians serves a valuable
educational function, it will not achieve
coverage without either a
new law or by forcing CMS to re-interpret the current law. And to do the
latter,
there must be a ground-swell of appeals from lymphedema
patients who are denied coverage for their
garments.
I will
make this offer: If you file a claim for the garments or bandaging kits that
you paid for in the last couple
of months, when the denial comes
from your insurance company or from Medicare, I will help you file the
three appeals necessary to reach an Administrative Law Judge. At this
point you have a good chance of
being reimbursed. I do not charge
for this help. I'm trying to get favorable decisions from as many different
ALJs as I can. Then I will confront CMS for a change in their
interpretation of the Social Security Act.
I will also help your
Congressional representative draft and introduce a bill to change Medicare, if
you can
interest him or her in your cause.
Robert Weiss,
M.S.
Lymphedema Treatment Advocate
National Lymphedema
Network
-------------------------------------------------------------------
There
have been recent "clarifications" to the "incident to" physician services rules
which may impact
provision of therapy services for some lymphedema
therapists. The changes to the policies are summarized
in
http://www.cms. hhs.gov/MLNMatte
rsArticles/ downloads/ MM5288.pdf
with the full-text policy revisions
given in
http://www.cms. hhs.gov/Transmit
tals/downloads/ R87BP.pdf
-------------------------------------------------------------------------------------------
Settlement
to Ease Drug Costs for Some on Medicare
By ROBERT
PEAR
http://www.nytimes.com/2008/06/20/health/policy/20drug.html?_r=1&ref=health&oref=slogin
Published:
June 20, 2008
WASHINGTON - The Bush administration promised on Thursday to
provide new
protections for low-income Medicare beneficiaries to ensure they
can get
prescription drugs promptly, at minimal cost.
The promise
came in the proposed settlement of a nationwide class-action lawsuit
filed
on behalf of hundreds of thousands of people who have had difficulty
getting
the medicines they need.
Under the 2003 Medicare law, more than six
million people eligible for both
Medicare and Medicaid are entitled to extra
help with their drug costs. But in
many cases, they could not get the
assistance, so they did not receive the drugs
they needed, or they
experienced long delays.
In early 2006, low-income beneficiaries were
often overcharged, and some were
turned away from pharmacies without getting
their medications. Several states
declared public health emergencies, and
many stepped in to pay for prescriptions
that should have been covered by
the federal Medicare program.
Under the proposed settlement, filed
Thursday with the United States District
Court in San Francisco, federal
Medicare officials promised to speed up the
process of providing extra help
to low-income people, who now could qualify
within days, rather than weeks
or months.
Drug benefits are delivered by private insurers under
contract to Medicare.
Under the settlement, these insurers will have to
provide medications at minimal
cost for any Medicare recipients who prove
they have low incomes and qualify for
extra help.
For most people
with incomes less than the poverty level ($10,400 a year for an
individual),
the maximum co-payment is $1.05 for a generic or preferred
brand-name drug
and $3.10 for other prescription drugs.
But many beneficiaries have been
asked to pay much higher amounts, from $30 to
$75 or more, because the
evidence of their low-income status was not properly
shared among federal
and state agencies, insurance companies and pharmacies.
"This settlement
agreement is a victory for many of the nation's most vulnerable
citizens,
who have faced life-threatening delays in obtaining vital
medications," said
Kevin Prindiville, a lawyer at the National Senior Citizens
Law Center,
which filed the lawsuit with another nonprofit group, the Center
for
Medicare Advocacy.
Gill Deford, a lawyer at the Center for
Medicare Advocacy, said the settlement
would "help hundreds of thousands of
people a year get their prescription drugs
more quickly, at nominal
cost."
Jeff Nelligan, a spokesman for the federal Centers for Medicare
and Medicaid
Services, said federal officials had "worked tirelessly" to
ensure that Medicare
recipients could fill their prescriptions. He refused
to comment on the
substance of the settlement, noting that it was subject to
approval by Judge
Thelton E. Henderson of Federal District Court in
California.
States administer the Medicaid program. They have crucial
information showing
whether Medicare beneficiaries are also enrolled in
Medicaid and therefore
eligible for extra help with their drug
costs.
Under the settlement, if a beneficiary claims to be eligible for
the low-income
subsidy but does not have the documents to prove it, and if
the person is about
to run out of a medication, federal officials would
immediately contact the
state Medicaid agency to check whether the person
had been on
Medicaid.
--------------------------------------------------------------------------------
News
from New York State
Assemblyman ALAN N. MAISEL
59th ASSEMBLY
DISTRICT
Date: June 23, 2008
Assembly Passes Maisel Measure
To
Raise Awareness of Lymphedema
Today, in Albany,
Assemblyman Alan Maisel (D-Kings County) announced passage in the Assembly of
legislation to promote lymphedema and lymphatic disease reporting
and awareness (A05892B). TThe
measure requires health care
providers, who are already required to report cases of cancer or oother
malignant disease, to also report instances of lymphedema related to
cancer treatment in their patients. This
legislation also requires
the Department of Health to develop a health care and wellness education and
outreach program for those seeking information on either primary or
secondary lymphedema.
"Lymphedema is not a high profile disease like
cancer or diabetes that generates a lot of press or mmoney
for
research, yet it affects an estimated six million men, women and children in
the United States," stated
Maisel. "The lymphatic system is vital
to the health of every individual as it is an integral part of tthe immune
system.� Lymphedema is an accumulation of lymphatic fluid that causes
painful, disfiguring sswelling,
usually in the arms or legs. There
are two major types of lymphedema: primary (congenital) and ssecondary
(caused by tissue injury, scarring, lymph node removal, or
infection).
"The largest group of people who acquire secondary
lymphedema arc cancer patients, including those with
breast,
prostate, lung, and melanoma patients," stated Maisel. "This bill helps to
ensure that when
lymphedema is acquired from the life-saving cancer
treatments, these instances of disease are also rreported
to the
cancer registry. This will help raise awareness of the disease and hopefully
increase the mmoney
raised to fund additional research to help find
the cause of and cure for lymphatic diseases, lymphedema,
and
related disorders."
"It amazes me that despite the essential role the
lymphatic system plays in human health, awareness,
education and
research have been relatively neglected," stated Maisel. "This lack of focus
has created
barriers to effective delivery of health care and
public education about these diseases, its diagnosis,
treatment,
therapy and long-term care. This legislation, which is on third reading in the
Senate, is just the first
step in raising public awareness about
lymphedema."
--------------------------------------------------------------------------------------------
UNINSURED
STATS:
At its best, the United States health care system is second to
none. It is quick to adopt and diffuse new
technologies.1 It scores
best in the world for patient participation in treatment decisions, respect for
confidentiality, provision of prompt care, respect for patients, and
clean surroundings.2 But despite having
the highest health care
spending per capita, the U.S. consistently scores at or near the bottom in
comparisons with other developed, high income countries on infant
mortality, life expectancy, and the
proportion of the population
with health insurance coverage (OECD, 2002, WHO, 2000). Almost everyone
in these countries has coverage. In the U.S., by contrast, 15.3 percent
of the population - or 44.8 million
people – were uninsured in
2005.3 What are the consequences of 36.7 million adults and 8.1 million
children living without health insurance coverage?
In a sweeping
6-volume series on the consequences of uninsurance, the Institute of Medicine
reported the
following conclusions:
Compared to people with
insurance, uninsured children and adults experience worse health and die
sooner.
Families can suffer emotionally and financially when even a single
member is uninsured.
"Uninsurance at the community level is associated with
financial instability for health care providers and
institutions,
reduced hospital services and capacity, and significant cuts in public health
programs, which may
diminish access to certain types of care for
all residents, even those who have coverage."4
The nation as a whole is
economically disadvantaged as a result of the poorer health and premature death
of
uninsured Americans. The IOM estimated that the lost economic
value of uninsurance is between $65 billion
and $130 billion
annually.5
--------------------------------------------------------------------------------
Sources
1Docteur,
Elizabeth, Hannes Suppanz, and Jaejoon Woo. 2003. The US Health System: An
Assessment
and Prospective Directions for Reform. Economics
Department Working papers No. 350. Accessed May
28, 2004. Available
at www.oedc.org/eco.
2Findings based on surveys conducted in 35
countries. World Health Organization. 2000. The World
Health Report
2000—Health Systems: Improving Performance. Geneva,
Switerland.
3Employee Benefit Research Institute estimates from the
March Current Population Survey, 2006
Supplement.
4Institute
of Medicine. 2004. Insuring America's Health. Washington, DC: National Academy
Press, p. xi
5Institute of Medicine. 2004. Insuring America’s Health.
Washington, DC: National Academy Press, p. xi.
Coverage Matters for
Individuals
Public opinion on this question has shifted overtime; but in
1993, when health care was at the top of the
national political
agenda, fully 43 percent of Americans agreed with the statement that uninsured
people are
"able to get the care they need from doctors and
hospitals."1 And just 7 years ago, in 1999, a majority (57
percent)
of Americans held this view. Clearly, there is a commonly held belief in this
country that uninsured
Americans get the health care they need.2
However, available evidence shows that this belief is clearly
false.
Adults
In their landmark study of the consequences of
uninsurance,3 the Institute of Medicine concluded that
"adults
without coverage do not get the care they need and are more likely to suffer
poor health and
premature death than are insured adults." A more
recent study also found that the uninsured receive less
care than
the insured and experience poorer outcomes.4
Long-term studies indicate
that, compared to insured adults, uninsured adults have a 25 percent greater
risk
of premature death. This mortality difference exists after
social, demographic, health status and health
behavior differences
are statistically removed.5
The Institute of Medicine estimates that the
number of excess deaths each year among uninsured adults, age
25-64, is 18,000.6 By way of comparison, consider the number of
estimated annual deaths in the under age
65 population due to the
following causes:
- Diabetes: 17,500
- Stroke: 19,000
- HIV/AIDS:
14,100
- Homicide 19,7007
Preventive Care
Uninsured adults are
less likely to receive recommended preventive and screening services than
insured
adults. This includes:
- Pap tests for cervical cancer
in women,
- Clinical breast exams and mammography in women,
- Fecal
occult blood tests for colorectal cancer,
- Sigmoidoscopies for colorectal
cancer,
- Blood pressure checks for hypertension, and
- Cholesterol
tests.8
Compared to adults with insurance, when uninsured adults
receive screening services, they are less likely to
receive them on
a timely basis.9
Because they lack timely access to screening services,
uninsured adults with cancer (breast, colon, prostate)
tend to have
poorer outcomes and are more likely to die prematurely than adult cancer
patients with
insurance. Poor access to screening services results
in delayed diagnosis; and survival probability is a
function of the
stage of the cancer at diagnosis.10
The longer adults under age 65 are
without health insurance, the less likely they are to receive preventive
services.11
Health insurance coverage increases access to and use of
preventive services, but it does not erase
disparities in the use of
these services among racial groups.12
Chronic Care
Chronic
conditions—including cardiovascular disease, diabetes, terminal kidney disease,
HIV infection, and
mental illness—are the leading cause of death,
disability, and illness in the United States.13
Uninsured adults with
cardiovascular disease receive fewer professionally recommended services and
experience worse health outcomes than insured adults with
cardiovascular disease. They are less likely to:
- be screened for
hypertension and high cholesterol,14
- have their blood pressure monitored
frequently,15 and
- stay on drug therapy for
hypertension.16
Diabetes requires intensive care management, but
non-elderly adult diabetics are almost as likely to be
uninsured as
non-elderly adults in general.17
- Compared to insured non-elderly adults
with diabetes, uninsured diabetics are less likely to receive
appropriate standards of care, which can lead to uncontrolled blood
sugar levels, greater risk of
hospitalization, and increased risk
of additional chronic disease and disability.18
- Among non-elderly adult
diabetics, lack of insurance is associated with less glucose monitoring and
fewer
foot and eye exams. These services are professionally
recommended disease management strategies.19
Compared to insured
non-elderly adults, those without insurance
- who have end-stage renal
disease are more likely to begin dialysis once the disease has progressed to a
more advanced stage, which has a negative effect on health
outcomes.20
- who have HIV infection are less likely to receive the most
effective drugs, are more likely to fail to receive
needed care21 ,
and have a higher risk of mortality.22
Compared to insured adults
with behavioral health coverage, uninsured adults are less likely to receive
mental health services consistent with recommended treatment
guidelines.23 Uninsured adults with severe
mental illness are much
less likely to use specialty mental health services than publicly insured
persons. 24
Pregnant Women and Children
After conducting an
exhaustive review of the literature, the Institute of Medicine concluded that
"[h]aving
health insurance increases the chances that infants,
children, and pregnant women will receive preventive
services when
well, and timely medical care when sick or at high risk of poor outcomes.
These, in turn, help
avoid unnecessary hospitalizations, premature
births, extended morbidity, or even death."25
The IOM was careful to
note, however, that "[a]lthough having insurance makes a difference, simply
making
insurance available may not be enough to improve health care
and health outcomes for all of the uninsured.
Some high-risk groups
may require additional services (e.g., educational interventions, targeted case
management) if they are to obtain good preventive and routine
care."26
Pregnant Women
Uninsured pregnant women use fewer
prenatal services than publicly or privately insured pregnant women.
In
one study, the rate of unmet needs reported by uninsured women (18 percent) was
more than twice that
of insured women.27
Pregnant women without
health insurance are less likely to receive expensive maternity and neonatal
services. For example, the caesarian section rate for uninsured
women is lower than the rate for insured
women. Although it is
believed by some that c-section is an overused procedure, a study that examined
insurance status differences in c-section rates when it was an
appropriate procedure (in cases of breech
presentation or fetal
distress) found lower use rates among uninsured women.28
Medicaid expansions
during the late 1980s brought public coverage to many previously uninsured
women.
Although the evidence is mixed, some studies show
significant population-level changes in the use of prenatal
services
following Medicaid expansion.29
Children
Uninsured children have
less access to health care providers and use health services less frequently
than
children with private or public insurance.30
When
previously uninsured children are enrolled in public insurance programs, they
use more health services
and use health services more
appropriately.31
Multiple factors hinder children's access to, and use of,
health services, including low income, immigrant
status, and
certain race/ethnicity categories. Because 40 percent of children in one of
these groups are in at
least one other, the barriers to health care
access and use are compounded for many children.32
Although having insurance
coverage improves access to and use of care for children, other important
factors
include "poverty, diet, exercise, smoking, and other
behavioral
factors."33
--------------------------------------------------------------------------------
Sources
1Blendon
et al., 1999, p. 207 (IOM, p 21, bottom)
2Institute of Medicine (IOM).
2001. Coverage Matters. Insurance and Health Care. Washington, DC:
National Academy Press, p. 21.
3Institute of Medicine (IOM).
2001. Coverage Matters. Insurance and Health Care. Washington, DC:
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Coverage. Too Little, Too
Late. Washington, DC: National Academy
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7Institute of Medicine (IOM). 2004.
Insuring America's Health. The National Academies Press,
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DC:
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10Institute of Medicine
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Weissman, Eric Schneider, Jack Ginsburg, et al. 2000. Unmet Health Needs of
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on the Consequences of
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"Chronic Disease Prevention: Heart Disease
and Health Promotion."
Web page, not accessible on April 13, 2004, but see other performance plans at
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John Moeller, and Randall Stafford. 2000. Patterns and Costs for Hypertension
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20(3):181-195; Fish-Parcham, Cheryl. 2001.
Getting Less Care: The
Uninsured with Chronic Health Conditions. Washington, DC: Families USA
Foundation.2001
17Harris, Maureen. 1999. Racial and Ethnic
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18Palta, Mari, Tamara LeCaire, Kathleen
Daniels, Guanghong Shen, et al. 1997. Risk Factors for
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19Beckles, Gloria, Michael Engelgau, KM
Venkat Narayan, William Herman, et al 1998. Population-
Based
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American Society of Nephrology
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35(1): 277-282.
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American Journal of Public Health 80(3):313-315.
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Program on Newly Enrolled Children. Journal of the
American Medical Association 279(22):1820-1825.
32Newacheck, Paul, Dana
Hughes, and Jeffery Stoddard. 1996. Children's Access to Primary Care:
Differences
by Race, Income, and Insurance. Pediatrics 97(1): 26-32.
33Institute of
Medicine (IOM). 2002. Health Insurance is a Family Matter. Washington, DC:
National
Academy Press, pp.IOM, 2:9 top.
Health care spending in
the United States has grown rapidly since the 1960s, at an average rate of 10
percent a year.
In 2005, nearly $2 trillion was spent on
health care in the United States. The amount of money spent on
health care is expected to increase to $4.1 trillion by
2016.1
Spending on health care accounted for about 16 percent of Gross
Domestic Product (GDP). By 2016, the
Center for Medicare and
Medicaid Services (CMS) projects that health care will account for about 20
percent of GDP.2
While health care spending has been increasing, the
distribution of health care spending among different
services has
been changing.
Since the 1980s, the percentage of health care spending
for hospital care has declined. In 1980, hospital
care accounted
for 40 percent of all health care spending. By 2004, it accounted for 30
percent, and is
expected to remain at roughly 31 percent between
now and 2016.3
By contrast, the share of spending for physician and other
professional services rose over the same time
period, from 27
percent of in 1980 to 28 percent in 2005. It is expected to fall slightly to 26
percent through
2016.4
The share of health care spending
accounted for by prescription drugs increased from 5 percent in 1980 to
10 percent in 2005, and is expected to reach 12 percent in
2016.5
The cost of providing health care services has been increasing
faster than the Gross Domestic Product
(GDP) since 1998, but the gap
between the two declined recently as the economy recovered from
recession and health care costs grew more slowly.
During 2001,
health care costs increased 11.3 percent, while GDP increased by only 2.1
percent. By 2006,
health care costs increased 7.7 percent, compared
to 5.9 percent GDP growth.7
Recent spending on health care services has
slowed for all categories of health care, but cost increases for
hospital outpatient services and prescription drugs continue to outpace
those for inpatient and physician
services.
Sources
1Employee Benefit Research Institute
estimates from Centers for Medicare and Medicaid Services and U.
S.
Department of Commerce.
2Employee Benefit Research Institute estimates
from Centers for Medicare and Medicaid Services and U.
S. Department
of Commerce.
3Employee Benefit Research Institute estimates from Centers
for Medicare and Medicaid Services.
4Employee Benefit Research Institute
estimates from Centers for Medicare and Medicaid Services.
5Employee
Benefit Research Institute estimates from Centers for Medicare and Medicaid
Services.
6Employee Benefit Research Institute estimates from Centers
for Medicare and Medicaid Services.
7Strunk, Bradley C., Paul B.
Ginsburg, and John P. Cookson. "Tracking Health Care Costs: Declining
Growth
Trend Pauses In 2004." Health Affairs Web Exclusive, June 21, 2005; and
Ginsburg, Paul B.,
Bradley C. Strunk, Michelle I. Banker, and John
P. Cookson. "Tracking Health Care Costs: Continued
Stability But At
High Rates In 2005.." Health Affairs Web Exclusive, Oct. 3,
2006.
=================================================================
The
Office of the Medicare Beneficiary Ombudsman was set up to help Medicare
Beneficiaries with their
problems with Medicare. The MBO web page
is
http://www.cms.hhs.gov/center/ombudsman.asp
The following
are some important links to resources in and outside this
organization:
Office of the Medicare Beneficiary Ombudsman
•
http://www.medicare.gov/Publications/Pubs/pdf/11173.pdf
•
http://www.cms.hhs.gov/OpenDoorForums/downloads/Ombudsman0506ReporttoCongress.pdf
• Contact Us - If you have an issue that requires a response,
please contact 1-800-MEDICARE. If your
inquiry requires a response
from the Medicare Ombudsman, 1-800-MEDICARE will direct your inquiry
to
the Medicare Ombudsman.
Resources for Assistance with Medicare
Issues
•
http://www.medicare.gov/CallCenter.asp- Get general
information about MEDICARE.
• http://www.medicare.gov/Ombudsman/resources.asp- Provides
information regarding how to file an
inquiry, complaint, grievance,
or appeal across different areas of Medicare.
Other Helpful
Resources
• http://www.medicare.gov/contacts/Static/RelatedWebsites.asp- Allows you
to access other websites
that can provide additional help or
information that is not presented in www.medicare.gov.
•
http://www.hhs.gov/od/
-
The Office of Disability oversees the implementation and coordination of
disability programs, policies and special initiatives for persons with
disabilities.
• http://www.aoa.gov/eldfam/eldfam.asp- The
Administration on Aging provides home and community-
based services
and opportunities to older persons and their caregivers through programs funded
under the
Older
Americans Act.
• http://www.cms.hhs.gov/home/medicaid.asp - If you
can't pay for your medical expenses right now, this
is the place to
find information on assistance that may be
available.
=================================================================
HOW
TO GET THE BEST CARE IN MEDICAL FACILITIES
This message is off topic,
but posted here because it is something that
is likely to affect almost
everyone at one time or another. This
information may be helpful to prevent
unnecessary illness or suffering,
and may even save a life.
The
material came from a list that discusses health care insurance issues
and
policies, and managed care. Most list members are either physicians
or
lawyers. The owner of the list is both, and is affiliated with UCLA.
I
posted this information to another list, and several individuals
wondered
about MRSA, one of the things discussed in the article. To
avoid confusion,
the material I posted in response to the inquiries is
also posted
here.
The reason for this post is to advise the public, regarding use
of
advocates to assist patients in hospitals, nursing homes, and other
such
similar residential medical institutions to obtain proper assistance
when
someone is in a medical facility, and to prevent injuries and death.
It
was never meant to constitute medical advice. Information about this
(or
any other medical) condition, how to diagnose it, treat it, or prevent
it
should be discussed with medical providers, not this list.
This is
posted for educational purposes only. It does not constitute
medical or
legal advice.
Any questions regarding this material should be directed
to undersigned
poster, at
X1234567890@Juno.Com
subject:
HEALTH CARE FACILITIES
************************
Bedside Manner:
Advocating for a Relative in the Hospital
By MELINDA BECK
Don't
go to the hospital alone, if you can possibly avoid it.
A friend of mine
slipped on the sidewalk recently and broke her hip. She
had surgery in one
of the best hospitals in the country.
But it was my friend's grown
daughter who noticed that she was having an
adverse reaction to a pain
medication. And that her IV drip had pulled
out of a vein and was pumping
her arm full of fluid. And that the hot
compresses to reduce the swelling in
her arm had left blisters on her
skin. And that the blood-sugar test she was
about to be given was meant
for her roommate instead.
Having someone
with you in a hospital who is alert and asking questions
can help stave off
all kinds of potential problems, from mistaken
identity to medication mixups
to MRSA infections. An estimated 100,000
hospital patients die every year in
the U.S. because of preventable
errors. Many hospitals are under financial
pressures to keep nursing
staffs lean. A personal advocate can be a valuable
resource. It doesn't
have to be a relative -- and it can be more than one
person -- as long as
they know you and are willing to speak up.
"If
we could make only one change in health care, it should be to change
the
notion that families are visitors. Families are allies and partners
for
safety and quality," says Beverly Johnson, president of the
nonprofit
Institute for Family-Centered Care, which is leading a movement
to
involve families more.
A growing number of hospitals are doing
just that -- including unlimited
visiting hours, letting family members
accompany patients to procedures
and even stay during emergencies. "We're
drawing on the strength of the
family. They're not out in the waiting room,
wondering what's going on,"
says Pat Sodomka, senior vice president for
Patient and Family-Centered
Care at MCG Health Inc., which runs a 630-bed
hospital in Augusta, Ga.
Some hospitals now have nurses give
change-of-shift reports at the
bedside and encourage families to share
observations.
"This is a huge cultural change," says Mary Chatman, Chief
Nursing
Officer of Pitt County Memorial Hospital in Greenville, N.C., which
is
giving family and patient advisory groups a voice in designing
new
facilities and interviewing physicians.
Initially, some staffers
worried that family involvement would take up
valuable time, but in the long
run, it saves time because doctors have
more information, says Ms. Chatman.
After MCG Health's neuroscience unit
became more family-centered, average
length of stay dropped 50% because
discharge planning went faster. Patient
satisfaction rose, and nursing
turnover dropped.
Still, it can be
difficult for family members to know when to raise an
alarm and
how.
Karen Aydt Curtiss, a market researcher in Lake Forest, Ill., often
felt
helpless while her 71-year-old father was recovering from a
lung
transplant in a big teaching hospital in 2005. He was faring well
until
he fell, hit his head and was made to lie flat until a neurologist
could
evaluate him. While he waited -- all weekend -- his new lungs filled
up
with fluid. He developed pneumonia, then a pulmonary embolism and
had
three MRSA infections. He died seven months after the transplant,
having
never left the hospital.
"I wish I had grabbed the neurologist
by the sleeve and dragged him to my
father's room," says Ms. Curtiss, who is
writing a book on how to help a
loved one in the hospital, titled "Someone
With You."
Among her suggestions:
- Ask everyone who enters the
room if they've washed their hands and
sterilized equipment. Use
antibacterial wipes on surfaces.
- Ask nurses to read drug orders aloud
and make sure they match the
patient's ID bracelet. If it's a new
medication, ask what it's for and
what to expect.
- Be alert for
pressure wounds, also known as bedsores, particularly in
long hospital
stays. Put a piece of sheepskin (available at
medical-supply stores) under
the sheet to provide padding and cut moisture. Make sure patients
are
moved often, and lifted, not slid, which can damage fragile
tissue.
- Bring a deck of cards and other games to help patients work
their minds
and motor skills.
- Keep a journal for observations --
especially if you're sharing the
watch with others.
- Never give a
patient medications on your own.
- Don't help a patient get in or out of
bed by yourself.
- Be respectful and appreciative and remember that
other patients may
have more urgent needs. But don't hesitate to speak up if
you have
concerns. Says Ms.
Sodomka: "You have knowledge that the
caregivers just don't have."
==========================
Below is a very
basic synopsis of the bacteria and how it functions, on a
very cursory
level. It is not intended to be taken as medical advice.
MRSA, which
stands for Methacillian resistant Staphylococcus Aureus, is a
bacterial
infection that can be contracted by direct contact with a
person who has
active MRSA, (or sometimes, colonized MRSA) or by exposure
to droplets
emitted from such a person, through coughing or sneezing.
MRSA is not
airborne, and N95 respirators are not required to protect
against infection
when visiting a patient with this diagnosis. However,
if that person also
has pneumonia, which is very common among those
infected by MRSA, that is
airborne, and droplet precautions and contact
precautions are not
sufficient. In those situations, it is prudent to
seek the advice of a
medical professional.
Basically, MRSA, which is referred to by the CDC
and NIH as USA300, is a
bacterium that destroys immune cells.
To
understand this concept, a little basic background is needed
here.
Humans have a reticuloendothelial system, or mononuclear
phagocytic
system, which basically consists of a series of organs and cells
that
protect the human organism against foreign invaders, such as
bacteria,
viruses and fungi.
White blood cells, or leukocytes,
protect against particular invaders.
(White cells also include Alpha, Beta
and Gamma Globulins, but these
generally protect organs, and are not subject
of this issue).
There are three types of leukocytes; granulocytes,
monocytes and
lymphocytes. Lymphocytes are either B cells, or T cells.
Most have
heard of the T4 or CD4 which is the lymphocyte that is affected
adversely
by HIV.
Monocytes produce the macrophage cell, which
basically consumes dead
cells and tissue, and removes it from the
body.
Granulocytes exist in three varieties; basophils, neutrophils
and
eosinophils. Neutrophils emit Cl [chlorine], H2O2 [hydrogen
peroxide],
and an antimicrobial protein that normally destroys such
invading
bacteria such as Staphylococcus, which is present in approximately
30% of
the US population, either on their dermal layers, or in their
mucosa.
Staphylococcus Aureus, however, recognizes the danger of the
emissions
from the neutrophil, and rather than allowing itself to be
destroyed by
it, it devours or consumes the neutrophil. Thus, the
expression, flesh
eating bacteria.
When staphylococcus Aureus is
Methacillian resistant, it does not respond
to the broad spectrum
antibiotics, such as Penicillins, Cephalosporins,
etc. USA300 can also
mutate to become Vancomycin resistant, wherein only
incision and debredment
or amputation options remain. If the bacterium
crosses the erythrocyte
barrier, and is carried by the erythrocytes into
internal organs, death is
likely.
That is the method by which MRSA destroys human tissue if left
untreated.
Common treatments include incision and debredment, with
antibiotics, or
the introduction of Vancomycin, a powerful gram specific
antibiotic.
Two common types of MRSA have been identified. HA-MRSA and
CA-MRSA.
HA-MRSA is hospital acquired Methacillian resistant
Staphylococcus
Aureus, and CA is community associated Methacillian
resistant
Staphylococcus Aureus.
The official medicare
website is located at :
http://www.medicare.gov/
How to find a
prescription plan under medicare:
http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/MPDPFIntro.asp?
version=default&browser=IE%7C6%
7CWinXP&language=English&defaultstatus=0&pagelist=Home&View&PDPYear=2006&M
APDYear=2006&MPDPF%5FMPPF%5FIntegrate=N
From the looks
of it there are 2 types of plans you can join:
Plans include HMOs, PPOs,
and Private-Fee-for-Service plans. They offer complete Medicare-covered
health care, including drug coverage, through a single plan. Most of
these plans generally offer extra benefits
and lower copayments
than the Original Medicare Plan. However, you may have to see doctors that
belong
to the plan or go to certain hospitals to get
services.
FROM NORD again:
Knowing Your Health History Could Save
Your Life
Most Americans believe that knowing their family health
history can be beneficial, but only about one-third
have actually
tried to gather and record information about family health, according to a
recent study by the U.
S. Centers for Disease Control and Prevention
(CDC).
Furthermore, the discussion of family history between physician
and patient typically lasts just a few minutes.
"But knowing your family
history can save your life," US Surgeon General Richard H. Carmona said at a
press conference in November to launch a project known as the
Family History Initiative. As part of this
project, the Department
of Health and Human Services has created a new computerized tool, called "My
Family Health Portrait," that can be downloaded at
www.hhs.gov/familyhistory/ to help in the process.
Francis S. Collins,
MD, PhD, director of the National Human Genome Research Institute, noted that
all
people have genetic abnormalities that make them more
susceptible to certain illnesses. Tracking illnesses
from one
generation of a family to the next can help identify illnesses for which the
family is at risk. This may
allow family members, working with
their physicians, to take steps to reduce their risk.
The tool guides
users through a series of screens to record information for each family member
about six
common diseases. Other conditions may also be added.
After the information has been collected, a diagram
can be printed
and shared with a physician.
All personal information is maintained on
the user's computer. No information is given to the government.
Eventually, the tool will be available in both English and Spanish.
Also, a print version will be provided to
those who call the
Federal Citizen Information Center at (888) 878-3256.
The federal
employees who have worked on this project, from the National Institutes of
Health, Surgeon
General's office and CDC, hope families will take
advantage of being together over the holidays to compile
a health
history. "It is our hope as families gather this holiday season, they'll take
the time to learn-and
record-their families' health histories so
that they can continue to have years of family gatherings together,"
said
Muin Khoury, MD, director of CDC's Office of Genomics and Disease
Prevention.
MEDICAID ALERT:
Medicare/Medicaid Information
regarding insurance with medicare:
You automatically qualify for extra
help and don't need to apply if you:
have Medicare and full coverage
from a state Medicaid program that currently pays for your prescriptions.
You should join a plan that meets your needs by December 31, 2005
because Medicaid will no longer pay
for prescription drugs. If you
don't, Medicare will enroll you in a plan effective January 1, 2006 so you
don't
miss a day of coverage. You can drop the plan or switch to
another any time.
get help from your state Medicaid program paying
your Medicare premiums (belong to a Medicare Savings
Program). You
should join a plan that meets your needs by December 31, 2005. If you haven't
signed up
by May 15, 2006, Medicare will enroll you in a plan
effective June 1, 2006 so you don't have to pay a
penalty. You can
drop the plan or switch to another any time.
get Supplemental
Security Income. You should join a plan that meets your needs by December 31,
2005. If
you haven't signed up by May 15, 2006, Medicare will
enroll you in a plan effective June 1, 2006 so you
don't have to pay
a penalty. If Medicare enrolled you in a prescription drug plan, you can switch
to another
plan one time before December 31,
2006.
Appeals Form
If you are having trouble with medicare
denying your compression garments, contact Bob Weiss. He can
help
you with your appeal and the form is above. Email Bob at:
lymphactivist@aol.com
Save Medicare
Act 2008
What To
Do When Medicare Says 'No'
http://www.elderlawanswers.com/resources/article.asp?id=2334&Section=4&state=
Your doctor
suggested you have a minor operation or procedure, you went ahead and had it
done, and now
Medicare won't pay for it. What should you do?
Appeal.
Your provider tells you that your lymphedema compression garments
are not covered. What should you
do? Appeal. [Added by Bob
Weiss]
Medicare covers procedures that are deemed medically necessary.
"Appealing is easy and most people win
so it is worth your while to
challenge a Medicare denial," says the Medicare Rights Center, a national
nonprofit organization. The denial of coverage may be due, for example,
to a simple coding error in your
doctor's office.
People
have a strong chance of winning their Medicare appeal. According to Center, 80
percent of
Medicare Part A appeals and 92 percent of Part B appeals
turn out in favor of the person appealing.
The Medicare Rights Center
offers the following tips to maximize your success when appealing your
denial:
a.. Write "Please Review" on the bottom of your Medicare Summary
Notice (MSN), sign the back and
send the original to the address
listed on your MSN by certified mail or with delivery confirmation.
b..
Include a letter explaining why the claim should be covered.
c.. When
possible, get a letter of support from your doctor or other health care
provider explaining why the
service was "medically
necessary."
d.. Save photocopies and records of all communications, whether
written or oral, with Medicare concerning
your denial.
e.. Keep
in mind that you only have up to 120 days from the date on the MSN to submit an
appeal.
The Center notes that the appeals process is slightly different if
you are in a private Medicare plan, like an
HMO or a PPO. One
difference is that you have only 60 days from the date on the denial notice to
file an
appeal.
Resources:
For information on how to
fight a hospital discharge, click here.
For more on the Medicare Rights
Center, visit its Web site at http://www.medicarerights.org
To download
Medicare appeal forms from the government's Medicare website, click
here.
--------------------------------------------------------------------------------------------
FILING
A CLAIM FOR REIMBURSEMENT FOR COMPRESSION GARMENTS
* Garment
supplier fills out an ABN and gives Beneficiary a copy. Beneficiary pays
garment fitter and gets a
receipt. Make sure that this is the
latest version of Form CMS-R-131. I have the version dated (03/08).
This is important since the Section (G) Options were in reverse order
from earlier versions. The option to be
chosen is the only one
which states in bold "I can appeal to Medicare".
* If the Supplier
should choose to file the claim for the beneficiary, they will file on a Form
1500. Ask that
they fill out Item 27 Acceptance of Assignment with
a "NO", and further place the note "Beneficiary refuses
to assign
benefits" in Item 19. (see note below why Supplier may not be motivated to file
for the beneficiary).
* Beneficiary submits CMS form 1490 Patient's
Request for Medical Payment to Medicare requesting
reimbursement for
the garment listed on the ABN, and attaches receipt. Block 6 Authorization says
"... and
request payment of medical insurance benefits to me." just
above beneficiary's signature.
* Medicare sends a denial directly to the
Beneficiary. Denial appears on the quarterly Medicare Summary
Notice (MSN). After the headers on this form, the sentence "This is a
summary of claims processed from ...
to ...". Following this there
should be a section labeled "Part B Medical Insurance-Unassigned Claims". In
the last column "See Notes Section" there will be a series of code
letters denoting the reason for the denial.
There will also be
detailed instructions for appealing the decision. There is a 120-day appeal
period after
which no appeal will be allowed.
* Beneficiary
consults Bob Weiss [LymphActivist@aol.com] to proceed further, i.e., several
more denials
will come down the pike before it goes to an
administrative law judge... At this point I will need a copy of
the
MSN and I will either guide the beneficiary in the first appeal, or I will file
it on behalf of the beneficiary.
This first appeal to an
"independent" Medicare Contractor is called a "Redetermination", the next
appeal to a
"Medicare Quality Independent Contractor" or a "DME
MAC" is a "Reconsideration", and the next appeal
is to an
Administrative Law Judge (ALJ). None of these appeals costs any more than the
cost of making
copies and postage. There is a 60-80% chance of a
favorable determination by the ALJ. In the event that
the ALJ
renders an unfavorable decision then we will appeal to the Medicare Appeals
Council, where I run
about a 50% favorable rate.
IF the
Beneficiary gets reimbursed after 2 years or so, the ABN states that "If
Medicare does pay, you will
refund any payments I made to you, less
co-pays or deductibles." This puzzles me. Does this mean that
Medicare will reimburse the garment fitter directly? (That's crazy
because it is definintely not in a garment
fitter's interest to go
to the trouble of submitting an ABN for a Beneficiary only to have to refund
their money
at a later time). You are correct that the Supplier has
little incentive to file your complaint. The supplier
receives a
reduced amount of reimbursement from the retail price of the item, and if they
are a Medicare
Supplier they are required to file a claim for
something they know will be denied. So they will ask for
payment in
advance. So as long as they are filing on behalf of the beneficiary it is
important for the
beneficiary to refuse to assign benefits on the
Form 1500. That way there will be no refunds necessary.
(Thanks to
therapist Kevern Hartmann for providing the framework for this piece and
forcing me to
research the appeal process. I would ask any reader
who discovers any errors or changes to the process to
contact me
immediately. Please remember that I am not allowed to provide medical or legal
advice. All I
can do is to read the appropriate regulations and
policies and tell you what my understanding is.)
Robert Weiss,
M.S.
Lymphedema Patient
Advocate
LymphActivist@aol.com
--------------------------------------------------------------------------------------------
Abstracted
this from an article in the San Francisco Chronicle. This applies to denials of
compression
bandages, garments and devices, which are medically
required in the treatment of lymphedema.
Bob Weiss
Medical care's
state of denial
Victoria Colliver, Chronicle Staff Writer
Monday,
June 23,
2008
http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/06/22/MNUK11C28G.DTL&tsp=1
What
to do if you are denied medical care
If your health insurance carrier is
refusing to approve treatment recommended by your doctor, you have a
number
of options. First, contact your health plan. You probably will have to go
through the plan's internal
grievance process first. If time is of
the essence, ask for an expedited review through the state.
Tips to help
you get the care you need:
-- Review your health plan policy. Many
are available online.
-- Make sure your doctor is aware of your problem.
Sometimes the initial denial comes from the medical
group, which is
charged with managing costs. In any case, your doctor's support is
important.
-- Request the reason for the denial in writing. Take
detailed notes of all conversations, including the date
and time of
the call and the name of the person you speak with. Save copies of all
paperwork, and keep
these records in chronological order.
--
Act soon. If you wait longer than six months, you could lose the right to file
a complaint, ask for an
independent medical review (also called an
IMR), or take other action against your health plan such as
arbitration or a lawsuit. An IMR decision is binding on the health
plan, but not the
patient.
-------------------------------------------------------------------------------------------
NHIC
Provider Education, Medicare Part B
Expiration of Therapy Cap
Exceptions
The exceptions to outpatient therapy caps expire on June 30,
2008. Outpatient therapy service providers
should not submit
claims with the KX modifier for services furnished on or after July 1, 2008.
To the
extent possible, CMS is working with Congress, health care
providers, and the beneficiary community to
avoid disruption in
the delivery of health care services and payment of outpatient physical
therapy,
occupational therapy and speech-language pathology claims
for services furnished by physicians, non-
physician
practitioners, and therapists paid under the physician fee schedule, beginning
July 1.
For physical therapy and speech language pathology services
combined, the limit on incurred expenses is
$1810. For
occupational therapy services, the limit is $1810. Deductible and coinsurance
amounts
applied to therapy services count toward the amount
accrued before a cap is reached. Therapy cap
accruals began on
January 1, 2008, and some patients may have reached the annual limits by June
30,
2008.
Providers may access the accrued amount or
remaining amount of therapy services from the Medicare
beneficiary
eligibility inquiry and response transactions. Specifically:
o For CWF
users, the system returns the “applied” amount. See CR4115 at http://www.cms.
hhs.
gov/transmit tals/downloads/ /R759CP.pdf
o For users of the
HETS 270/271, the system returns the “remaining” amount. See the page 18 of the
270/271 user guide at http://www.cms. hhs.gov/HETSHelp
/Downloads/ HETS%20270- 271%20User%
20Compan ion%20Guide. pdf
o The Medicare contractors' Interactive Voice Response units (IVR) return
either the remaining or applied
amounts based upon contractor
programming. For those few contractors that do not provide this
information on their IVRs, providers can call the contractors' customer
service representatives.
For additional information, Providers and
Suppliers should also read the Medicare Claims Processing
Manual,
chapter 5, section 10. 2 at http://www.cms. hhs.gov/manuals/ downloads/
clm104c05TXT. pdf
Patients Who Have Reached Their Limit(s) on Outpatient
Therapy Services:
Note that patients who have reached their limit(s) on
outpatient therapy services, other than those who
reside in a
Medicare-certified part of a skilled nursing facility, may obtain medically
necessary therapy
services that exceed the caps if the services
are furnished and billed by the outpatient department of a
hospital. In other settings, outpatient therapy services in excess of
the caps are not covered, and the
therapy provider may charge for
those services. An Advance Beneficiary Notice is recommended, but not
required for services that exceed therapy caps.
An ABN is
available at the following link: http://www.cms. hhs.gov/BNI/ 02_ABNGABNL.
asp#TopOfPage (click on ABN-CMS-R-131 Form). In the box titled
"Reason Medicare will not pay"
the following language is suggested
Medicare will not pay more than $1810 for expenses incurred for
physical therapy and speech-language pathology services combined or
for occupational services in 2008.
Patients may be referred to this
website for further information:
http://www.medicare .gov/Publication
s/Pubs/pdf/ 10988.pdf which will be activated by July 3, 2008.
We will
continue to be in communication with you with further information about payment
of Medicare
physician fee schedule claims. In addition, be on the
alert for more information about other legislative
provisions
which may affect you.
Reference: JSM/TDL-08387;
7/3/2008
----------------------------------------------------------------------------------
Extension
of Therapy Cap Exceptions
July 16, 2008
The Medicare
Improvements for Patients and Providers Act of 2008 was enacted on July 15,
2008. One
provision of this legislation extends the effective date
of the exceptions process to the therapy caps to
December 31, 2009.
Outpatient therapy service providers may now resume submitting claims with the
KX
modifier for therapy services that exceed the cap furnished on
or after July 1, 2008.
For physical therapy and speech language
pathology services combined, the limit on incurred expenses is
$1810 for calendar year 2008. For occupational therapy services, the
limit is $1810. Deductible and
coinsurance amounts applied to
therapy services count toward the amount accrued before a cap is
reached. Services that meet the exceptions criteria and report the KX
modifier will be paid beyond this
limit.
Before this
legislation was enacted, outpatient therapy service providers were previously
instructed to not
submit the KX modifier on claims for services
furnished on or after July 1, 2008. The extension of the
therapy
cap exceptions is retroactive to July 1, 2008. As a result, providers may have
already submitted
some claims without the KX modifier that would
qualify for an exception.
Providers submitting these claims using the
837 institutional electronic claim format or the UB-04 paper
claim
format would have had these claims rejected for exceeding the cap. These
providers should resubmit
these claims appending the KX modifier so
they may now be processed and paid. Providers submitting
these
claims using the 837 professional electronic claim format or the CMS-1500 paper
claim format would
have had these claims denied for exceeding the
cap. These providers should request to have their claims
adjusted
in order to have the contractor pay the claim.
In all cases, if the
beneficiary was notified of their liability and the beneficiary made payment
for services that
now qualify for exceptions, any such payments
should be refunded to the
beneficiary.
---------------------------------------------------------------------------------------
Seven
Mistakes to Avoid When Seeking Social Security Disability BenefitsAllsup
outlines missteps that can
be obstacles when applying for SSDI
benefits.Belleville, Ill. (Vocus) July 11, 2008 -- People with severe
disabilities
know what it means to wait. They wait medical test results; they wait doctors’
diagnoses and they
wait for answers to their questions about the
future. Delays are typical for people filing for Social Security
Disability Insurance
(http://allsup.com/About-SSDI/Free-SSDI-Evaluation.aspx) (SSDI) benefits, but
there
are ways to avoid common mistakes that make the process even
more difficult to navigate, according to
Allsup
(http://allsup.com/Home.aspx). Founded in 1984 and headquartered near St.
Louis, Allsup
represents people nationwide for their entitled SSDI
benefits.Two-thirds of all SSDI applicants will have
their initial
claim denied. If they appeal, and even if they are successful, they will go
through several
additional steps and may wait two years or longer
before they ev er see a disability payment. There are
some
missteps, however, that can actually add time and increase the delay for an
SSDI award, according to
Allsup.“Social Security disability
payments are a significant, and often the sole, income source for millions of
individuals with disabilities and their families,” said Edward
Swierczek (http://www.allsup.com/About-
Us/News-Room/Resources-for-Journalists/Allsup-Experts/Edward-Swierczek.aspx),
senior claimant
representative with Allsup. “Unfortunately, people
with disabilities often make mistakes in applying for their
SSDI
benefits. This may result in even more delays, which puts more stress on what
could already be a
precarious financial situation.”To help educate
claimants, Allsup provides the following information on seven
common mistakes people make when filing for SSDI benefits.Seven Common
Mistakes When Filing for
SSDI1. Going into the process uneducated.
Some people believe it’s just a matter of filling out a few forms,
sending them in and waiting for their checks. They would be surprised
to find out just how complicated the
SSDI process really is. The
Social Security Administration follows a five-step sequential evaluation
process
to determine if an individual qualifies for disability
benefits (http://allsup.com/About-SSDI/Why-You-Want-
SSDI.aspx),
explained Swierczek, including:* You must not be gainfully employed, which
is defined as
earning $940 a month or more, * Your condition is
severe, meaning it interferes with basic activities of
work, *
Your condition is on the Social Security Administration’s list of disabling
conditions, or medically
equals one of the disabling conditions on
the list, and you will be disabled for more than 12 months, * You
are not able to do the work you had been doing before the impairment,
and, * You can’t perform any
other type of work. “You have to
meet the first two criteria before the Social Security Administration will
consider your claim,” said Swierczek, who has more than 30 years of
experience helping individuals through
the complexities of the SSDI
application process (http://allsup.com/About-SSDI/SSDI-Process.aspx). “If
you’re a 40-year-old ironworker who hurt your back, the Social Security
Administration may find that you
are not disabled if you can do
desk work. You may not think you can, but if you don’t provide compelling
evidence20why you can’t, they will deny your claim,” he said.2. Going
through the SSDI process alone.
Individuals who apply for Social
Security Disability Insurance benefits (http://www.allsup.com/About-
SSDI/Choosing-Representation.aspx) without representation are more
likely to have their claim denied.
“Working with government
agencies and understanding the nuances of what’s needed to comply with the
regulation isn’t something the average person is aware of,” said Allsup
senior claimant representative David
Bueltemann
(http://www.allsup.com/About-Us/News-Room/Resources-for-Journalists/Allsup-
Experts/David-Bueltemann.aspx), who has successfully represented
thousands of SSDI applicants.“Just as
people hire accountants to
complete their tax returns and represent them before the Internal Revenue
Service if they’re audited, individuals are recognizing they need
representation when they go into the Social
Security Disability
Insurance process,” he added.3. Underestimating the impact of your disability.
Sometimes pride leads people to underplay the extent of their
disabilities because they have endured a
condition so long that they
have learned how to cope with the stress of daily life. But many people
underestima te how much their disability affects their day-to-day
lives. A good example, Bueltemann
explained, is a 50-year-old
grandmother who tells the state Disability Determination Service (DDS) that she
takes care of her grandchildren. If the woman doesn’t explain that
the children are teen-agers and self-
sufficient, the DDS may deny
her claim because it believes that she is capable of working in a day care
center.4. Exaggerating the impact of your disability. On the other end
of the spectrum are people who want
to make their condition appear
worse than it is. For example, a man who uses a cane at a hearing before an
administrative law judge but doesn’t normally use a cane would be
over-representing his condition. “If the
judge asks to look at the
cane and sees the tip is not worn, the claim is immediately suspect, even
though the
claimant may have had a legitimate case if he’d just
stuck to the unexaggerated truth,” Swierczek explained.
“It is
important to elaborate, but not exaggerate.”5. Being vague about your work
history. Knowing what
the expectations are for your work, and
showing accurately from the outset why you can’t perform this
work
any longer, is an essential part of qualifying for SSDI benefits
(http://www.allsup.com/About-
SSDI/SSDI-Guidelines-by-Disability.aspx). For example , Swierczek said,
a service technician might be
required to drive for extended
periods as part of the job. “If your impairment means you can only drive for
10 minutes without experiencing extreme pain, yet your job requires
you drive in 60-minute stretches, you
need to make it clear on your
disability application what the work expectations are and what your limitations
are,” said Swierczek. “Otherwise, you may end up in double jeopardy:
Your disability claim is rejected
because the Social Security
Administration believes you can still perform your work,” he said. “But you’re
out of work because you really can’t meet the requirements of the
job.”6. Missing the appeals deadline. The
Social Security
Administration denies more than 60 percent of all initial SSDI applications,
but there is a
formal appeals process with three levels. If you are
rejected at any level, you have only 60 days to appeal to
the next
level. If you miss the deadline, you need to start the process from the
beginning. If you’ve applied
on your own and received a denial,
it’s not too late to choose an SSDI representative (http://www.allsup.
com/Allsup-Representation/How-It-Works-At-Allsup.aspx),
such as Allsup, to handle the appeal and
continue with your case.
Taking this step may make the differenc e in experiencing further delays to
receiving
your SSDI benefits.7. Giving up. The process can be
excruciatingly long and cumbersome. Nearly 750,000
people are
waiting for a hearing before an administrative law judge, which is only one
level of the SSDI
appeals process. For individuals already facing
significant physical or mental disabilities, this delay can add
to
the difficulty. Bueltemann, however, is quick to point out that receiving SSDI
is a benefit that individuals
with disabilities and their families
have earned, if they meet the SSDI requirements. An SSDI award also is
essential in securing other forms of financial support, including
Medicare benefits (http://www.allsup.
com/Financial-Matters/Managing-Healthcare-Costs/Medicare.aspx) and
retirement protection. “It may not
be as easy as it should be to
receive your payments, but don’t give up,” Bueltemann said. “Make sure you
have good representation and don’t lose hope that you can secure your
benefits.”ABOUT ALLSUPAllsup,
Belleville, Ill., is a leading
nationwide provider of financial and healthcare related services to people with
disabilities. Founded in 1984, Allsup has helped more than 100,000
people receive their entitled Social
Security Disability Insurance
and Medicare benefits. Allsup employs more than 500 professionals who
deliver
se rvices directly to consumers and their families, or through their employers
and long-term disability
insurance carriers. For more information,
visit www.Allsup.com.Contacts: Allsup - Rebecca Ray(800) 854-
1418,
ext. 5065 Dan Allsup, ext.
5760.
----------------------------------------------------------------------------------------
I
have no idea if this is good or not, cause if the cap is 1810, my
therapy
for less than 2 weeks 3 years ago was almost $9,000 so what
good is 1810?
Well I hope this does help someone out there and that
it is a good
thing.
If you are on Medicare and are provided lymphedema treatment
by a Medicare-approved physical
therapist, you do not pay (except
for deductables and 20% co-pay) for the service up to $1800. The
therapist is not alowed to charge any more, and (s)he is reimbursed by
Medicare. The reimbursement rates
vary from state to state, but run
about $25 per unit, with 3-4 units per visit, that provides about 15-20
visits.
But this annual limit has been suspended for many years by
Congress, but is now back in place. But
Congress has also said that
in cases where there is a medical necessity for more than the capped amount per
year, there would be an exception process for certain conditions.
Last year lymphedema was on the list of
exception conditions, so
the limit did not apply. But starting July 1, the exception process
expired.
This new law just put the exception process back. That's good,
since if you need more than 15-20
treatments in any one year for
your lymphedema, you can have them justified.
I have no idea how your
therapist charged you $9,000 for a course of lymphedema treatment. Did that
cost
include bandages or garments (not covered by
Medicare)?
Bob Weiss
Lymphedema Patient
Advocate
-----------------------------------------------------------------------------------
Bob...
I just got a new prescription for Compression hose... I have never worn any...
I just can't afford them
right now.. I had one RX but did not even
try to get them because I knew that I could not afford them.. I am
on Medicaid.. should I try with this RX and then when I get turned down
then try the appeals process or
should I wait until I can afford a
pair and then try and after I have to pay for them go for an appeal? I really
just can't afford them.. I can't afford my treatment at all.. so I
am just waiting in limbo right now... It is a little
hard to do
when I get fluid in my knees and can't stand up on my own at times... any
advice???? Thanks,
Marbeth :)
Marbeth,
Find a
Medicare approved supplier and give them a copy (you keep the original) of the
doctor's prescrition
and ask them to request an advanced approval to
Medicaid and to Medicare if you are on both. It will be
denied, but
you will then have something to appeal and a claim number that can be tracked.
The prescription
should clearly state that the stocking is
necessary to treat your lymphedema, with the appropriate diagnostic
code.
Bob
Weiss
----------------------------------------------------------------------------------
By
accepting the denial of treatment or a compression garment on the basis of the
the letter of denial which
says it is not covered, we allow this
insurance travesty to continue. Appeal each and every denial of
lymphedema treatment. If you run into what appears to be a brick wall
contact me and I'll see how to
approach an appeal.
Bob
Weiss
Lymphedema Treament
Advocate
=================================================================
San
Francisco Chronicle Examines Health Insurance Claim Denials
The San
Francisco Chronicle on Monday examined how "[e]ach year, thousands of
Californians find
themselves at odds with their health insurers
over whether they, as patients, should get the treatment their
doctors prescribed."
Insurers say that physicians do not always
prescribe the most cost-effective treatments. Anthem Blue Cross
says it follows strict protocols in denying care and relies on medical
evidence to determine what care is
appropriate. Michael Belman,
Anthem's medical director, said, "Even in a dire situation, it is ethically
appropriate to withhold treatment if it's not effective." Alan Sokolow,
chief medical officer for Blue Shield of
California, said, "We
think that is our job -- to help patients and providers apply the benefit
package the
patient has, the dollars they put for insurance
coverage and health care, in the most appropriate and effective
way," adding that patients should appeal denials if they
disagree.
According to the Chronicle, in 2007, the state's HMO Help
Center received about 90,000 calls from
individuals with health
insurance disputes. The majority of disputes involved whether treatment or
procedures prescribed by physicians were "medically necessary" or
considered "experimental" or
"investigational." The state
Department of Insurance, which regulates a smaller number of insurance plans,
received 35,280 complaints and resolved 262 independent medical
review cases in 2007. The Department
of Managed Health Care since
2001 has offered third-party medical reviews and has resolved 1,716 IMRs
since 2007. According to DMHC, roughly 40% of decisions are settled in
favor of the patient.
Jerry Flanagan, health advocate for Consumer
Watchdog, said that issues arise because health insurers "are
going
back to the old strategies of the '90s, when they interrupted care on the front
end by denying or
delaying treatment offered by a doctor." He said
insurers hope patients will not dispute the decisions or
settle for
less, in order to save money -- a statement that insurers dispute.
The
Chronicle also profiled the cases of three individuals whose claims were denied
by insurers (Colliver,
San Francisco Chronicle,
6/23).
------------------------------------------------------------------------------
Analysis
Examines Cost Of Employer-Sponsored Health Coverage; Report Looks At Medicare
Part D
Plan
Changes; More
http://www.medicalnewstoday.com/articles/130355.php
Connecticut
Attorney General Calls For Rebidding Of State Health Insurance Programs,
Governor Says
Move Is Unnecessary
http://www.medicalnewstoday.com/articles/130352.php
Michigan
Attorney General Says Lawmakers Should Not Pass Health Insurance Legislation In
Lame-Duck
Session
http://www.medicalnewstoday.com/articles/130351.php
Average Annual
Deductible For Individual Employer-Sponsored PPO Now Over $1,000, According To
Survey
http://www.medicalnewstoday.com/articles/130349.php
AHIP, BCBS Say
They Support Guaranteed Coverage For People With Pre-Existing Health
Conditions,
As Long As All Individuals Required To Obtain
Cover
http://www.medicalnewstoday.com/articles/130344.php
Senate Leaders
Hold Closed-Door Meeting To Discuss Health Care Overhaul
Legislation
http://www.medicalnewstoday.com/articles/130342.php
Obama Appoints
Former Sen. Daschle As HHS Secretary, Democratic Officials
Say
http://www.medicalnewstoday.com/articles/130341.php
Board Adopts
Recommendations To Overhaul Oregon Health Care System
http://www.medicalnewstoday.com/articles/130146.php
AARP Hires
Outside Investigator To Examine Sales Of Limited-Coverage
Plans
http://www.medicalnewstoday.com/articles/130138.php
President-Elect Obama Likely To
Pick CBO Director Orszag As Director Of U.S. Office Of Management
And Budget
http://www.medicalnewstoday.com/articles/130135.php
Automaker
Bankruptcies Would Require Taxpayers To Pay $3B Annually For Health Care, UAW
President Gettelfinger Says
http://www.medicalnewstoday.com/articles/130133.php
Sen. Kennedy
Taps Senators To Lead Various Working Groups Aimed At Improving U.S. Health
Care
http://www.medicalnewstoday.com/articles/130132.php
Several Recent
Editorials, Opinion Pieces Address Health Care Reform
http://www.medicalnewstoday.com/articles/129958.php
New York Times
Editorial Calls U.S. Chronic Disease Care 'Abysmal'
http://www.medicalnewstoday.com/articles/129956.php
Kaiser Daily
Health Policy Report Feature Highlights Recent Blog Entries
http://www.medicalnewstoday.com/articles/129955.php
Connecticut
Gov. Rell Keeps HUSKY Kids Insurance Program Separate From Adult Coverage
Program
http://www.medicalnewstoday.com/articles/129954.php
Growing Number
Of Companies Provide On-Site Health Care Services For
Workers
http://www.medicalnewstoday.com/articles/129949.php
Coalition Of
National Organizations Urges Steps To Reduce Health Care Costs, Improve
Quality
http://www.medicalnewstoday.com/articles/129948.php
Sen. Edward
Kennedy Plans To Introduce Universal Health Care Bill
http://www.medicalnewstoday.com/articles/129943.php
Health
Insurance Premiums Rise Up To 33 Percent With State Pricing Rule,
USA
http://www.medicalnewstoday.com/articles/129802.php
Boston Globe
Examines Discrepancies In Massachusetts Hospitals' Insurance Reimbursement
Payments
http://www.medicalnewstoday.com/articles/129763.php
New York
Attorney General Investigates Relationships Between Colleges, Health Insurers
That Cover
Students
http://www.medicalnewstoday.com/articles/129760.php
Wall Street
Journal Examines Steep Health Plan Premium Increases For Many Sm Businesses In
2009;
New York Times Examines High-Deductible Health
Plans
http://www.medicalnewstoday.com/articles/129759.php
President-Elect Barack Obama,
Congressional Democrats Frame Health Care, Other Proposals As Job-
Creation Plans
http://www.medicalnewstoday.com/articles/129756.php
Study Shows
Half Of Individual Health Insurance Policy Holders Paid Under $130 Per Month,
USA
http://www.medicalnewstoday.com/articles/129651.php
Briefs
Highlight Issues Involving Integration Of Mental Health Services In Health
Reform; Statehealthfacts.
org Adds New, Updated Data;
More
http://www.medicalnewstoday.com/articles/129570.php
Arizona
Rejects Ballot Measure To Make Mandated Health Coverage
Illegal
http://www.medicalnewstoday.com/articles/129566.php
Philadelphia
Inquirer Series Examines Health Care Delays For Patients Without Health
Insurance
http://www.medicalnewstoday.com/articles/129563.php
PhRMA To
Launch Ad Campaign Lauding Free-Market Health Care System; SEIU Pushes For
Health
Reform
http://www.medicalnewstoday.com/articles/129560.php
-------------------------------------------------------------------------------------------------
EE
page 11 --
topic 08.71
Garments to be discussed :
FLEXITOUCH.
We need to continue to contact our local politicians to
continue to push for
all lymphedema garments expenses to be
covered!
Thanks Lisa for the heads-up.
This request is for Medicare
Codes for the body garments used with the Flexitouch pneumatic compression
controller. They are coded as "durable medical equipment" since they are
used in conjunction with a piece of
durable medical equipment. This
ruling will in no way affect coverage of compression bandages or garments,
which are a different Medicare benefit category (i.e. "prosthetic
devices").
I'm afraid that while contacting our local politicians serves
a valuable educational function, it will not achieve
coverage
without either a new law or by forcing CMS to re-interpret the current law. And
to do the latter,
there must be a ground-swell of appeals from
lymphedema patients who are denied coverage for their
garments.
I will make this offer: If you file a claim for the
garments or bandaging kits that you paid for in the last couple
of
months, when the denial comes from your insurance company or from Medicare, I
will help you file the
three appeals necessary to reach an
Administrative Law Judge. At this point you have a good chance of
being reimbursed. I do not charge for this help. I'm trying to get
favorable decisions from as many different
ALJs as I can. Then I
will confront CMS for a change in their interpretation of the Social Security
Act.
I will also help your Congressional representative draft and
introduce a bill to change Medicare, if you can
interest him or her
in your cause.
Robert Weiss, M.S.
Lymphedema Treatment
Advocate
National Lymphedema
Network
-------------------------------------------------------------------
There
have been recent "clarifications" to the "incident to" physician services rules
which may impact
provision of therapy services for some lymphedema
therapists. The changes to the policies are summarized
in
http://www.cms. hhs.gov/MLNMatte
rsArticles/ downloads/ MM5288.pdf
with the
full-text policy revisions given in
http://www.cms. hhs.gov/Transmit
tals/downloads/ R87BP.pdf
-------------------------------------------------------------------------------------------
Settlement
to Ease Drug Costs for Some on Medicare
By ROBERT
PEAR
http://www.nytimes.com/2008/06/20/health/policy/20drug.html?_r=1&ref=health&oref=slogin
Published:
June 20, 2008
WASHINGTON - The Bush administration promised on Thursday to
provide new
protections for low-income Medicare beneficiaries to ensure they
can get
prescription drugs promptly, at minimal cost.
The promise
came in the proposed settlement of a nationwide class-action lawsuit
filed
on behalf of hundreds of thousands of people who have had difficulty
getting
the medicines they need.
Under the 2003 Medicare law, more than six
million people eligible for both
Medicare and Medicaid are entitled to extra
help with their drug costs. But in
many cases, they could not get the
assistance, so they did not receive the drugs
they needed, or they
experienced long delays.
In early 2006, low-income beneficiaries were
often overcharged, and some were
turned away from pharmacies without getting
their medications. Several states
declared public health emergencies, and
many stepped in to pay for prescriptions
that should have been covered by
the federal Medicare program.
Under the proposed settlement, filed
Thursday with the United States District
Court in San Francisco, federal
Medicare officials promised to speed up the
process of providing extra help
to low-income people, who now could qualify
within days, rather than weeks
or months.
Drug benefits are delivered by private insurers under
contract to Medicare.
Under the settlement, these insurers will have to
provide medications at minimal
cost for any Medicare recipients who prove
they have low incomes and qualify for
extra help.
For most people
with incomes less than the poverty level ($10,400 a year for an
individual),
the maximum co-payment is $1.05 for a generic or preferred
brand-name drug
and $3.10 for other prescription drugs.
But many beneficiaries have been
asked to pay much higher amounts, from $30 to
$75 or more, because the
evidence of their low-income status was not properly
shared among federal
and state agencies, insurance companies and pharmacies.
"This settlement
agreement is a victory for many of the nation's most vulnerable
citizens,
who have faced life-threatening delays in obtaining vital
medications," said
Kevin Prindiville, a lawyer at the National Senior Citizens
Law Center,
which filed the lawsuit with another nonprofit group, the Center
for
Medicare Advocacy.
Gill Deford, a lawyer at the Center for
Medicare Advocacy, said the settlement
would "help hundreds of thousands of
people a year get their prescription drugs
more quickly, at nominal
cost."
Jeff Nelligan, a spokesman for the federal Centers for Medicare
and Medicaid
Services, said federal officials had "worked tirelessly" to
ensure that Medicare
recipients could fill their prescriptions. He refused
to comment on the
substance of the settlement, noting that it was subject to
approval by Judge
Thelton E. Henderson of Federal District Court in
California.
States administer the Medicaid program. They have crucial
information showing
whether Medicare beneficiaries are also enrolled in
Medicaid and therefore
eligible for extra help with their drug
costs.
Under the settlement, if a beneficiary claims to be eligible for
the low-income
subsidy but does not have the documents to prove it, and if
the person is about
to run out of a medication, federal officials would
immediately contact the
state Medicaid agency to check whether the person
had been on
Medicaid.
--------------------------------------------------------------------------------
News
from New York State
Assemblyman ALAN N. MAISEL
59th ASSEMBLY
DISTRICT
Date: June 23, 2008
Assembly Passes Maisel
Measure To
Raise Awareness of Lymphedema
Today, in Albany,
Assemblyman Alan Maisel (D-Kings County) announced passage in the Assembly of
legislation to promote lymphedema and lymphatic disease reporting
and awareness (A05892B). TThe
measure requires health care
providers, who are already required to report cases of cancer or oother
malignant disease, to also report instances of lymphedema related to
cancer treatment in their patients. This
legislation also requires
the Department of Health to develop a health care and wellness education and
outreach program for those seeking information on either primary or
secondary lymphedema.
"Lymphedema is not a high profile disease like
cancer or diabetes that generates a lot of press or mmoney
for
research, yet it affects an estimated six million men, women and children in
the United States," stated
Maisel. "The lymphatic system is vital
to the health of every individual as it is an integral part of tthe immune
system.” Lymphedema is an accumulation of lymphatic fluid that causes
painful, disfiguring sswelling, usually
in the arms or legs. There
are two major types of lymphedema: primary (congenital) and ssecondary (caused
by tissue injury, scarring, lymph node removal, or
infection).
"The largest group of people who acquire secondary
lymphedema arc cancer patients, including those with
breast,
prostate, lung, and melanoma patients," stated Maisel. "This bill helps to
ensure that when
lymphedema is acquired from the life-saving cancer
treatments, these instances of disease are also rreported
to the
cancer registry. This will help raise awareness of the disease and hopefully
increase the mmoney
raised to fund additional research to help find
the cause of and cure for lymphatic diseases, lymphedema,
and
related disorders."
"It amazes me that despite the essential role the
lymphatic system plays in human health, awareness,
education and
research have been relatively neglected," stated Maisel. "This lack of focus
has created
barriers to effective delivery of health care and
public education about these diseases, its diagnosis,
treatment,
therapy and long-term care. This legislation, which is on third reading in the
Senate, is just the first
step in raising public awareness about
lymphedema."
=======================================================================
To
lymphedema patients, therapists and activists:
A wonderful article on
lymphedema was printed in the prestigious cancer journal "CA A Cancer Journal
for
Clinicians" [CA Cancer J Clin 2009;59;8-24] written by by Brian
D. Lawenda, Tammy E. Mondry and
Peter A. S.
Johnstone.
"Lymphedema: A primer on the identification and management of
a chronic condition in oncologic treatment"
can be downloaded from
URL <http://caonline.amcancersoc.org/cgi/reprint/59/1/8>
An
accompanying description of lymphedema and its treatment can also be downloaded
at the same source
from URL <http://caonline.amcancersoc.org/cgi/content/full/59/1/25>
I
urge all of the readers of this message to download these references, print
them out, and bring copies to
your physicians, oncologists, and
medical and insurance staffs. This is a well written and authoritative
reference which should be brought to the attention of all medical
providers and insurers.
Robert Weiss, M.S.
Lymphedema Treatment
Advocate
National Lymphedema
Network
=======================================================================
Written
Clarification on Medicare for Patients and Providers Act of 2008
(MIPPA)
MIPPA section 154(b) added a new subparagraph (F) to
section 1834(a)(20) of the Social Security Act.
This subparagraph
states that eligible professionals and other persons are exempt from meeting
the
September 30, 2009 accreditation deadline that generally applies
to other DMEPOS suppliers unless
CMS determines that the quality
standards are specifically designed to apply to such professionals and
persons.
The eligible professionals to whom this
exemption applies are set out at sections 1848(k)(3)(B) and 1861(r)
of the Act, and include Physicians, Physical Therapists, Occupational
Therapists, Qualified Speech-
Language Pathologists, Physician
Assistants, and Nurse Practitioners.
Additionally, section
154(b) of MIPPA allows the Secretary to specify “other persons” that, like the
eligible
professionals described above, are exempt from meeting the
accreditation requirements unless CMS
determines that the quality
standards are specifically designed to apply to such other persons. At this
time,
we are defining “such other persons” as Orthotists,
Prosthetists, Opticians, and Audiologists.
CMS will define how
the quality standards apply to these eligible professionals and other persons
by
rulemaking in 2009.
Individuals not included in
this exemption list, such as pedorthotists, mastectomy fitters, orthopaedic
fitters/
technicians or athletic trainers applying for Medicare
enrollment in order to bill for Medicare part B services
are not
exempt from meeting the September 30, 2009 deadline for DMEPOS
accreditation.
-----------------------------------------------------------------
New
HCPCS Codes
The following new codes are effective for dates of service
on or after January 1, 2009. If billed before
January 1, 2009, the
code will be returned as unprocessable or denied as an invalid code. The
appearance
of a HCPCS code in the list below does not necessarily
indicate coverage.
HCPCS Code
Description
A6545
GRADIENT
COMPRESSION WRAP, NON-ELASTIC, BELOW KNEE, 30-50 MM HG,
EACH
E0656
SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC
COMPRESSOR,
TRUNK
E0657
SEGMENTAL PNEUMATIC APPLIANCE FOR
USE WITH PNEUMATIC COMPRESSOR, CHEST
Verbiage Changes for
2008
The following list contains HCPCS codes for which verbiage will be
changed effective January 1, 2009.
L4360
WALKING BOOT, PNEUMATIC
AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR
WITHOUT INTERFACE
MATERIAL, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
=======================================================================
December
05, 2008
The Advance Beneficiary Notice of Noncoverage (ABN) and Correct
Use of Modifiers GA and GY -
Revised
Both Medicare
beneficiaries and durable medical equipment, prosthetics, orthotics, and
supplies
(DMEPOS) suppliers have certain rights and protections
related to financial liability under the Fee-for-
Service (FFS)
Medicare program. These financial liability and appeal rights and protections
are
communicated to beneficiaries through Advance Beneficiary
Notices of Noncoverage (ABN) given by
suppliers.
An ABN is a
written notice the supplier gives to a Medicare beneficiary before providing
items and or
services that are expected to be denied by Medicare
based on one of the following statutory exclusions:
1. The item or
service may be denied as "not reasonable and necessary" pursuant to Section
1862(a)(1)
of the Social Security Act
2. The item or
service may be denied due to an unsolicited telephone contact pursuant to
Section 1834(a)
(17)(B)
3. The supplier number
requirements not being met pursuant to Section 1834(j)(1)
4. Denial
of a request for Advance Determination of Medicare Coverage (ADMC) pursuant to
Section
1834(a)(15)
When an item or service is provided to a
Medicare beneficiary and is expected to be denied based on one
of
the four exclusions listed above, it is the responsibility of the supplier to
notify the beneficiary in writing
through the use of the ABN before
the item or service is delivered or purchased. If the supplier issues a
properly executed ABN with Option 1 selected by the beneficiary, the
DMEPOS supplier must submit the
claim to Medicare using the GA
modifier on each Healthcare Common Procedural Coding System
(HCPCS)
code that is expected to be denied. The GA modifier indicates that the supplier
has a waiver of
liability statement on file.
Statutorily
Excluded Items
The GY modifier indicates that an item or service is
statutorily excluded or does not meet the definition of
any Medicare
benefit. Some local coverage determinations (LCD) require the use of the GY
modifier when
the item or service may be excluded from coverage. In
this situation, suppliers are instructed to code the
claim with the
appropriate HCPCS code indicated in the LCD and append the GY modifier. Some
examples of statutory exclusions where the GY modifier is required
per policy would include:
• An infusion drug not administered using
a durable infusion pump
• A wheelchair that is for use for mobility
outside the home
To determine if an exclusion of Medicare benefits
exist, suppliers must review the applicable LCD and
policy article
for the item or service being provided.
Suppliers are reminded that
modifiers GA and GY should never be coded together on the same line for the
same HCPCS code. It is important to distinguish situations in which an
item is denied because it is statutorily
excluded or does not meet
the definition of any Medicare benefit from those situations in which at item
is
denied because it is not reasonable and necessary. Some examples
of statutorily excluded items or situations
include, but are not
limited to:
• eyeglasses or contact lenses-except those provided
following cataract removal or other cause of
aphakia;
•
Durable Medical Equipment and related accessories and supplies provided to
patients in nursing
facilities;
• personal comfort items;
and
• orthopedic shoes or shoe inserts-other than those covered under
the therapeutic shoes for diabetics
benefit or those that are
attached to a covered leg brace.
Some examples of items or situations
which do not meet the definition of a Medicare benefit include, but are
not limited to:
• Parenteral or enteral nutrients that are
used to treat a temporary (rather than permanent) condition;
•
Enteral nutrients that are administered orally;
• Infusion drugs
that are not administered through a durable infusion pump;
•
Surgical dressings that are used to cleanse a wound, clean intact skin, or
provide protection to intact
skin;
• Irrigation supplies
that are used to irrigate the skin or wounds;
• Immunosuppressive
drugs when they are used for conditions other than following organ
transplants;
• Most oral drugs;
• Oral anticancer drugs
when there is no injectable or infusion form of the drug;
•
Nondurable items (that are not covered under any other benefit category);
•
e.g., compression stockings and sleeves;
• Durable items that are
not primarily designed to serve a medical purpose;
• e.g., exercise
equipment.
To access the LCDs and policy articles, please visit the
DME MAC A Web site at: http://www.
medicarenhic.com/dme click on the
LCDs/Medical Policies link in the left hand navigation under Medical
Review.
Voluntary
Notification
Under the new instruction for the revised ABN, the Centers
for Medicare & Medicaid Services (CMS)
advise that this form
may be used to voluntarily notify Medicare beneficiaries of an expected
noncovered
denial of Medicare payment due to the statutory exclusion
of an item or service, or the item or service not
meeting the
definition of any Medicare benefit.
Section 1848(g)(4) of the Social
Security Act states that items that are categorically excluded from
Medicare benefits (i.e. hearing aids, personal comfort items, etc.) are
not required to be submitted to the
Medicare program by the
supplier. However, if the beneficiary requests the supplier to submit the claim
to
Medicare, the claim should be coded with the designated HCPCS,
however, neither modifiers GA nor GY
are required. The supplier and
the Medicare beneficiary will receive a patient responsibility denial for the
noncovered services.
For additional instruction regarding
the proper execution of an ABN, suppliers are encouraged to review the
CMS Internet-Only Manual Medicare Claims Processing Manual, Chapter 30,
"Financial Liability
Protections," Sections 50 and 60 at:
http://www.cms.hhs.gov/manuals
========================================================================
====================
The official Medicare Contractor or Supplier
position is that compression garments are not covered. In fact
the
policy explicitly states:
• Nondurable items (that are not covered
under any other benefit category);
• e.g., compression stockings and
sleeves;
But recent Administrative Law Judge decisions are that these
compression garments DO meet the statutory
definition of
"prosthetic devices" when they are used in the compression therapy for
lymphedema, and ARE
covered. But until the policies are rewritten
Beneficiaries are forced to pay in advance, sign an ABN Form,
and
make an appeal of the denied claim. Under these conditions note that the
Medicare Supplier MUST file
a claim.
I am available to help
Beneficiaries with their appeals of denied claims.
Robert Weiss,
M.S.
Lymphedema Patient Advocate
National Lymphedema
Network
LymphActivist
------------------------------------------------------------
The
bottom line is that compression bandage systems and compression garments remain
NON-COVERED
in the treatment of lymphedema in the absense of an
open venous stasis ulcer.
A new CircAid garment has been added to the
HCPCS Coding but this below-the-knee device is covered
only in the
presence of an open venous ulcer.
Revisions to the Surgical Dressing LCD
effective January 1, 2009 in the following states:
Connecticut
District
of Columbia
Delaware
Massachusetts
Maryland
Maine
New
Hampshire
New Jersey
New York - Entire State
Pennsylvania
Rhode
Island
Vermont
Surgical Dressings LCD for Surgical Dressings
(L11471)
Revision Effective Date: 01/01/2009
INDICATIONS AND
LIMITATIONS OF COVERAGE:
Added: Frequency of replacement for compression
wrap (A6545).
Coverage of a non-elastic gradient compression wrap (A6545) is
limited to one per 6 months per
leg. Quantities exceeding this amount will
be denied as not medically necessary. Refer to Policy
Article for statement
concerning noncoverage if the ulcer has healed.
LIGHT COMPRESSION
BANDAGE (A6448-A6450), MODERATE/HIGH COMPRESSION
BANDAGE (A6451,
A6452),SELF-ADHERENT BANDAGE (A6453-A6455),CONFORMING
BANDAGE (A6442-A6447),
PADDING BANDAGE (A6441):
Light compression bandages, self-adherent
bandages, and conforming bandages are covered when
they are used to hold
wound cover dressings in place over any wound type.
Moderate or high
compression bandages, conforming bandages, self-adherent bandages,
and
padding bandages are covered when they are part of a multi-layer
compression bandage system
used in the treatment of a venous stasis
ulcer.
All of these bandages are noncovered when used for strains,
sprains, edema, or situations other
than as a dressing for a
wound.
GRADIENT COMPRESSION STOCKINGS/WRAPS (A6531, A6532,
A6545):
A gradient compression stocking described by codes A6531 or
A6532 or a non-elastic gradient
compression wrap described by code A6545 is
covered when it is used in the treatment of an open
venous stasis
ulcer.
Codes A6531, A6532, and A6545 are noncovered for the following
conditions: venous insufficiency
without stasis ulcers, prevention of stasis
ulcers, prevention of the reoccurrence of stasis ulcers that
have healed,
treatment of lymphedema in the absence of ulcers. In these situations, since
there is
no ulcer, the stockings/wraps do not meet the definition of a
surgical dressing. Gradient
compression stockings described by codes A6530,
A6533-A6544, A6549 and surgical stockings
described by codes A4490-A4510 are
noncovered for all indications because they do not meet the
definition of a
surgical dressing.
A nonelastic binder for an extremity (A4465) is
noncovered for all indications because it does not
meet the definition of a
surgical dressing.
HCPCS CODES AND MODIFIERS:
Added:
A4490-A4510, A6545.
GRADIENT COMPRESSION WRAP (A6545): [This is a Knee
length CircAid used in the treatment of
an open venous stasis
ulcer.]
Coverage of a non-elastic gradient compression wrap (A6545) is
limited to one per 6 months per
leg. Quantities exceeding this amount will
be denied as not medically necessary. Refer to Policy
Article for statement
concerning noncoverage if the ulcer has healed.
Revised: A6010-A6024,
A6196-A6199, A6203-A6215, A6219-A6248, A6251-A6266,
A6407.
APPENDICES:
Revised: Definitions of pressure ulcer
stages.
SOURCES OF INFORMATION AND BASIS FOR DECISION:
Added: Reference
to NPUAP guidelines for pressure ulcer staging.
Article for Surgical
Dressings - Policy Article - Effective January 2009 (A23664)
Revision
Effective Date: 01/01/2009
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT
RULES:
Clarified: Allowance for HCPCS codes which use the term
“kit”.
Added: Coverage statements for compression wraps (A6545).
The
only products that may be billed with code A6545 (non-elastic compression wrap)
are those
which have received a written Coding Verification Review from the
Pricing, Data Analysis, and
Coding (PDAC) contractor and that are posted in
the Product Classification List on the PDAC web
site.
Added:
Noncoverage statement for surgical stockings (A4490-A4510).
CODING
GUIDELINES:
Added: Requirement for PDAC Coding Verification Review for
non-elastic compression
wraps (A6545).
Revised: Changed SADMERC to
PDAC.
==========================================================
The
above all applies to coverage and coverage criteria created by the Social
Security Act, Title XVIII,
section 1861(s)(5) Surgical
Dressings.
Lymphedema compression bandages, garments and devices
functionally meet the definition of the Social
Security Act, Title
XVIII, section 1861(s)(8) Prosthetic Devices, and do not have to meet the
coverage
criteria for surgical dressings.
The undersigned is
not empowered to interpret Medicare statute or Medicare policy, but the above
statements based on my reading of the relevant statutes and CMS
policies are my opinion, and have been
validated by eight U.S.
Medicare Administrative Law Judges in ten separate Medicare
Appeals.
Robert Weiss, M.S.
Lymphedema Patient Advocate
National
Lymphedema
Network
-----------------------------------------------------------------
A
revision to the LCD for Pneumatic Compression Devices (L11503) becomes
effective on January 1,
2009 affecting the following
states:
Connecticut
District of
Columbia
Delaware
Massachusetts
Maryland
Maine
New
Hampshire
New Jersey
New York - Entire State
Pennsylvania
Rhode
Island
Vermont
Pneumatic Compression Devices LCD L11503
Revision
Effective Date: 01/01/2009
INDICATIONS AND LIMITATIONS OF
COVERAGE:
Added: Statement regarding appliances for the chest and
trunk.
HCPCS CODES AND MODIFIERS:
Added: E0656 and E0657:
E0656
SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR,
TRUNK
E0657 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC
COMPRESSOR,
CHEST
Article for Pneumatic Compression Devices
- Policy Article - Effective January 2009 (A37216)
Revision Effective Date:
01/01/2009
CODING GUIDELINES:
Changed: References from SADMERC to
PDAC.
References from DMERC to DME
MAC.
==================================================================
Physician’s Letter and Certificate
of Medical Necessity
July 30, 2002
Mrs. Jane
Patient 555-55-5555 DOB: 06/14/1942
Patient Diagnosis: Chronic
Intractable Lymphedema of the left lower extremity. Her condition is
marked
by severe 4+ edema of the left lower extremity, weeping wounds, and pain
affecting
mobility. The tissue is hard and fibrotic. There is no
discoloration. Mrs. Patient recalled her
mother having difficulty
with lower extremity edema, although she was never diagnosed with
Lymphedema. Mrs. Patient began to experience lower extremity edema
about ten years ago,
after undergoing a hysterectomy, at which time
a lower abdominal, hip-to-hip incision was made,
possibly
interrupting the inguinal lymphatics.
Patient History: Mrs. Patient is also
diagnosed with diabetes, and is Insulin dependent.
Surgical History:
Hysterectomy, October 11, 1992. Laproscopic Gall Bladder Surgery, February,
1972.
Complications Resulting From Lymphedema: In 1996, Mrs. Patient
was treated with oral
antibiotics for cellulitis. In January, 2002,
Mrs. Patient was hospitalized for 14 days for cellulits,
and
weeping wounds.
Previous Treatment:
Elevation 01/93 to present no
results
Exercise 01/93 to present no results
Diuretics 01/93 to
present no results
Graduated Compression Stockings 01/93 to present no
results
MLD and Physical Therapy 03/01 to 04/01 minimal
results
Compression Bandaging 03/01 to 04/01 minimal results
Unna
Boots after January 2002 hospitalization for three months. Dressing changed
weekly. No
results.
At this time I am ordering a Bio
Compression Gradient Sequential Compression Device to be
used at
55mmHg for 2 hours BID for the remainder of her lifetime. This device will
apply
gradient sequential compression, on a thirty second cycle,
thus pushing the excess fluid back into
the vascular system for
removal from the body. She is also to wear the OptiFlow SC during
compression therapy and for nighttime compression. A Gradient pump is
required for Mrs.
Patient as she is unable to tolerate the uniform
compression, and long cycle times, which is
delivered by the
standard sequential pumps. If her condition is not treated effectively, she is
at
risk of her condition worsening, re-occurring cellulitis,
chronic weeping wounds, resulting in
possible multiple
hospitalizations.
Prognosis: Good with effective treatment.
If you
have any questions, please contact me at
702-555-5555.
Sincerely,
Dr. Joe Doctor, M.D.
What to do when
your health plan denies your claim
If your health insurance company
denies your claim and you believe the treatment should be
covered,
first check your policy to see what benefits your plan provides. The Patient
Bill of Rights
requires the policy to contain a description of the
appeals process.
Be sure to send your letter of appeal by registered
mail and have the receipt returned to the
address listed in the
policy.
=================================================================
Insurance
Information
INSURANCE COVERAGE TOOLS
I have compiled some healthcare
insurance codes and healthcare conditions as relating to
Lymphedema
coverage. PLEASE NOTE, These conditions, codes, rulings etc are different from
state to state, insurance plan to inusurance plan and are constantly
changing. Proper
documentation and codes may be crucial in getting
treatment covereage. Please check with your
insurer on the
requirements and restrictions as it concerns lymphedema treatment. The codes
and
medical language should be an asset to your physician or
therapist in putting together the request
for treatment/therapy
coverage or appealing a declination.
Conditions For Insurance Coverage
(taken from various state medicare sources sources): This
coverage
policy was developed to provide medical necessity guidelines for complex
decongestive
physiotherapy for lymphedema.
1. There is a
physician documented diagnosis of lymphedema: and the physician specifically
orders CDP 2. The patient is symptomatic for lymphedema, with
limitation of function related to
self care, mobility and/or
safety. 3. The patient or patient caregiver has the ability to understand
and comply with home care continuation of treatment regimen. 4. The
services are being
performed by a health care professional who has
received specialized training in this form of
treatment.
ICD-9 diagnosis codes:
457.0 - Post-mastectomy
Lymphedema Syndrome
457.1 - Other lymphedema
757.0 - Hereditary
edema of the legs (congenital lymphedema)
CPT Codes:
97001 -
Physical therapy evaluation
97002 - Physical therapy
re-evaluation
97003 - Occupational therapy evaluation
97004 -
Occupational therapy re-evaluation
97110 - Therapeutic procedure, one or
more areas, each 15 minutes: therapeutic exercises to
develop
strength and endurance, range of motion and flexibility
97140 - Manual
therapy techniques (e.g. mobilization/manipulation, manual lymphatic drainage,
manual traction), one or more regions, each 15 minutes
97535
- Self-care/home management training (e.g., activities of daily living (ADL)
and
compensatory training, meal preparation, safety procedures, and
instructions in use of adaptive
equipment)direct one on one contact
by provider, each 15 minutes
Current Facts on Lymphedema in the United
States
Lymphedema is not a widely discussed condition as many in the medical
field are actually quite
blind to its seriousness. That having been
said, the situation has begun to improve as more and
more doctors
and health care professionals are beginning to recognize the importance of
properly
treating this condition. Though insurance companies have
been rather slow on the uptake,
lymphedema treatments are fast
becoming a respected field of medical practice.
Every year millions of
American find themselves suffering from lymphedema. Some of these
cases are primary in nature but the overwhelming majority are acquired
after surgery or radiation
for specific types of cancer; any type
of surgery that removes lymph nodes (like breast cancer
surgery)
could result in lymphedema. Fortunately, doctors are beginning to wise up and
send
afflicted patients to lymphedema therapists so they can get
the help that they need.
Personal devices and services
Businesses are
not required to provide personal devices (such as wheelchairs) , individually
prescribed devices (such as eyeglasses or hearing aids), or
services of a personal nature (such as
assistance in eating,
toileting, or dressing), to customers with disabilities. A business may choose
to provide services like this as a way to attract customers. For
example, some large retail stores
provide electric carts for use by
customers while shopping. Some fancy dress shops provide
assistance
for a customer trying on clothes in the dressing room.
The ADA does not
require these services; it leaves it up to the business to decide what services
it
wants to provide. The ADA simply says a business should provide
the same goods and services to
all of its customers, including
those with disabilities.
--------------------------------
For
those readers who have the military health insurance offered by Tricare For
Life and turn 65,
the coordination of the TFL and Medicare can
become confusing. California Health Advocates
has issued an
informative Information sheet for you. It can be found on
URL:
http://www.cahealthadvocates.org/_pdf/facts/F-002-CHAFactSheet.pdf
Bob
Weiss
---------------------------------
The following website has
been set up by America's Health Insurance Plans (AHIP) to help
consumers through the administrative maze of their healthcare provider.
It provides great
common-sense information to help you with your
appeal of denied medical treatment, and leads
you to state
insurance sites which can help you file a complaint with your state if you get
no
satisfaction from your provider.
http://www.healthclaimappeals.org/
Bob
Weiss
Robert Weiss, M.S.Lymphedema Patient
Advocate
=====================================================================
To
Lymphedema Therapists in CA, NV and HI:
There are two draft local
coverage determinations (LCDs) of interest to the lymphedema
community which are being made available by Palmetto GBA for comment.
Palmetto is the
Medicare Part A/B Jurisdiction 1 Contractor
responsible for issuing the LCDs which govern
Medicare treatment
and billing policy, and which affect reimbursements and allowable
treatment.
These two LCDs are for Outpatient Physical Therapy (DLCD
#28689) and Outpatient
Occupational Therapy (DLCD #28691). They are
available from the Palmetto web page or I can
send a .pdf file to
interested persons who wish to read and comment.
The comment period is
from March 6, 2009 to April 20, 2009.
There will be a number of Open
Meetings to discuss these two LCDs and a number of other draft
LCDs, but the meetings are only 2 hours long and I would advise
submitting comments and
evidence before the meetings so that they
are sure to be considered. Comments are sent to:
Palmetto GBA, Attention
Part A J1 Medical Affairs, P.O.Box 1437, Augusta, GA 30903-1437.
Email Part
A comments to J1A.Policy@Palmetto GBA.com
Palmetto GBA, Attention Part B J1
Medical Affairs, P.O.Box 1476, Augusta, GA 30903-1476. Email Part
B
comments to J1B.Policy@Palmetto GBA.com
The Part A and Part B LCDs are
the same, so I don't know whether it matters which address the comments
are sent to.
The open meetings scheduled are as
follows:
Hawaii: March 5, 2009 8-10AM @ The Queens Medical Center, 1301
Punchbowl Street, Conference
Room 203, Honolulu, HI
96813;
Nevada: March 12, 2009 9-11AM @ Clark County Medical Association,
2590 E. Russell Road, Las
Vegas, NV 89120;
California: March
17, 2009 9-11AM @ Prostate Cancer Research Institute, 5777 W. Century Blvd.,
Suite
800, Los Angeles, CA 90045.
I will be attending the
California meeting and submitting comments. There is a registration process for
these
meetings on the Palmetto web page.
There are a number
of issues I have noted which I plan to comment on and make suggestions for
changes.
These issues include:
A. Omission of a number of
medical diagnoses which are treated with MLD but which are not included in
the list of diagnoses which support treatment. These include codes for
hereditary LE of the lower limbs,
localized swelling, edema of the
eyelid, penis, breast and vulva, vericose veins with edema, etc.
B.
Vasopneumatic Device Therapy is indicated for lymphedema of the extremity, and
should probably
include lymphedema of the torso now that a number
of pump manufacturers have body garments, and the
body garments have
separate HCPCS codes (but are not yet covered).
C. Manual Decongestive
Therapy is described to "reduce lymphedema of extremity" and should not be
limited to the extremity. See A above.
D. Some clarification is
needed for billing for education on exercise.
E. Fitting of compression
garments is not mentioned.
F. It is not clear which protocol (if any) might
include education on wearing and care for compression
garments,
specialized exercises, use of lasers, etc.
I'm sure that the therapists
who read this note will have many additional clarifications they'd like to have
made. Send them to me and I'll try to include them in the document
I will be submitting at the Open Meeting..
Robert Weiss,
MS
Lymphedema Patient
Advocate
================================================================
Personal
devices and services
Businesses are not required to provide personal devices
(such as wheelchairs) , individually prescribed
devices (such as
eyeglasses or hearing aids), or services of a personal nature (such as
assistance in eating,
toileting, or dressing), to customers with
disabilities. A business may choose to provide services like this as a
way to attract customers. For example, some large retail stores provide
electric carts for use by customers
while shopping. Some fancy dress
shops provide assistance for a customer trying on clothes in the dressing
room.
The ADA does not require these services; it leaves it up
to the business to decide what services it wants to
provide. The
ADA simply says a business should provide the same goods and services to all of
its
customers, including those with
disabilities.
--------------------------------
For those readers
who have the military health insurance offered by Tricare For Life and turn 65,
the
coordination of the TFL and Medicare can become confusing.
California Health Advocates has issued an
informative Information
sheet for you. It can be found on URL:
http://www.cahealthadvocates.org/_pdf/facts/F-002-CHAFactSheet.pdf
Bob
Weiss
---------------------------------
The following website has
been set up by America's Health Insurance Plans (AHIP) to help consumers
through the administrative maze of their healthcare provider. It
provides great common-sense information to
help you with your
appeal of denied medical treatment, and leads you to state insurance sites
which can help
you file a complaint with your state if you get no
satisfaction from your provider.
http://www.healthclaimappeals.org/
Bob
Weiss
Robert Weiss, M.S.Lymphedema Patient
Advocate
=================================================================
Current Facts on Lymphedema in the
United States
Lymphedema is not a widely discussed condition as many in the
medical field are actually
quite blind to its seriousness. That
having been said, the situation has begun to improve as
more and
more doctors and health care professionals are beginning to recognize the
importance of properly treating this condition. Though insurance
companies have been
rather slow on the uptake, lymphedema
treatments are fast becoming a respected field of
medical
practice.
Every year millions of American find themselves suffering from
lymphedema. Some of
these cases are primary in nature but the
overwhelming majority are acquired after
surgery or radiation for
specific types of cancer; any type of surgery that removes lymph
nodes (like breast cancer surgery) could result in lymphedema.
Fortunately, doctors are
beginning to wise up and send afflicted
patients to lymphedema therapists so they can get
the help that
they
need.
================================================================
Insurance
Information
INSURANCE COVERAGE TOOLS
I have compiled some healthcare
insurance codes and healthcare conditions as relating to Lymphedema
coverage. PLEASE NOTE, These conditions, codes, rulings etc are
different from state to state, insurance
plan to inusurance plan
and are constantly changing. Proper documentation and codes may be crucial in
getting treatment covereage. Please check with your insurer on the
requirements and restrictions as it
concerns lymphedema treatment.
The codes and medical language should be an asset to your physician or
therapist in putting together the request for treatment/therapy coverage
or appealing a declination.
Conditions For Insurance Coverage (taken
from various state medicare sources sources): This coverage
policy
was developed to provide medical necessity guidelines for complex decongestive
physiotherapy for
lymphedema.
1. There is a physician
documented diagnosis of lymphedema: and the physician specifically orders CDP
2.
The patient is symptomatic for lymphedema, with limitation of
function related to self care, mobility and/or
safety. 3. The
patient or patient caregiver has the ability to understand and comply with home
care
continuation of treatment regimen. 4. The services are being
performed by a health care professional who
has received
specialized training in this form of treatment.
ICD-9 diagnosis
codes:
457.0 - Post-mastectomy Lymphedema Syndrome
457.1 - Other
lymphedema
757.0 - Hereditary edema of the legs (congenital
lymphedema)
CPT Codes:
97001 - Physical therapy
evaluation
97002 - Physical therapy re-evaluation
97003 -
Occupational therapy evaluation
97004 - Occupational therapy
re-evaluation
97110 - Therapeutic procedure, one or more areas, each 15
minutes: therapeutic exercises to develop
strength and endurance,
range of motion and flexibility
97140 - Manual therapy techniques (e.g.
mobilization/manipulation, manual lymphatic drainage, manual
traction), one or more regions, each 15 minutes
97535 -
Self-care/home management training (e.g., activities of daily living (ADL) and
compensatory
training, meal preparation, safety procedures, and
instructions in use of adaptive equipment)direct one on
one contact
by provider, each 15 minutes
Surgical Dressings Billing Instruction for
HCPCS Code A6545
Recent revisions to the Local Coverage Determination
(LCD) for Surgical Dressings and the related Policy
Article were
published with an effective date of January 1, 2009. The Policy Article
revision neglected to
include billing instructions for HCPCS Code
A6545.
HCPCS Code Description A6545 Gradient compression wrap,
non-elastic, below knee 30- 50 MM HG,
each
Similar to codes
A6531 and A6532 (compression stockings) which are addressed in the Policy
Article
Coding Guidelines section, HCPCS modifiers A1-A9 are not to
be used with A6545.
When a gradient compression wrap, A6545, is used for
an open venous stasis ulcer, the code must be billed
with the AW
modifier. If there is no open ulcer, the AW modifier must not be used. Claims
for code A6545
without an AW modifier will be denied as statutorily
noncovered.
The right (RT) and left (LT) modifiers must also be used
with this code. When the same code for bilateral
items (left and
right) is billed on the same date of service, bill both items on the same claim
line using LTRT
modifiers and 2 units of service.
These
guidelines will be included in a future revision of the Surgical Dressings
medical policy.
The only products that may be billed with code A6545
(non-elastic compression wrap) are those which
have received a
written Coding Verification Review from the Pricing, Data Analysis, and Coding
(PDAC)
contractor and that are posted in the Product Classification
List on the PDAC Web site.
Suppliers should review the entire Surgical
Dressings LCD and related Policy Article at http://www.
cignagovernmentservices.com/
jc/coverage/LCDinfo.html for additional guidance on the
coverage, coding
and documentation
requirements.
===================================
Comments to the above
clarification:
These billing notes are based on coverage criteria for
surgical dressings, covered by §1861(s)(5) of the
Social Security
Act. They are based on the requirements for the surgical dressing benefit
category that
requires there be an open debridable wound. It is my
contention, disputed by Medicare Contractors, that
when used to
treat lymphedema, a compression wrap is covered by the requirements of
§1861(s)(8)
prosthetic devices, and need not meet the coverage
criteria for surgical dressings--a different benefit
category.
Furthermore, Medicare policy is that HCPCS coding does
not determine coverage, and cannot be used to
establish or deny
coverage, so any argument that the A-group coding means that it id denied in
any other
benefit group other than surgical dressings is an invalid
statement, in my humble opinion.
The above comments are not the opinions
of Medicare, and are not to be construed as medical or legal
advice. They are my own opinions, validated by approximately 10
Administrative Law Judges in hearings in
a dozen individual
Medicare hearings.
Robert Weiss, MS
Lymphedema Patient
Advocate
-----------------------------------------------
Medicare
has found a new method of denying covered compression therapy items without
actually denying
them. Medicare Summary Notices are now noting
"Medicare will process your first claim only. In the future
you
must use a Medicare-Enrolled supplier and provide the supplier identification
number on your claim."
and "Medicare cannot process this claim as
you were previously notified that you must use a supplier who
has a
Medicare supplier identification number."
If you plan to appeal the
denial of compression bandage systems, garments or devices, it would be prudent
for you to purchase them from an enrolled supplier. Since these
items will be denied, the supplier will ask
you to pay up front and
sign an Advance Beneficiary Notice of Nonpayment (ABN) form signifying that you
understand that Medicare may not reimburse you for the purchase.
This gets the supplier off the hook when
it is denied. The supplier
is then obliged BY LAW to file the initial claim for you.
It seems that
Medicare will process one claim and one claim only from a beneficiary who has
purchased a
medical item from a non-enrolled supplier or from the
manufacturer. In this case the beneficiary files a
Patient's
Request for Medicare Payment and the claim is processed by hand, instead of by
computer, and
takes a longer time to process.
The following
is a recent CMS clarification on participating and non-participating
suppliers:
"**Updated February 10, 2009- Clarification from January's
DMEPOS Special Open Door Forum.
Participating Provider/Supplier and
Accreditation requirements
Medicare enrolled participating providers and
suppliers must always accept assignment. Assignment is an
agreement
between beneficiaries, their providers/suppliers, and Medicare where the
beneficiary authorizes
the provider/supplier to request direct Part
B payment from Medicare for health care services, equipment,
and
supplies. When the provider/supplier agrees to (or is required by law to)
accept assignment from
Medicare, then the provider/supplier is
prohibited from attempting to collect more than the applicable
Medicare deductible and coinsurance amounts from the beneficiary, the
beneficiary's other insurance, or
anyone else. Providers/suppliers
that enter into a Medicare Participating Physician or Supplier Agreement
(OMB No.0938-0373) agree to accept the Medicare-approved amounts as
payment in full for all Part B
services and supplies. A beneficiary
should only pay the 20% co-pay (and any remaining Part B deductible)
when
they receive their equipment or supplies or when the equipment is
repaired.
A Medicare enrolled non-participating provider/supplier, can
choose which services to accept assignment
for (unless mandatory
assignment applies to the service; e.g., for drugs or biologicals, ambulance
services,
etc.). Therefore, the provider's/supplier's charges for
DME supplies may be higher than the Medicare
approved amount and
the beneficiary has to pay the entire charge for the Part B services and
supplies at the
time of service. (NOTE: Medicare's limiting charge
does not apply to DME supplies.)
In either case, participating and
non-participating, Medicare providers/suppliers must bill Medicare on
behalf
of the beneficiary and must be accredited by September 30, 2009 in order to
retain their Medicare
Part B billing privileges."
The above
material is the undersigned's interpretation of Medicare policy and procedures.
It is my opinion
only and is not authorized or approved by
Medicare. This information is not to be used for medical or legal
purposes, and is offered only as an aid in navigating the Medicare
labyrinth.
Source: Bob Weiss, Lymphedema Patient Advocate,
Medicare.gov
website.
=======================================================
Letter
to write for lymphedema day
Senator
_________________
[Address]
[City, State, Zip]
Dear Senator
_____________________:
I am a [lymphedema patient, breast cancer survivor,
advocate and volunteer at the Carol Baldwin
Breast Care Center]. I
would like to call your attention to Virginia House Joint Resolution No.
524 (please see enclosed copy). This resolution proclaims each March 6th
as Lymphedema D-
Day in the State of Virginia.
It would be a
great step forward for this "orphan disease" if each state and the United
States
government would proclaim March 6th of each year as
Lymphedema D-Day. As one of your
constituents, I cannot stress
enough the impact that this disease has on patients.
For further
information, you may contact the National Lymphedema Network (800-541-3259 or
online at www.lymphnet.org).
If I can be of any assistance in
promoting this resolution, please do not hesitate to contact me.
I thank
you, in advance, for your support.
Very truly yours,
[Your
name]
=====================================================
There are
several bills before the NY State Assembly and the NY State Senate regarding
lymphedema that would be of interest and concern to you.
What
the bill(s) say in part are: "To create awareness of lymphedema through
education and to
promote and support the availability of quality
medical treatment for all individuals at risk or
affected by
lymphedema".
The bills that are to be voted on are A5320 (NY Assembly
bill), S629 (NY Senate bill) and A5321
(NY State Assembly bill),
S2585 (NY State Senate bill.
To read all of the information on these
important bills regarding lymphedema go to www.ny.gov
which is the
home page for the State of New York.
On the right side you will find a
section called LEGISLATIVE and under that heading you will find
New
York State Assembly and New York State Senate. By clicking onto those headings
you will
find on the left side Bills and Laws where you can enter
the bill number to read what it entails,
they are quite detailed.
The bills in both the Assembly and the Senate are cross-referenced so
you
can look at both in as much detail as you like by checking boxes of what
information you want
to review.
Also on the left side you
will find Assembly and Senate and you can click onto those and it will
give you a list of your representatives for your area and you can write
to them if you like and let
them know how you feel about the bill(s)
that are to be voted on. You can search by your zip code
to find
the appropriate members for your area and their email addresses to write to
them if you
want.
If you are wanting to write and give your
support, non-support or comments and feelings on the
particular
bill the Assembly Members and Senate Members will be better equipped to vote on
that bill.
It would also be good if you wanted to email
Senator Thomas K. Duane at duane@senate.state.ny.
us who chairs the
health committee and let him know how you feel on these particular
bills.
Of course, it is your decision if you want to email these people
to let them know how you feel
about these important bills
concerning lymphedema legislation for the State of New York. You
MUST be a New York State resident to have an effect to comment on these
bills that are now in
process so this post is meant for NY
residents only however anyone can look at them if they want
to.
This is meant to be informational only and is not an
endorsement by Lymphland or it's
management, these decisions are for
NY State residents to make through their legislative process.
The
following is a summary of a Wall Street Journal article on a subject of
potential impact to all
lymphedema patients on Medicare or
Medicaid. One of the impacts of this upcoming competitive
bidding
program for durable medical equipment, prosthetics, orthotics and supplies
(DMEPOS) is that
you wil have to obtain DMEPOS (compression
bandages, garments, supplies, devices) from a small
number of
selected enrolled Suppliers. This might represent a major business impact for
the specialized
manufacturers and suppliers of lymphedema treatment
items, and preclude any attempt for the
patient/Beneficiary to
obtain reimbursement for these items.
I urge you all to call your
Congressional legislators and ask them whether the small savings to Medicare
are worth the major reduction in access to the items you use daily
in the treatment of your
lymphedema. Ask your DMEPOS Supplier about
the impact of this program on the availability of your
lymphedema
treatment items.
Bob Weiss
Thursday, March 19,
2009
Medicare Wall Street Journal Examines Potential Effects of Medicare
Competitive Bidding Program
for Durable Medical
Equipment
The Wall Street Journal on Thursday examined "Medicare's
second attempt at putting a competitive
bidding program in place"
for durable medical equipment and the potential effects on access to services
for beneficiaries (Martinez, Wall Street Journal, 3/19). CMS
attempted to implement the program last
year, but a law enacted
last summer delayed the initiative and required the agency to repeat the
initial
bidding process. In February, CMS announced plans to
implement the program on April 19 (Kaiser
Daily Health Policy
Report, 2/23).
According to the Journal, the program likely will reduce
costs for Medicare and beneficiaries, who pay
20% of the cost of
DME, but suppliers and some patient advocacy groups have raised concerns that
"it also may mean new hassles for patients." In addition, some
Medicare beneficiaries "worry about no
longer being able to do
business with providers they have come to rely on for lifesaving equipment,"
the
Journal reports.
Tyler Wilson -- president of American
Association for Homecare, which represents DME suppliers --
said,
"Competitive bidding is going to eliminate 90% of home care providers," adding,
"The result is
going to be lower quality and lower access to care
for seniors and people with disabilities." In addition,
AAH
officials said that the program will reduce costs for Medicare by only a small
amount.
Expenditures for DME will account for less than 2% of the
estimated $500 billion budget for Medicare
this year, they
said.
Laurence Wilson, director of the chronic care policy group at CMS,
said that the program will provide
"value to Medicare and its
beneficiaries, as well as taxpayers" and ensure that beneficiaries have access
to needed DME. CMS officials also said that the program would reduce
costs for Medicare by $1
billion annually (Wall Street Journal,
3/19).
---------------------------
The following clarification
refers to supplies used in conjunction with previously obtained DME, and
how to document the medical necessity of the supplies. It is my opinion
that this concept applies
equally to supplies necessary for the use
with prosthetic devices such as Reid Sleeves, Circaids, etc.
These
supplies, such as finger bandages, gauze sleeves, localized foam pads, etc are
coverable, in my
opinion, and should be claimed by Medicare
patients. Make sure that you have a physician's
prescription for
use in the treatment of lymphedema.
Bob Weiss
Lymphedema Patient
Advocate
April 21, 2009
Supplies and Accessories Used With
Beneficiary Owned Equipment
April 2009 Clarification
The DME MACs
recently published an article addressing documentation requirements for
supplies and
accessories used with beneficiary owned equipment.
This article only addressed equipment that was
not paid for by
Medicare FFS - i.e., only equipment that was paid by other insurance or by the
beneficiary. For supplies and accessories used with that equipment,
all of the following information
must be submitted with the initial
claim in Item 19 on the CMS-1500 claim form or in the NTE segment
for electronic claims:
* HCPCS code of base equipment;
and,
* A notation that this equipment is beneficiary-owned; and,
* Date
the patient obtained the equipment.
Claims for supplies and accessories
must include all three pieces of information listed above. Claims
lacking any one of the above elements will be denied for missing
information.
Medicare requires that supplies and accessories only be
provided for equipment that meets the existing
coverage criteria
for the base item. In addition, if the supply or accessory has additional,
separate
criteria, these must also be met. In the event of a
documentation request from the contractor or a
redetermination
request, suppliers should provide information justifying the medical necessity
for the
base item and the supplies and/or accessories. Refer to
the applicable Local Coverage Determination
(s) and related Policy
Article(s) for information on the relevant coverage, documentation and coding
requirements.
-------------------------------------------------------------------------------------------
July
Quarterly Update for 2009 for Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies
(DMEPOS)
MLN Matters Number:
MM6511
HCPCS codes A6545, E0656, E0657 and L0113 were added to the HCPCS
file effective January 1,
2009. The fee schedule amounts for these
HCPCS codes are established as part of this update and are
effective for claims with dates of service on or after January 1, 2009.
These items were paid on a local
fee schedule basis prior to
implementation of the fee schedule amounts established in accordance with
this update. Claims for the above codes with dates of service on or
after January 1, 2009 that have
already been processed will not be
adjusted to reflect the newly established fees if they are resubmitted
for adjustment.
As part of this update CMS is adding the AW
modifier to the fee schedule file for HCPCS code
A6545 Gradient
Compression Wrap, Non-Elastic, Below Knee, 30-50 MM HG, Each. Code A6545
is covered when it is used in the treatment of an open venous stasis
ulcer. Currently, code A6545 is
noncovered for the following
conditions:
Venous insufficiency without stasis ulcers, prevention of
stasis ulcers, prevention of the reoccurrence of
stasis ulcers that
have healed, and treatment of lymphedema in the absence of ulcers. In these
situations, since an ulcer is not present, the gradient compression
wraps do not meet the definition of a
surgical dressing. Suppliers
are advised that when the non-elastic gradient compression wrap code
A6545
is used in the treatment of an open venous stasis ulcer, it must be billed with
the AW modifier.
Claims for code A6545 that do not meet the covered
indications should be billed without the AW
modifier and as such,
will be denied as non-covered.
For Information on Lymphedema-related
items:
A6545 is the CircAid JuxtaFit
E0656 is Segmental Pneumatic
Appliance for the Trunk
E0657 is Segmental Pneumatic Appliance for the
Chest
Note that the CircAid is not approved for the treatment of
lymphedema in the absence of an open
wound since it does not meet
the coverage requirements of a “secondary surgical dressing” benefit.
This
is not to say that it could not be held to meet the coverage requirements of a
different benefit
category, such as “prosthetic
devices”.
Bob
Weiss
-------------------------------------------
please make
the following correction.
A6545 code covers the T3M only, not the Juxta-Fit
as stated.
T3M garment is specifically for Venous Disease not
Lymphedema.
If have any questions, please feel free to contact me.
Thank
you for your attention to this matter.
Ingrid Adams
Director of
Sales
CircAid Medical Products
Phone: 800-247-2243 ext 233
Fax:
858-576-3555
=====================================
If you are
associated with a wound clinic you may wish to comment on this upcoming policy
change.
Bob Weiss
Healthcare Common Procedure Coding System
(HCPCS) Coding Decision and Preliminary Medicare
Payment Decision
for Negative Pressure Wound Therapy (NPWT) Devices
CMS' preliminary
Healthcare Common Procedure Coding System (HCPCS) coding decision and
preliminary
Medicare Payment decision for negative pressure wound therapy (NPWT) devices is
now
published in the July 9, 2009 NPWT Public Meeting Agenda. This
public meeting affords stakeholders
an opportunity to provide input
concerning the preliminary decision.
The Medicare Improvements for Patients
and Providers Act of 2008 required the Secretary to
evaluate
existing HCPCS codes for NPWT devices to ensure accurate reporting and billing
for the
items and services under such codes; use an existing
process for the consideration of coding changes:
and consider all
relevant studies andinformation furnished through the process.
CMS partnered
with Agency of Healthcare Research and Quality (AHRQ) to commission a review of
NPWT devices to ensure all relevant studies and information on NPWT
were captured. ECRI Institute
solicited information from
stakeholders and searched literature in conducting this review. A draft report
of their findings was published for comment in April 2009. After
analysis of comments received, ECRI
concluded that the available
evidence does not support significant therapeutic distinction of a NPWT
system or component of a system. The report informed CMS' HCPCS
workgroup's decision. The final
report will be publicly available
no later than June 10, 2009 on AHRQ's homepage for the Technology
Assessment Program at http://www.ahrq. gov/clinic/ techix.htm.
============================
The
Durable Medical Equipment Medicare Administrative Contractor Jurisdiction A
(DME MAC A)
NHIC, Corp. has announced a change in Medicare billing
policy in a Surgical Dressing LCD Article
Surgical Dressings
Policy
Article
Revision Effective Date: 01/01/2009 (September
Publication)
CODING GUIDELINES:
Added: A6545 to list of codes requiring
the AW modifier.
Added: A6545 to list of codes requiring the RT and/or LT
modifier(s).
Revised: RT/LT modifier instructions.
The change may be
found in Article for Surgical Dressings - Policy Article - Effective January
2009
(September 2009 Publication) (A23664)
Abstracted
information of possible interest to the lymphedema/wound care community is as
follows:
A6545 GRADIENT COMPRESSION WRAP, NON-ELASTIC, BELOW KNEE, 30-50
MM
HG, EACH
GRADIENT COMPRESSION STOCKINGS/WRAPS (A6531,
A6532, A6545):
A gradient compression stocking described by codes A6531
or A6532 or a non-elastic gradient
compression wrap described by code A6545
is covered when it is used in the treatment of an open
venous stasis
ulcer.
Codes A6531, A6532, and A6545 are noncovered for the following
conditions: venous insufficiency
without stasis ulcers, prevention of stasis
ulcers, prevention of the reoccurrence of stasis ulcers that
have healed,
treatment of lymphedema in the absence of ulcers. In these situations, since
there is
no ulcer, the stockings/wraps do not meet the definition of a
surgical dressing. Gradient
compression stockings described by codes A6530,
A6533-A6544, A6549 and surgical stockings
described by codes A4490-A4510 are
noncovered for all indications because they do not meet the
definition of a
surgical dressing.
A nonelastic binder for an extremity (A4465) is
noncovered for all indications because it does not
meet the definition of a
surgical dressing.
The only products that may be billed with code A6545
(non-elastic compression wrap) are those
which have received a written
Coding Verification Review from the Pricing, Data Analysis, and
Coding
(PDAC) contractor and that are posted in the Product Classification List on the
PDAC web
site.
When tape codes A4450 and A4452 are used
with surgical dressings, they must be billed with the
AW modifier (in
addition to the appropriate A1-A9 modifier). When gradient compression
stocking
codes A6531 and A6532 or the gradient compression wrap code A6545
are used for an open venous
stasis ulcer, they must be billed with the AW
modifier (but not an A1-A9 modifier). For this policy,
codes A4450, A4452,
A6531, and A6532, and A6545 are the only codes for which the AW modifier
may
be used.
The RT and/or LT modifiers must be used with codes A6531,
A6532, and A6545 for gradient
compression stockings and wraps. When the same
code for bilateral items (left and right) is billed
on the same date of
service, bill both items on the same claim line using RTLT modifiers and 2
units
of service. Claims billed without modifiers RT and/or LT will be
rejected as incorrect coding.
GRADIENT COMPRESSION WRAP
(A6545):
Coverage of a non-elastic gradient compression wrap (A6545) is
limited to one per 6 months per
leg. Quantities exceeding this amount will
be denied as not medically necessary. Refer to Policy Article
for
statement concerning noncoverage if the ulcer has healed.
Revision
History Explanation
Revision Effective Date: 01/01/2009 (September
Publication)
CODING GUIDELINES:
Added: A6545 to list of codes requiring
the AW modifier.
Added: A6545 to list of codes requiring the RT and/or LT
modifier(s).
Revised: RT/LT modifier instructions.
Revision
Effective Date: 01/01/2009
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT
RULES:
Clarified: Allowance for HCPCS codes which use the term
“kit”.
Added: Coverage statements for compression wraps (A6545).
Added:
Noncoverage statement for surgical stockings (A4490-A4510).
CODING
GUIDELINES:
Added: Requirement for PDAC Coding Verification Review for
non-elastic compression wraps
(A6545).
Revised: Changed SADMERC to
PDAC.
------
I found another article you may be interested in
reading that came from Center for Medicare and
Medicaid
Services...."Medicare's New Requirements For Durable Medical Equipment,
Prothestics,
Orthotics, And Supplies".
This may be accessed
at the following:
http://www.medicare.gov/publications/pubs/pdf/11437.pdf
--------------------------
I
came across an article from the National Cancer Institute that you might be
interested in reading...."
Weight Lifting Does Not Exacerbate And
May Improve Lymphedema Symptoms After Breast
Cancer".
You
can access the article at:
http://www.cancer.gov.clinicaltrials/results/lymphedema0909
==================================
The
above Local Coverage Determination LCD) and its accompanying coverage article
represent the
Medicare basis for denial of compression bandages,
garments and sevices. In this writer's humble
opinion, validated
by several Administrative Law Judges, this LCD applies only to the coverage
criteria
for the Medicare benefit category of SURGICAL DRESSINGS,
which by statute and policy, covers
only materials used in the
treatment of open wounds, incisions, venous ulcers, etc. They derive
ultimately
from the Social Security Act section 1861(s)(5), surgical dressings. As a
matter of law, the
criteria for coverage under one benefit category
cannot be used to deny coverage of an item which falls
into the
definition of a different benefit category.
When used in the compression
treatment of lymphedema these materials (compression bandages,
garments and sevices) meet the definition of PROSTHETIC DEVICES, and
are therefore covered by
Medicare. They cannot be denied by invoking
the coverage criteria for surgical dressings as
documented in the
"LCD for Surgical Dressings (L11471)" and its "Article for Surgical Dressings
Policy Article A23664)".
Robert Weiss, MS
Lymphedema
Patient Advocate
National Lymphedema Network
LymphActivist@aol.com
-----
Plaintiffs
win suit to keep their Social Security benefits even if they reject Medicare
Constitutional attorney Kent Masterson Brown has won an important legal
victory on behalf of three
plaintiffs — former Congressman Dick
Armey, Brian Hall and John Kraus — who sued to keep their
Social
Security benefits after they withdrew from Medicare Part A, preferring to keep
their private
healthcare coverage. The Department of Health and
Human Services had sought to dismiss the suit,
arguing that the
plaintiffs had not exhausted their administrative remedies. But U.S. District
Judge
Rosemary Collyer, noting that one plaintiff has waited three
years for an administrative hearing without
action, ruled that the
plaintiffs had standing to contest their claim on the merits of the case. On
October
5, 2009, the Wall Street Journal published an editorial
regarding the judge’s decision, saying, “This
(case) could be a big
deal”.
The plaintiffs argued that as they had paid a lifetime of taxes
into Social Security, they should not be
denied benefits simply
because they are willing to pay for their own medical care. In 1993, under the
Clinton administration, Social Security’s Program Operations Manual
System (POMS) was changed
to state that seniors who withdraw from
Medicare A also surrender their Social Security benefits. You
can’t
have one without the other. But POMS is not in the statute or regulations that
govern Medicare.
According to the Wall Street Journal, the response of
the Department of HHS speaks volumes about
the contradiction
between the Obama administration’s principles and its rhetoric: “President
Obama
says his plan for a ‘public option’ wouldn't be coercive,
saying that ‘If you like your health-care plan,
you keep your
health-care plan. Nobody is going to force you to leave your health-care plan.’
But here
is a case where federal bureaucrats are using their power
to force Medicare on seniors. Let's hope the
courts restore a
genuine right to choose.”
Freedom of healthcare choice is a big deal.
Should Medicare become insolvent, as it is widely
expected to do,
seniors may not be able to opt out in order to preserve their health insurance.
Coercion in your choice of healthcare is a key part of the current
healthcare legislation.
October 20, 2009
Plaintiffs win suit to
keep their Social Security benefits even if they reject Medicare
Constitutional attorney Kent Masterson Brown has won an important legal
victory on behalf of three
plaintiffs — former Congressman Dick
Armey, Brian Hall and John Kraus — who sued to keep their
Social
Security benefits after they withdrew from Medicare Part A, preferring to keep
their private
healthcare coverage. The Department of Health and
Human Services had sought to dismiss the suit,
arguing that the
plaintiffs had not exhausted their administrative remedies. But U.S. District
Judge
Rosemary Collyer, noting that one plaintiff has waited three
years for an administrative hearing without
action, ruled that the
plaintiffs had standing to contest their claim on the merits of the case. On
October
5, 2009, the Wall Street Journal published an editorial
regarding the judge’s decision, saying, “This
(case) could be a big
deal”.
The plaintiffs argued that as they had paid a lifetime of taxes
into Social Security, they should not be
denied benefits simply
because they are willing to pay for their own medical care. In 1993, under the
Clinton administration, Social Security’s Program Operations Manual
System (POMS) was changed
to state that seniors who withdraw from
Medicare A also surrender their Social Security benefits. You
can’t
have one without the other. But POMS is not in the statute or regulations that
govern Medicare.
According to the Wall Street Journal, the response of
the Department of HHS speaks volumes about
the contradiction
between the Obama administration’s principles and its rhetoric: “President Obama
says his plan for a ‘public option’ wouldn't be coercive, saying
that ‘If you like your health-care plan,
you keep your health-care
plan. Nobody is going to force you to leave your health-care plan.’ But here
is a case where federal bureaucrats are using their power to force
Medicare on seniors. Let's hope the
courts restore a genuine right
to choose.”
Freedom of healthcare choice is a big deal. Should Medicare
become insolvent, as it is widely
expected to do, seniors may not
be able to opt out in order to preserve their health insurance.
Coercion in your choice of healthcare is a key part of the current
healthcare legislation.
October 20, 2009
Plaintiffs win suit
to keep their Social Security benefits even if they reject Medicare
Constitutional attorney Kent Masterson Brown has won an important legal
victory on behalf of three
plaintiffs — former Congressman Dick
Armey, Brian Hall and John Kraus — who sued to keep their
Social
Security benefits after they withdrew from Medicare Part A, preferring to keep
their private
healthcare coverage. The Department of Health and
Human Services had sought to dismiss the suit,
arguing that the
plaintiffs had not exhausted their administrative remedies. But U.S. District
Judge
Rosemary Collyer, noting that one plaintiff has waited three
years for an administrative hearing without
action, ruled that the
plaintiffs had standing to contest their claim on the merits of the case. On
October
5, 2009, the Wall Street Journal published an editorial
regarding the judge’s decision, saying, “This
(case) could be a big
deal”.
The plaintiffs argued that as they had paid a lifetime of taxes
into Social Security, they should not be
denied benefits simply
because they are willing to pay for their own medical care. In 1993, under the
Clinton administration, Social Security’s Program Operations Manual
System (POMS) was changed
to state that seniors who withdraw from
Medicare A also surrender their Social Security benefits. You
can’t
have one without the other. But POMS is not in the statute or regulations that
govern Medicare.
According to the Wall Street Journal, the response of
the Department of HHS speaks volumes about
the contradiction
between the Obama administration’s principles and its rhetoric: “President
Obama
says his plan for a ‘public option’ wouldn't be coercive,
saying that ‘If you like your health-care plan,
you keep your
health-care plan. Nobody is going to force you to leave your health-care plan.’
But here
is a case where federal bureaucrats are using their power
to force Medicare on seniors. Let's hope the
courts restore a
genuine right to choose.”
Freedom of healthcare choice is a big deal.
Should Medicare become insolvent, as it is widely
expected to do,
seniors may not be able to opt out in order to preserve their health insurance.
Coercion in your choice of healthcare is a key part of the current
healthcare legislation.
October 20, 2009
http://www.healthfreedom.net/index.php?option=com_content&task=view&id=922&Itemid=1
------
The amount in
Controversy minimums to be able to bring an appeal to a Medicare Administrative
Law
Judge (ALJ) hearing has been raised from $120.00 in 2009 to
$130.00 in 2010. What that means is
that a disputed item
(compression bandage kit or compression garment) must cost more than $162.50
before you can have an ALJ hearing since the disputed amount, which
is the purchase price minus the
20% co-pay, must be more than
$130.00). Otherwise don't bother filing a claim or an appeal. You
need two garments anyway so that one can be worn while the other
dries.
Bob Weiss
Reference [Federal Register: September 25, 2009
(Volume 74, Number 185)]
[Notices]
[Page
48976-48977]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for
Medicare & Medicaid Services
[CMS-4141-N]
Medicare
Program; Medicare Appeals; Adjustment to the Amount in
Controversy Threshold
Amounts for Calendar Year 2010
AGENCY: Centers for Medicare &
Medicaid Services (CMS), HHS.
----
How can a Medicare beneficiary
find out if their supplier does not meet the new requirements?
Medicare
beneficiaries should ask their suppliers if they meet the new Medicare
requirements so they
can continue to get their suppliers covered by
Medicare and to avoid any interruption in their services.
What should a
Medicare beneficiary do if their supplier does not meet the new
requirements?
If a beneficiary's supplier isn't going to meet the new
requirements, they will have to look for another
Medicare-approved
supplier in order for Medicare to pay for their equipment and
supplies.
How does a beneficiary find a new Medicare
supplier?
Beneficiaries should ask their current supplier if they are
working with another supplier who can help
the beneficiary. If the
beneficiary's current supplier can't help, the beneficiary should call
1-800-
MEDICARE (1-800-633-4227) and a customer service
representative can help them find a new
supplier. TTY users should
call 1-877-486-2048. Or, visit www.medicare.gov and select "Find
Suppliers of Medical Equipment in Your Area." In order to ensure
Medicare payment, beneficiaries
should always ask any new supplier
they contact if they are still approved by Medicare to provide
covered medical equipment and supplies.
What if a beneficiary
doesn't want to change suppliers?
Starting October 1, 2009, all
suppliers must meet the new Medicare requirements in order to be paid
by
Medicare. If a supplier hasn't met these requirements and a beneficiary
continues to get supplies
from the supplier, the beneficiary may
have to pay the full cost for the supplies.
What should a beneficiary do
if they have oxygen and their current supplier told them that they are
removing their equipment after October 1, 2009?
A beneficiary
should call 1-800-MEDICARE (1-800-633-4227) and a customer service
representative can help them find a new supplier. TTY users should call
1-877-486-2048.
What will happen with equipment in a beneficiary's home
if they have to change suppliers?
A beneficiary's current supplier
should make arrangements to remove the equipment after the
beneficiary has received replacement equipment from their new
supplier.
What if my new supplier does not provide a beneficiary with
the supplies their doctor originally
ordered?
The new
supplier has an obligation to provide a beneficiary with the supplies that
their physician orders
for them. If a beneficiary has any concerns,
they should contact their doctor to discuss them.
What if a
beneficiary's existing supplier is the only one in their town and is not
Medicare approved?
A beneficiary's existing supplier may choose not to
participate. Beneficiaries should call 1-800-
MEDICARE
(1-800-633-4227) and a customer service representative can help them find a new
supplier in their area. TTY users should call
1-877-486-2048.
What can a beneficiary do if they have a complaint about
their DME supplier?
CMS can assist a beneficiary who has a complaint
about their DME supplier. Beneficiaries should call
1-800-MEDICARE
(1-800-633-4227) and give the customer service representative the name and
address of their supplier and the nature of their complaint. Someone
from CMS and/or the supplier will
get back to the beneficiary as
soon as possible.
Will a beneficiary's prescription drugs be affected by
the new requirements?
A beneficiary's prescription drugs are not
affected by the new requirements, only the medical supplies
that
they are receiving.
Why can't a beneficiary continue to go to their
pharmacy to get their diabetic supplies?
If a beneficiary's pharmacy
hasn't met Medicare's new requirements, they won't be able be able to
provide
the beneficiary's diabetic supplies after October 1, 2009. To find a pharmacy
that can provide
diabetic supplies or a mail order supplier, a
beneficiary should visit www.medicare.gov and select
"Find
Suppliers of Medicare Equipment in Your Area." Or, call 1-800-MEDICARE
(1-800-633-
4227). TTY users should call 1-877-486-2048.
Must
a non-accredited supplier use an Advance Beneficiary Notice (ABN) before
selling DMEPOS
items to a beneficiary?
Non-accredited
suppliers should use an Advance Beneficiary Notice (ABN) before providing a
Medicare beneficiary with an item or service to alert the beneficiary
to the fact that the supplier is non-
accredited and unable to bill
Medicare for the item – so the beneficiary knows they will have to pay the
full cost for the item or service. The only exception to this rule is
when a non-accredited supplier has
posted clearly visible signs
(undisputed by the beneficiary) at the supplier's place of business that
informs beneficiaries that it is not accredited by Medicare and cannot
bill Medicare, so the beneficiary
knows they must pay for the item
or service.
Is a beneficiary protected if they purchase a supply from a
non-accredited supplier?
There are retail outlets and pharmacies that
furnish DMEPOS items to cash and carry customers which
do not meet
the new Medicare requirements. Therefore beneficiaries should always ask if the
supplier
meets the new Medicare requirements to make sure Medicare
will pay for their supplies. Medicare
"may" reimburse a beneficiary
for a one-time only supply and give notice to the beneficiary that any
future bills will not be reimbursed. The supplier locator tool on
www.medicare.gov is available to
beneficiaries to locate enrolled
DMEPOS suppliers that service their area.
Can a non-accredited pharmacy
that provides DME supplies to a dual eligible beneficiary be
reimbursed by Medicaid?
As long as the pharmacy is a Medicaid
provider, the pharmacy may be reimbursed by Medicaid for a
Medicaid-covered item.
Will a beneficiary's Medicare premium
increase because the suppliers now need to be
accredited/obtain a
surety bond?
A beneficiary's Medicare premium is not affected by these
new Medicare requirements.
-----
NHIC, Corp., Medicare DME MAC
Jurisdiction A has posted the results of a review of claims for a
lymphedema pump. The review revealed that over half of the claims for
lymphedema pumps have been
rejected or down-graded. An analysis of
the reasons for rejection can help future requests for these
devices. The results point up the importance of having a well-written
Certificate of Medical Necessity
(CMN) DME MAC Form 04.04B /CMS
Form 846 Pneumatic Compression Devices signed by the
patient's
physician.
The CMN must show that the use of a multichambered sequential
pressure pneumatic compressor with
calibrated gradient pressure is
medically necessary for the treatment of the patient's lymphedema, that
other "more conservative" protocols such as elevation, compression and
exercise have been tried and
have not been successful, that there
is a medical reason for this patient to have a pump because of
difficulty in performing CDT at home. Note that 14% of the claims were
denied on the basis that
"equipment is the same or similar to
equipment already in use" even though Medicare frequently
requires
a failed trial of non-segmented pumps before a more appropriate model is
approved [Ref.
LCD L11503].
Physicians must be meticulous
and complete in writing their prescription, including the diagnostic code
for lymphedema, the physician's name address and NPI, and as full a
description of the type of pump
that is medically indicated,
including the designation of the kinds of garments required (e.g. full sleeve
or
legging, upper or lower body segment, etc.)
Bob
Weiss
Results of Widespread Prepayment Review of Claims for HCPCS
Code E0652
(Pneumatic Compressor, Segmental Home Model with Calibrated
Gradient Pressure)
Posted October 30, 2009
The DME MAC A Medical
Review Department concluded a widespread review of HCPCS code
E0652
from June 2009 through September 2009.
The results of the quarterly
review of the claims from June 1, 2009 through September 30, 2009
identified eight hundred sixty-five (865) claims of which two hundred
sixty-three (263) were denied.
This resulted in an overall Charge
Denial Rate of 54.00%.
The following are the top five (5) reasons for
denial:
o The equipment is considered not reasonable and necessary (69
claims)
o The prescription is incomplete (46 claims)
o Duplicate claims
(43 claims)
o Equipment is same or similar to equipment already in use (38
claims)
o Claim not payable under Jurisdiction A (e.g., claim submitted to
incorrect contractor) (16 claims)
The other reasons for denial are as
follows: (51 claims)
o Patient eligibility (e.g., patient cannot be
identified as Medicare insured; beneficiary not covered by
Medicare;
or beneficiary covered by another plan or HMO, etc.)
o Date of death
precedes date of service
o Missing or incomplete supplier information
o
Claim contains incomplete or invalid information (e.g., missing or incomplete
diagnosis or condition)
o No response to medical records request
o The
equipment was provided while the patient is in the nursing home
o Lifetime
benefit maximum for equipment has been reached
The Local Coverage
Determination (LCD) for Pneumatic Compression Devices (L11503) states in
part:
Pneumatic Compression Devices are only covered for the
treatment of lymphedema or for the
treatment of chronic venous
insufficiency with venous stasis ulcers, prescribed by a physician and
determination by the physician of the medical necessity which must
include the following:
o The patient's diagnosis and prognosis;
o
Symptoms and objective findings, including measurements which establish the
severity of the
condition;
o The reason the device is required,
including the treatments which have been tried and failed; and
o The
clinical response to an initial treatment with the device. The clinical
response includes the change
in pre-treatment measurements, ability
to tolerate the treatment session and parameters and ability of
the
patient (or caregivers) to apply the device for continued use in the
home.
The medical documentation submitted for five hundred thirty-four
(534) claims supported the medical
necessity for a lower level item,
thus the services were down-coded to the least costly alternative.
The
Pneumatic Compression Devices (L11503) LCD states:
“When a segmented
device with manual control of the pressure in each chamber (E0652) is ordered
and provided, payment will be based on the allowance for the least
costly medically appropriate
alternative, E0651, unless there is
clear documentation of medical necessity in the individual case. Full
payment
for code E0652 will be made only when there is documentation that the
individual has unique
characteristics that prevent satisfactory
pneumatic compression treatment using a non-segmented
device (E0650)
with a segmented appliance/sleeve (E0671 - E0673) or a segmented device without
manual control of the pressure chamber (E0651).”
For any
item to be covered by Medicare, it must:
o Be eligible for a defined
Medicare benefit category;
o Be reasonable and necessary for the diagnosis
or treatment of illness or injury or to improve the
functioning of a
malformed body member; and
o Meet all other applicable Medicare statutory
and regulatory requirements.
Suppliers are reminded that documentation
must be made available to the DME MAC upon request.
Reference the following
under the Documentation Requirements section in the Pneumatic Compression
Devices (L11503) LCD, which states in part:
“Section 1833 (e) of
the Social Security Act precludes payment to any provider of services unless
“there has been furnished such information as may be necessary in
order to determine the amounts due
such provider” (42 U.S.C. section
13951 (e)). It is expected that the patient's medical records will
reflect the need for the care provided. The patient's medical records
include the physician's office
records, hospital records, nursing
home records, home health agency records, records from other
healthcare professionals and test reports. This documentation must be
available upon request.”
Reference the following publications for
documentation requirements for HCPCS code E0650 -
E0652, the DME
MAC A Supplier Manual and the Pneumatic Compression Devices (L11503) LCD.
These are available on the DME MAC A Web site at: http://www.medicarenhic.com/dme/index.shtml
_____________________________________________________________________________
_____________________________________________________________________________
_____________
Document Name: DME Web site Article Template Document
Number: TMP-EDO-0049
Release Date: 11/28/2007 Version: 1.0
The master
copy of this document is stored in the NHIC ISO Documentation
Repository.
Any other copy, either electronic or paper, is an uncontrolled
copy and must be deleted or destroyed
when it has served its
purpose.
------------------
NHIC, Corp., Medicare DME MAC
Jurisdiction A has posted the results of a review of claims for a
lymphedema pump. The review revealed that over half of the claims for
lymphedema pumps have been
rejected or down-graded. An analysis of
the reasons for rejection can help future requests for these
devices. The results point up the importance of having a well-written
Certificate of Medical Necessity
(CMN) DME MAC Form 04.04B /CMS
Form 846 Pneumatic Compression Devices signed by the
patient's
physician.
The CMN must show that the use of a multichambered sequential
pressure pneumatic compressor with
calibrated gradient pressure is
medically necessary for the treatment of the patient's lymphedema, that
other "more conservative" protocols such as elevation, compression and
exercise have been tried and
have not been successful, that there
is a medical reason for this patient to have a pump because of
difficulty in performing CDT at home. Note that 14% of the claims were
denied on the basis that
"equipment is the same or similar to
equipment already in use" even though Medicare frequently
requires
a failed trial of non-segmented pumps before a more appropriate model is
approved [Ref.
LCD L11503].
Physicians must be meticulous
and complete in writing their prescription, including the diagnostic code
for lymphedema, the physician's name address and NPI, and as full a
description of the type of pump
that is medically indicated,
including the designation of the kinds of garments required (e.g. full sleeve
or
legging, upper or lower body segment, etc.)
Bob
Weiss
Results of Widespread Prepayment Review of Claims for HCPCS
Code E0652
(Pneumatic Compressor, Segmental Home Model with Calibrated
Gradient Pressure)
Posted October 30, 2009
The DME MAC A Medical
Review Department concluded a widespread review of HCPCS code
E0652
from June 2009 through September 2009.
The results of the quarterly
review of the claims from June 1, 2009 through September 30, 2009
identified eight hundred sixty-five (865) claims of which two hundred
sixty-three (263) were denied.
This resulted in an overall Charge
Denial Rate of 54.00%.
The following are the top five (5) reasons for
denial:
o The equipment is considered not reasonable and necessary (69
claims)
o The prescription is incomplete (46 claims)
o Duplicate claims
(43 claims)
o Equipment is same or similar to equipment already in use (38
claims)
o Claim not payable under Jurisdiction A (e.g., claim submitted to
incorrect contractor) (16 claims)
The other reasons for denial are as
follows: (51 claims)
o Patient eligibility (e.g., patient cannot be
identified as Medicare insured; beneficiary not covered by
Medicare;
or beneficiary covered by another plan or HMO, etc.)
o Date of death
precedes date of service
o Missing or incomplete supplier information
o
Claim contains incomplete or invalid information (e.g., missing or incomplete
diagnosis or condition)
o No response to medical records request
o The
equipment was provided while the patient is in the nursing home
o Lifetime
benefit maximum for equipment has been reached
The Local Coverage
Determination (LCD) for Pneumatic Compression Devices (L11503) states in
part:
Pneumatic Compression Devices are only covered for the
treatment of lymphedema or for the
treatment of chronic venous
insufficiency with venous stasis ulcers, prescribed by a physician and
determination by the physician of the medical necessity which must
include the following:
o The patient's diagnosis and prognosis;
o
Symptoms and objective findings, including measurements which establish the
severity of the
condition;
o The reason the device is required,
including the treatments which have been tried and failed; and
o The
clinical response to an initial treatment with the device. The clinical
response includes the change
in pre-treatment measurements, ability
to tolerate the treatment session and parameters and ability of
the
patient (or caregivers) to apply the device for continued use in the
home.
The medical documentation submitted for five hundred thirty-four
(534) claims supported the medical
necessity for a lower level item,
thus the services were down-coded to the least costly alternative.
The
Pneumatic Compression Devices (L11503) LCD states:
“When a segmented
device with manual control of the pressure in each chamber (E0652) is ordered
and provided, payment will be based on the allowance for the least
costly medically appropriate
alternative, E0651, unless there is
clear documentation of medical necessity in the individual case. Full
payment
for code E0652 will be made only when there is documentation that the
individual has unique
characteristics that prevent satisfactory
pneumatic compression treatment using a non-segmented
device (E0650)
with a segmented appliance/sleeve (E0671 - E0673) or a segmented device without
manual control of the pressure chamber (E0651).”
For any
item to be covered by Medicare, it must:
o Be eligible for a defined
Medicare benefit category;
o Be reasonable and necessary for the diagnosis
or treatment of illness or injury or to improve the
functioning of a
malformed body member; and
o Meet all other applicable Medicare statutory
and regulatory requirements.
Suppliers are reminded that documentation
must be made available to the DME MAC upon request.
Reference the following
under the Documentation Requirements section in the Pneumatic Compression
Devices (L11503) LCD, which states in part:
“Section 1833 (e) of
the Social Security Act precludes payment to any provider of services unless
“there has been furnished such information as may be necessary in
order to determine the amounts due
such provider” (42 U.S.C. section
13951 (e)). It is expected that the patient's medical records will
reflect the need for the care provided. The patient's medical records
include the physician's office
records, hospital records, nursing
home records, home health agency records, records from other
healthcare professionals and test reports. This documentation must be
available upon request.”
Reference the following publications for
documentation requirements for HCPCS code E0650 -
E0652, the DME
MAC A Supplier Manual and the Pneumatic Compression Devices (L11503) LCD.
These are available on the DME MAC A Web site at: http://www.medicare nhic.com/ dme/index.
shtml
____________
_________ _________ _________ _________ _________ _________
_________ _________ _________ _________ _________ _________ _________
_________
_________ _________ _________ __
Document Name: DME
Web site Article Template Document Number: TMP-EDO-0049
Release Date:
11/28/2007 Version: 1.0
The master copy of this document is stored in the
NHIC ISO Documentation Repository.
----
Worth
reading!
http://www.aarpmagazine.org/money/health_claim_game.html?print=yes#
If you need help with your
lymphedema claim please contact me.
Bob Weiss
LymphActivist@aol.com
------
Thu, 12 Nov 2009
13:49:00 -0600
Date: 11/12/2009
Subject: AHRQ Draft TA for
review
Content: and Treatment of Secondary Lymphedema
The
Agency for Healthcare Research and Quality's (AHRQ) Technology Assessment
Program will be
posting a draft technology assessment for review on
November 18, 2009. This draft is entitled
"Diagnosis and Treatment
of Secondary Lymphedema." If you are interested in reviewing this
document, please visit: http://www.ahrq. gov/clinic/ ta/tareview.
htm.
The document will be available
for review from 9:00 AM on November
18, 2009 to 5:00 PM December 8, 2009.
Call for Public
Review
--------------------------------------------------------------------------------
The
Agency for Healthcare Research and Quality's (AHRQ) Technology Assessment (TA)
Program
develops systematic reviews, health technology assessments,
and other reports at the request of the
Centers for Medicare &
Medicaid Services (CMS) Coverage and Analysis Group. These reports are
funded by an Interagency Agreement from CMS to AHRQ and used to inform
national coverage
policies, discussion at public Medicare Evidence
Development and Coverage Advisory Committee
(MedCAC) meetings,
and/or for other policy considerations.
To get complete public review,
the AHRQ TA Program will post draft reports on the AHRQ TA Web
site. To meet the timelines for Medicare coverage decisions mandated by
the Medicare Prescription
Drug, Improvement, and Modernization Act
of 2003, draft technology assessment reports will be
available for
public review for a limited time. A notice will be sent out on the CMS Medicare
Coverage
and AHRQ Effective Health Care E-mail distribution lists 1
week before the posting of draft reports.
Each report will be
available for public review on this Web site for a total of 2
weeks.
AHRQ's TA Program supports and is committed to the transparency
of its review process. Therefore,
starting March 18, 2009, invited
peer review comments and public review comments will be publicly
posted on the TA Program Web site at http://www.ahrq. gov/clinic/
techix.htm
within 3 months after
the associated final report is posted on this
Web site. The report authors' responses to the comments
(the
"disposition of comments") will be posted on the same Web page as the
associated comments.
Review Steps
When a draft Technology Assessment
report is available for review, you may review the draft report
by
completing the associated review form and then selecting "Submit" on the
form.
Note: Comments received after the review period will not be
accepted.
Available Soon
Diagnosis and Treatment of Secondary
Lymphedema. Available for review November 18 to
December 8,
2009
Questions
Please contact ahrqtap@ahrq. hhs.gov
if you have any questions.
This is an opportunity (maybe the last for
another 10 years) to use your knowledge and experience to
help
shape Medicare lymphedema coverage policy.
--
Robert
Weiss, MS
Lymphedema Patient Advocate
National Lymphedema
Network
----
If you are one of the millions of people who are
struggling to pay
medical bills, you should be aware of the steps you can
take to reduce
or manage your debt. If you owe money to a hospital or
medical
provider, do not ignore your bills. It will be harder to straighten
out
billing mistakes or get financial assistance if you wait. Making
timely
payments will also help you avoid further debt, damage to your
credit
score, lawsuits, and “garnishment” (deductions from your wages or
bank
account). But, if you cannot pay anything right now, you may be able
to
get financial assistance, and you should see if your provider
will
agree to wait before charging interest or sending your debt to
a
collection agency.
This consumer guide covers steps for paying your
medical bills,
understanding your rights, and other information you need to
know if
you are struggling with medical debt. The guide also includes links
to
other useful resources.
http://www.familiesusa.org/resources/resources-for-consumers/coping-with-medical-debt.html
Robert Weiss, M.S.
Lymphedema
Treatment Advocate
National Lymphedema Network
----
CMS MEDCAC
Meeting on Lymphedema (Impressions of LymphActivist)
On November 18 the
CMS Medicare Evidence Development & Coverage Advisory Committee
(MEDCAC) conducted a full-day forum on the evidence basis of lymphedema
measurement and
treatment at their quarterly meeting, the first
time in their ten-year existence that this subject was
discussed.
The NLN took a leading position in organizing
lymphedema medical experts from around the country
to “focus on the
quality of evidence surrounding the diagnosis and treatment of secondary
lymphedema”. Evidence was submitted to the Lymphedema Panel regarding
evidence supporting
commonly used lymphedema diagnosis and treatment
protocols. NLN Medical Advisory Committee
(MAC) members sat on the
panel, gave an invited speech, and gave scheduled and unscheduled
testimony.
The open meeting featured a presentation of the
Technology Assessment HHS/AHRQ commissioned
from McMaster
University Evidence-based Practice Center, Hamilton ONT Canada, followed by
assessments by Stanley Rockson, MD and Jane Armer, PhD, RN, FAAN. This
was followed by
scheduled public comments from 13 lymphedema
experts from lymphedema and venous organizations.
The NLN was well
represented at this meeting and provided valuable inputs to CMS.
The
Expert Panel comprised 10 voting members chosen from the eighty-eight permanent
MEDCAC
members plus a Patient Advocate, an Industry Representative
and three guest panel members who
were non-voting. The goal of the
meeting was to present the best evidence on the measurement and
diagnostic and treatment methods for secondary lymphedema, to question
and hear testimony of the
community of experts and to vote on the
adequacy of the evidence to support use (coverage?) of each
method.
In the afternoon the Panel questioned the presenters and
discussed the evidence, with the goal of
eventually voting on a
number of issues concerning their confidence in the adequacy of the evidence to
support coverage of individual measurement and treatment modalities.
It was the suggestion of one of
the NLN MAC Physicians that the
treatment of multimodal, and that it made little sense to vote on
individual modalities when the current treatment standard CDT is a
combination of modalities. CDT
was added to the list to be voted
on. CDT plus sequential pneumatic compression was also added
since
one of the high-level trials considered it.
An open vote by the expert
panel indicated that the final assessment would be that there is at least
intermediate confidence that CDT alone, CDT with adjuvant pneumatic
compression, compression
bandages and compression garments, and
pneumatic compression devices produce clinically
meaningful
improved health outcomes for lymphedema patients. A vote on measurement methods
was
that no imaging technique had adequate evidence to identify and
stratify severity of secondary
lymphedema, that only physical exam,
patient-reported symptomatology, water displacement and
circumferential measurement had adequate evidence to determine limb
volume, and that only patient-
reported symptomatology had adequate
evidence to identify sub-clinical lymphedema.
Another conclusion was
that there is little confidence that our knowledge and measurement tools allow
us to classify secondary lymphedema into stages of severity that
will be useful to guide choice of
therapy or predict response to
therapy.
We fared much better with respect to the question of whether
there was expert confidence that
improvement in a number of
measures would be associated with improvement of patients' health. Limb
circumference, limb volume, symptom assessment, limb function,
activities of daily living, frequency of
skin breakdown, frequency
of skin infection, quality of life assessment and social integration were all
felt to have medium to high confidence based on existing
evidence.
The MEDCAC Lymphedema Panel will be publishing their final
assessment, with all supporting
evidence and comments submitted by
the public, on the CMS MEDCAC web site within 90 days. The
assessment will presumably be used by the CMS Coverage & Analysis
Group in future discussions of
Medicare coverage of lymphedema
diagnosis and treatment. There will be future opportunities for
public and expert inputs into proposed Medicare coverage changes and we
must continue to take
advantage of these
opportunities.
Since most of the clinical trials which went into these
determinations were trials involving upper limb
breast
cancer-related lymphedema, the last question asked whether there was confidence
that the
diagnostic strategies and treatment methods were
generalizable to Medicare beneficiaries with
secondary lymphedema.
There was intermediate confidence that they were generalizable.
A key
point to be made here is that this entire meeting was focused on the evidence
resulting from
randomized clinical trials, and had no way of
considering clinical evidence, anatomical and biological
knowledge,
observational evidence, expert clinician opinion, consensus-based guidelines,
case studies,
non-randomized experiments, etc. The “rules of
evidence” do not consider this vast body of
knowledge and experience
that form the basis of lymphedema treatment. This evidence was brought in
by the meeting attendees.
So what's the bottom line, you
ask?
I am greatly encouraged. Medicare has finally, after ten years,
started the process of looking into the
coverage of lymphedema
diagnosis and treatment. The process of defining coverage change is a long,
fairly well defined process that has finally started. The process
starts with recognition that there is a
problem with current
coverage, the gathering of peer-reviewed evidence, the evaluation of that
evidence and judgment by an expert panel that the evidence is sufficient
to support a change. The
process then progresses to discussions of
the ways coverage might change. Medicare then implements
the
changed coverage policies at a national level, and they are flowed down to the
local regions. The
process involves writing National and Local
Coverage determinations, revising the HCPCS Codes,
revising billing
procedures, etc.-a long process.
By law, the public and the stakeholder
communities must be involved in every step of the process. I
was
gratified to see that the stakeholder community was not only involved in this
important step, but
was able to influence the conclusions to the
good.
There were still large gaps in the knowledge because the right
questions were not asked and the
contracted technology assessment
valued process over substance. The community was given only three
weeks to respond to the request for evidence, and did not have the
benefit of seeing where the gaps
were in the Technology Assessment
before the meeting. The absence of some groups of stakeholders
to
submit evidence on the efficacy of their products led to gaps in the issues
voted on (e.g. dielectric
constant measurement of skin fluid
content, ultrasound measurement of skin thickness, MRI
diagnostics,
low level laser treatment), and therefore a lack of recommendation of what
might be
promising measurement or treatment modalities to receive
Medicare coverage. I hope that these
information gaps will be
filled in future public interactions with the CMS coverage
organizations.
We're on our way on a 2-3year voyage. Let's continue our
research and trials to show that there is no
hard line between
primary and secondary lymphedema (see recent Rockson editorials), and the
diagnostic and treatment techniques are the same. Let's accelerate our
research and trials on diagnosis
and treatment of non-extremity
lymphedema (e.g. breast, torso, head and neck). Let's get more
evidence of effectiveness or non-effectiveness of non-conventional
treatments such as
electrical/electrostatic/electromagnetic
modalities, vibration modalities, laser/light therapies, and
acupuncture techniques. Let's push our knowledge on hormonal and
inflammation interactions with
lymphedema and treatment of
recurrent infection.
We've taken the first step. That's the importance
of the MEDCAC meeting that took place November
18. And I think it
went well.
Robert Weiss, MS
Lymphedema Patient Advocate
National
Lymphedema Network
The opinions expressed above are solely those of the
writer, and do not reflect the policies or opinions
of any
organization, government agency or manufacturer.
-----
Date
01/19/2010
Subject CMS Updates to Coverage Pages
Content Posted
information from November 18 MEDCAC meeting. Also updated Bariatric Surgery
and Carotid Artery Stenting facility lists.
Medicare Evidence
Development & Coverage Advisory Committee (MEDCAC)
Meetings
11/18/2009 - Lymphedema
Posted transcript from
meeting
http://www.cms.hhs.gov/mcd/viewmcac.asp?where=index&mid=51
----------------
The
following are two extremely informative articles appearing in the New York
Times Health Section
concerning health insurance and hospital
bills. In particular read the end of the first article with sound
advice on filing claims of insurance denials -- much the same as I have
been advising. The numbers of
denials made routinely by insurers is
astounding!
Fighting Denied Claims Requires Perseverance
http://www.nytimes.com/2010/02/06/health/06patient.html?emc=eta1
A Guide Through a Medical
Wilderness
http://www.nytimes.com/2009/08/08/health/08patient.html?_r=1
Bob
Robert Weiss,
M.S.
Lymphedema Patient
Advocate
--------------------------
A6542 Gradient compression
stocking, custom made
A6543 Gradient compression stocking,
lymphedema
Changed HCPCS Codes
A6549 Gradient compression
stocking/sleeve, not otherwise specified
I am not authorized to speak
for Medicare or offer advice in coding or reimbursement, but the
following is my interpretation of the impact of the above changes on
lymphedema treatment
reimbursement.
There is a HCPCS group of
Gradient Compression Stockings (GCS) which are listed in the 2010
HCPCS Code Book with A-codes, appropriate for Surgical Dressings.
Listing does not guarantee
coverage, and the majority of these items
are coded with notes that indicate coverage restrictions or
exclusions based on their not meeting the coverage requirements for
durable medical equipment, splints
and braces and surgical
dressings. They are therefore denied coverage in the treatment of lymphedema
in the absence of an open wound. A detailed analysis of the members
of this group follows:
A6530, A6533-A6541 Gradient Compression Stockings
@ various styles and compression
These are not covered because they do not
meet the rentability requirement of SSA §1861(n) for
"DME" as found
in Coverage Issue #60-9/National Coverage Determination (NCD) Manual §280.1
DME List. They are excluded as "surgical dressings" when not used to
treat burns per NCD §270.5.
They are also excluded by the Medicare
Contractor Manual (MCM section 2133 as they do not meet
the rigidity
requirement for "splints and braces". They are therefore not covered as
surgical dressings
[SSA §1861(s)(5)], durable medical equipment
[SSA §1861(s)(6)] and orthotics [SSA §1861(s)(9)].
Nowhere are they
excluded from coverage in their medical function in lymphedema compression
therapy as prosthetic devices [SSA §1861(s)(8).
A6531-A6532
Gradient Compression Stocking, Below Knee, 30-40 and 40-50 mmHg
These
knee-high stockings have been covered as secondary surgical dressings in the
treatment of open
venous wounds since 1/1/2006, when they replaced
the L8110 and L8120 prosthetic device codes.
Local Coverage
Determinations (LCDs) exclude their coverage as surgical dressings in the
treatment of
lymphedema per MCM 2079/Benefit Policy Manual §100
Surgical Dressings. But this coverage
criteria does not apply to
prosthetic devices.
A6544 Gradient Compression Stocking, Garter
Belt
These are not covered for the same reasons as above.
A6545
Gradient Compression Wrap, Non-Elastic, Below Knee, 30-50 mmHg
Thee wraps
(CircAid T-3M and BiaCare CompreFit Universal Models 1101-1115 BKT/R) have
been approved for coverage since 1/1/2009 and 10/30/2009 respectively,
but only in the presence of
open venous wounds. They have the same
restrictions as A6531 and A6532 above, and must be billed
with an
AW Modifier, designating and open stasis wound. The 2010 pricing for this item
is $89.45.
The pricing codes for the three covered items is for surgical
dressings, which means that a fixed
reimbursement is established
independent of the actual cost of the item. Medicare Suppliers must
accept this fixed amount and cannot balance-bill the
Beneficiary.
A6542 Gradient Compression Stocking, Custom Made and A6543
and Gradient Compression
Stocking Lymphedema
Neither of these
GCSs were covered for the same reasons stated above for A6533-A6541. Prior to
the administrative code change on 1/1/2006 they were designated as
prosthetic devices L8210 and
L8220 and were covered. The HCPCS code
has been deleted and the products described included in
the A6549
Gradient Compression Stocking/Sleeve, Not Otherwise Specified. This HCPCS code
is
still not covered in the treatment of lymphedema in the absence
of an open wound. So nothing was lost
that we had before. The two
deleted codes did not cover upper limb compression sleeves which were
only
listed with non-reimbursable S-codes.
The A6549 code used to apply only
to "gradient compression stockings, and the description has been
broadened to include sleeves. The inclusion of both stockings and
sleeves in a "not otherwise specified"
category implies that the
category is wide, and the reimbursement will be based on the usual cost and
not a fixed amount for all items in this code. HCPCS defers pricing of
these items to the DME MAC.
If these items are eventually covered
by Medicare as prosthetic devices, the reimbursement may be
based
on the price of the custom item and not a fixed reimbursement for the
group.
We must wait for changes in the coverage LCD and Article to
define the coverage criteria t be used for
this code, i.e. whether
an open wound is required or whether these items, still coded with a surgical
supply A-code, would be covered as prosthetic devices when used in
the compression treatment of
lymphedema. CMS is aware of my
successful ALJ decisions supporting this interpretation.
Bob
Weiss
------------
Although the following letter deals with
covered items such as rental items and recurring supplies, it
might
be prudent to follow the same procedures to support the recurring purchases of
compression
bandage systems, compression garments and devices, even
though they are not currently covered by
Medicare. Always get a
prescription for these items from a PECOS listed physician and purchase them
from a Medicare-enrolled Supplier if you hope to be reimbursed
through the Medicare appeal system.
Bob
Robert Weiss,
M.S.
Lymphedema Patient Advocate
National Lymphedema
Network
===========================================================
March
17, 2010
Durable Medical Equipment - Documentation of Continued Medical
Necessity
Dear Physician,
To assure that correct payment is made for
items and services that are provided to Medicare
beneficiaries, the
need for detailed medical documentation is paramount. If your treatment plan
includes
durable medical equipment, prosthetics, orthotics, and
supplies (DMEPOS), Medicare requires that
suppliers have access to
information from the patient's medical record that addresses the coverage
criteria for the items prescribed. Accessibility of pertinent medical
record information protects both the
patient and the supplier in
the event of an audit.
For many items, Medicare coverage requires that
continued use must be assessed and documented by
the treating
physician. Rental items such as oxygen, nebulizers, CPAP, wheelchairs, and
hospital beds
and recurring supplies such as glucose test strips,
urological supplies, and ostomy supplies must be
periodically
justified in the medical record. Ongoing need for and use of the item must be
documented
in your patient's record in order for Medicare to
continue reimbursement for the equipment or supplies.
In these
instances, you or your staff should regularly review the use of medical
equipment and supplies
by your patients. This review should be no
different than your review of the continued need for
medication or
other treatments.
Recent audits conducted by the Comprehensive Error Rate
Testing program have shown that patients'
medical records
frequently lack sufficient information to justify the continued need for the
item(s)
ordered. This results in claim denials for the DMEPOS
supplier and potential financial liability for your
patient. When a
claim is denied, the DMEPOS supplier may be unable to continue to provide the
item
(s) ordered. Clearly, this outcome may affect your care plan.
As the patient's treating physician, it is
important that you
understand the applicable Medicare coverage criteria related to the DMEPOS you
are prescribing and adequately document the applicable policy
criteria for those items on an ongoing
basis.
Medicare DMEPOS
Local Coverage Determinations (LCDs), which include details on specific
coverage criteria, are available in the Medicare Coverage Database or
on each DME MAC's Web site.
Sincerely,
Paul J. Hughes,
M.D.
Medical Director, DME MAC, Jurisdiction A
Adrian M. Oleck,
M.D.
Medical Director, DME MAC, Jurisdiction B
Robert D. Hoover, Jr.,
MD, MPH, FACP
Medical Director, DME MAC, Jurisdiction C
Richard W.
Whitten, MD, MBA
Medical Director, DME MAC, Jurisdiction
D
----
The following announcement summarizes a change to the
Medicare claims and appeals procedures that
shortens the time after
a service is provided for filing the initial claim:
Timely Filing
Requirements for Medicare Fee-For-Service Claims
On March 23, 2010,
President Obama signed into law the Patient Protection
and Affordable Care
Act (PPACA), which amended the time period for filing
Medicare
fee-for-service (FFS) claims as one of many provisions aimed at
curbing
fraud, waste, and abuse in the Medicare program. Under the new law,
claims
for services furnished on or after January 1, 2010, must be filed
within one
calendar year after the date of service. In addition, Section
6404 mandates
that claims for services furnished before January 1, 2010,
must be filed no
later than December 31,
2010.
http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/844LP34117?opendocument
--
Robert
Weiss, MS
Lymphedema Patient Advocate
National Lymphedema
Network
LymphActivist@aol.com
------
The following
letter sent to physicians writing prescriptions for DMEPOS items clearly states
the
requirement for documentation of the medical need for the
items. Unfortunately the consequence of a
physician's or supplier's
non-compliance with these statutes falls on the patient, who must pay for the
medical items. It is always a good idea for you, the patient, to
obtain a copy of your medical records
and obtain a letter of
medical necessity for all compression items you
need.
Bob
Robert Weiss, M.S.
Lymphedema Patient
Advocate
National Lymphedema
Network
========================================================
Attention
Physicians Ordering Supplies!
Dear Physician,
The National Durable
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Task
Force
would like to encourage physicians to please respond to any Comprehensive Error
Rate Testing
( CERT ) documentation request they receive from CERT
or the providing supplier.
DMEPOS suppliers can only provide to the CERT
contractor the documentation that the physicians
provide to them. In
order for DMEPOS suppliers to continue to provide the necessary items/service
to
your patient, they must be able to rely on your cooperation in
providing any additional documentation
requested. S ince physicians
are the ones treating the beneficiaries and are responsible for maintaining
records to support medical necessity of the services they provide, this
typically means copies of your
office notes, pertinent test
reports, and other pertinent healthcare records maybe required to support
the DMEPOS items/service ordered. As it is stated in the Social
Security Act:
Section 1833(e) of the Social Security Act precludes payment
to any provider of services unless "there
has been furnished such
information as may be necessary in order to determine the amounts due such
provider." It is expected that the patient’s medical records will
reflect the need for the care provided.
The patient’s medical
records include the physician’s office records, hospital records, nursing home
records, home health agency records, records from other healthcare
professionals and test reports.
This documentation must be
available upon request.
When physicians are unable to provide the requested
documentation, the suppliers receive denials for
the items billed
and their payment is recouped which could result in your patient being
financially
responsible for all or part of the charges for the
items/service received.
The DMEPOS Task Force is asking for the cooperation
of the physician community. If a supplier
contacts your office to
request additional clinical documentation, partner with the supplier to
establish
what clinical records are needed to support that the
service/item you ordered is medically necessary.
Section 1842(p)(4) of the
Social Security Act mandates that:
[i]n case of an item or service…ordered
by a physician or a practitioner…but furnished by another
entity,If
the Secretary (or fiscal agent of the Secretary) requires the entity furnishing
the item or service
to provide diagnostic or other medical
information in order for payment to be made to the entity, the
Physician or practitioner shall provide that information to the entity
at the time that the item or service is
ordered by the physician or
practitioner.
Providing medical records to the supplier is not a violation
of the HIPAA Privacy Rule. Thank you for
your cooperation in future
documentation requests.
The National DMEPOES Task
Force
-------
April 14, 2010
Medicare Appeals – The Importance
of Getting it to the Right Place at the Right Time!
Over the past year,
the Qualified Independent Contractor (QIC) Part B North (the processor of
second – level appeals or reconsiderations) has consistently made a high
rate of dismissal decisions.
Based on data analysis, the driving
factor in this high rate is that appellants, primarily providers, request
reconsideration when a redetermination (first level appeal performed by
CIGNA Government Services
following the processing of the original
claim) has not been completed.
While often the cause appears to be
simply confusion over the steps of the appeals process and the
parties involved, we have also noted that some providers are confusing
written and telephone inquiry
responses from CIGNA Government
Services with official redetermination decisions. In accordance
with current instructions, contractors are required to issue a written
notice of redetermination. If you
disagree with this decision, you
may then file a reconsideration request in writing with the QIC.
Please
remember…..
Your first level appeal, a redetermination, is performed by
the contractor who processed the original
claim and those requests
should be sent directly to CIGNA Government Services. Sending a first level
appeal request to the QIC will result in a dismissal.
* You have
120 days from the date of receipt of the Remittance Advice to request a
redetermination.
You do not get extra days if you send it to the
wrong entity (i.e. if you send it to the QIC and
subsequently
receive a dismissal for no redetermination, the 120 day clock is still ticking
against the
original claim process date).
* The Medicare
Redetermination Notice (MRN) should specifically reference the date of the
original
decision, state a clear decision of favorable, partially
favorable, unfavorable or dismissed, and advise of
any further
appeal rights with the QIC’s address. Please review the entire MRN
carefully.
* Your request for a second level appeal, a reconsideration,
should be sent directly to the QIC at the
address in the MRN,
within 180 days of receipt of the notice. It is helpful if you include a copy
of the
redetermination decision.
Lastly, please be sure your
request details specifically all the claims you are requesting an appeal on,
including the beneficiary’s name, the Medicare Health Insurance
claim number, the dates of service at
issue, the services at issue,
your reason for appealing, the name and signature of the party or
representative of the party, and the name of the contractor that made
the redetermination.
Bob
Robert Weiss, M.S.
Lymphedema
Patient Advocate
National Lymphedema
Network
-------------------------------
Extension of Therapy
Cap Exceptions Process
Section 3103 of the Patient Protection and
Affordable Care Act extends the
exceptions process for outpatient therapy
caps. Outpatient therapy service
providers may continue to submit claims
with the KX modifier, when an exception
is appropriate, for services
furnished on or after January 1, 2010, through
December 31, 2010.
Therapy caps are determined on a calendar year basis, so all patients
began a
new cap year on January 1, 2010. For physical therapy and speech
language
pathology services combined, the limit on incurred expenses is
$1,860. For
occupational therapy services, the limit is $1,860. Deductible
and coinsurance
amounts applied to therapy services count toward the amount
accrued before a
cap is reached.
Bob
Robert Weiss,
M.S.
Lymphedema Patient Advocate
National Lymphedema Network
Medicare Advantage premiums to dip
in 2011
..By Susan Heavey Susan Heavey – Tue Sep 21, 4:46 pm
ET
WASHINGTON (Reuters) – Elderly and disabled Americans enrolled in private
Medicare health insurance
plans will pay slightly lower premiums in
2011 while gaining more benefits from recently passed healthcare
reforms, U.S. health officials said on Tuesday.
The plans, called
Medicare Advantage, are offered by health insurance companies as an alternative
to
traditional, government fee-for-service Medicare. Rates are
expected to be 1 percent lower next year than
in 2010, the
government's Centers for Medicare and Medicaid Services (CMS)
said.
Enrollment in the plans is expected to grow 5 percent. More than
11 million people are already enrolled in
the plans, which have come
under fire from critics who say the government pays too much to the companies
running them.
Jonathan Blum, director of CMS' Center for
Medicare, said the lower costs and projected expansion show
that
companies are still interested in offering such plans despite new consumer
protections under the
healthcare law and recent payment caps to
insurers.
"This is still a very attractive marketplace for Medicare
Advantage plans," he told reporters.
Companies such as Humana Inc and
UnitedHealth Group Inc are some of the biggest providers of such
plans.
Shares of health insurers were up more than 1 percent on
both the Morgan Stanley Healthcare Payor Index
and the S&P
Managed Health Care Index, outpacing the stock market overall.
Stifel
Nicolaus analyst Thomas Carroll said the government's announcement was "in line
with our view of
what the competitive environment will be like next
year."
The companies, Carroll said, appear poised to endure some margin
deterioration in order to boost market
share, just as the post-war
baby boomer population becomes eligible for Medicare.
The news comes as
the healthcare reform law, passed in March, hits its six-month anniversary this
week,
triggering a host of changes for insurers overall, such as
ending lifetime coverage caps and banning policy
cancellations after
an enrollee gets sick.
Under the law, Medicare Advantage consumers will
see their out-of-pocket expenses limited and a
reduction in how much
they have to share costs when it comes to kidney dialysis, chemotherapy and
other
expensive care, Blum said.
Starting in January,
enrollees can also see greater discounts for prescription drugs sold either as
a separate
Part D plan or as part of bundled Medicare Advantage
coverage.
The healthcare law offers a 50 percent discount from
drugmakers in the so-called 'donut hole' when drug
benefits
temporarily stop. Officials also said more insurers were expected to offer
plans that covered the
gap.
Overall, about 5 percent of
beneficiaries will have to choose a new provider because their Medicare
Advantage plan has shut down, officials said.
The insurance
industry warned, however, that seniors can expect more costs and fewer benefits
with
Medicare Advantage plans after payment freezes have more time
to take effect.
"As deep cuts go into effect in the coming years,
government experts have forecasted that millions of
seniors will
experience higher costs, reduced benefits and fewer choices," America's Health
Insurance Plans
President and CEO Karen Ignagni said in a
statement.
The group, along with its insurer members, fought against
many of the healthcare reforms before they
passed but now says it
is committed to implementing the law.
The government's Centers for
Medicare and Medicaid Services said some companies chose to abandon
the Medicare business next year, mostly those offering private
fee-for-service plans that wanted to increase
beneficiaries' costs
while increasing profit margins.
About 300 out of 2,100 plans were not
allowed to offer plans unless companies agreed to change them,
officials said. Most agreed to make changes, but others did
not.
(Reporting by Susan Heavey; Additional reporting Lewis Krauskopf;
Editing by Dave Zimmerman, Gary
Hill)
The following
presents a rare opportunity to get your suggestions considered regarding
changes to the
Medicare coverage and billing of physical and
occupational therapy protocols for treatment of
lymphedema. You
have a chance to do more than just complain about reimbursement for lymphedema
services you provide.Are you happy with your reimbursement for:
Patient instruction in home self care;
Time for measurement of
swelling, skin tone, bioimpedance, etc.; Time in bandaging; Cost of
bandages
used incident to your services (as distinguished from the
bandages provided as replacements for home use)
[issue: billing
Part B VS DME]; Compression garment measurement, fitting, specification,
evaluation?Do
you feel that there should be special qualifications
for lymphedema providers?Should there be a separate
code for CDT and
MLD other than 97140 to distinguish these procedures from other physical
therapy and
rehabilitation procedures?Should there be coordination
between the services provided under 97140 and
97016?Do you feel
that the goals of physical therapy and rehabilitation and the goals of
complexdecongestive
therapy should be distinguished from each other and policies reflect that
distinction?
Meetings are scheduled in Mid October where you can present
your comments and propose changes to
the Palmetto Medical
Directors, and then there will be a 6-week comment period to submit formal
comments.J1 Part B LCD DL28290 Comment Period Start October
15
Share with your staff - The comment period for J1 Part B Local
Coverage
Determination (LCD) Physical Medicine and Rehabilitation Policy
DL28290
will begin on October 15 and end on December 3,
2010.
http://www.palmettogba.com/palmetto/providers.nsf/ls/J1B~89GQLZ0524?opendocument
OPEN
DRAFT LCD MEETINGS OCTOBER 2010
Palmetto GBA J1 A/B Medicare
Administrative Contractor (MAC) has scheduled Open Draft Local
Coverage Determination (LCD) meetings in the following areas in October
2010. The general public is
invited to submit information related
to the proposed LCDs for Palmetto GBA's consideration. The draft
LCDs will be posted in the next few weeks on our Web site.
LCDs
are administrative and educational tools that assist providers, physicians and
suppliers in submitting
correct Medicare claims for
coverage.
California
Time: 9 a.m. to 11 a.m. PDT on October 19,
2010
Location: Crowne Plaza San Francisco International Airport, 1177
Airport Blvd., Burlingame, CA 94010
Hawaii
Time: 8 a.m. to 10 a.m. HDT on
October 14, 2010
Location: The Pacific Club, 1451 Queen Emma Street,
Honolulu, HI 96813
Nevada
Time: 9 a.m. to 11 a.m. PDT on October 21,
2010
Location: Nevada State Medical Association, 2590 E. Russell Road, Las
Vegas, NV 89120
Robert Weiss, M.S.
Lymphedema Treatment
Advocate
National Lymphedema Network
A Message for North Carolina
Physical Therapy Providers
This is to alert you that July 15, 2010, CMS
will be releasing approximately 5,000 Comparative Billing
Reports
(CBRs) studying the comparison of a provider’s utilization of the KX modifier
with their peers in
their state and across the nation. A single
state release will be done first, followed by a national release.
North Carolina has been chosen as the single state; approximately 70
CBRs will be disseminated initially,
with the remaining CBRs to
follow. The purpose of this CBR is to educate independent Physical Therapy
providers and help prevent improper payments. A sample is attached.
Please note in the sample, that
providers who have questions about
the content of their CBR can call the CBR Support Team at 530-896-
7080, 8 a.m. to 5 p.m. local time. They can also get answers to their
frequently asked questions by visiting
the CBR Services website at
www.cbrservices.com
Click
here for the sample file
http://www.cignagov ernmentservices. com/partb/ pubs/pdf/
A-CBR001. pdf
CBR
Services Overview
The Centers for Medicare and Medicaid Services (CMS)
awarded the Comparative Billing Report (CBR)
contract to SafeGuard
Services LLC (SGS). A Comparative Billing Report or CBR is a documented
analysis that shows a provider's billing pattern for various procedures
or services and compares that billing
to their peers.
CMS has
authorized SGS to begin producing nationwide CBRs beginning in 2010. SGS, as
the CBR
Producer, has begun to develop an inventory of potential
topics for study. CBRs will be produced using
national data from
Medicare A, B and DME. Once each study has been completed, the CBR will be
mailed or faxed to the providers that were selected under the topic
criteria. A maximum of 5,000 providers
will be selected per CBR
topic. The CBR, approximately 4 pages in length will also be distributed to
each
provider in a PDF format. If, after reviewing the document the
provider has any questions, they would then
be able to call into
the SGS CBR support team, whose contact information will be provided on each
CBR.
The CBR is not intended to be punitive or sent as an indication of
fraud. Rather it is intented to be a
proactive statement that will
help the provider identify potential errors in their billing practice. A CBR
contains peer comparisons which can be used to provide helpful
insights into their coding and billing
practices. The information
provided is designed to help the provider prevent improper billing and
payment.
August 19, 2010 -
Correct Coding for Pneumatic
Compression Devices
Pneumatic compression devices (PCD) consist of an
inflatable garment for the arm or leg and an electrical
pneumatic
pump that fills the garment with compressed air. The garment is intermittently
inflated and
deflated with cycle times and pressures that vary
between devices. Several categories of these devices
exist. It is
important to use the correct HCPCS code for the item provided.
PCDs
used for the treatment of lymphedema and chronic venous insufficiency with
ulcers are coded based
upon the characteristics of the base device.
The codes used are:
• E0650 - PNEUMATIC COMPRESSOR,
NON-SEGMENTAL HOME MODEL
• E0651 - PNEUMATIC COMPRESSOR, SEGMENTAL HOME
MODEL WITHOUT
CALIBRATED GRADIENT PRESSURE
• E0652 -
PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH
CALIBRATED GRADIENT
PRESSURE
PCDs used for the treatment of arterial disease are
coded:
• E0675 - PNEUMATIC COMPRESSION DEVICE, HIGH PRESSURE,
RAPID
INFLATION/DEFLATION CYCLE,FOR ARTERIAL INSUFFICIENCY
(UNILATERAL AND
BILATERAL SYSTEM)
Sleeves used with E0650 -
E0652 and E0675 are billed separately using codes E0655 - E0673 depending
upon the specific item provided.
There are other types of
PCDs that are often referred to as deep vein thrombosis (DVT) pumps, massage
therapy pumps, post surgical DVT preventative pumps, etc. (not all
inclusive). These types of devices are
coded:
• E0676
- INTERMITTENT LIMB COMPRESSION DEVICE (INCLUDES ALL
ACCESSORIES),
NOT OTHERWISE SPECIFIED
The garments/sleeves that are used with E0676
are included in the payment for E0676 and must not be
billed
separately. If a supplier chooses to bill separately for the garment/sleeve,
then HCPCS code A9900
- MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR
SERVICE COMPONENT OF
ANOTHER HCPCS CODE must be
used.
HCPCS code A4600 - SLEEVE FOR INTERMITTENT LIMB COMPRESSION
DEVICE,
REPLACEMENT ONLY, EACH is used only when the sleeve is
being replaced, not at the time of initial
issue. This code may only
be used with compressors coded with E0676. HCPCS codes E0655 - E0673
must
not be used when billing for garments used with E0676 devices.
Refer
to the Local Coverage Determination (LCD) and Policy Article for Pneumatic
Compression Devices
for coverage and HCPCS coding
requirements.
August 23, 2010 -
Physical Therapists Are
First Recipients Of CMS Comparative Billing Reports
The Centers
for Medicare & Medicaid Services mailed its first-ever comparative billing
reports (CBRs) to
as many as 5,000 physical therapists during the
week of Aug. 9, according to an Aug. 16 e-mail notice
from
CMS.
The CBRs, produced by SafeGuard Services LLC and
distributed by Livanta LLC under contracts with
CMS, compare
providers' individual billing practices for specific procedures and services
with their peer
group. CMS developed the program to reduce improper
payments and to educate providers on Medicare
billing
requirements.
CMS has issued similar reports in the past,
including the Program for Evaluating Payment Patterns
Electronic
Report (PEPPER) sent to inpatient hospitals, and Resource-Based Relative Value
Scale
(RBRVS) feedback reports sent to physicians, but this is the
first time CMS has issued CBRs, agency
spokesman Peter Ashkenaz
told BNA Aug. 17.
The initial CBRs apply to outpatient physical
therapy services provided by independent physical therapists
and
are based on 2009 Medicare claims data.
Physical therapists were
chosen due to an identified vulnerability in their billing procedures centered
on use
of the KX modifier. The KX modifier is required to indicate
that a service was medically necessary and
justified by medical
records, that the physical therapy financial limitation cap was met, and that a
patient's
condition requires further
treatment.
Moving forward, SafeGuard will produce and send new
CBRs to Livanta each month for distribution to
providers.
By James Swann
Information on
the CBR program is at
http://www.safeguard-servicesllc.com/cbr/default.asp.
Medicare
Provider-Centered Comparative Billing Report (CBR)
Last week,
the Centers for Medicare & Medicaid Services mailed Comparative Billing
Reports (CBRs) to
up to 5000 physical therapists across the
country. The reports provide comparative data on how an
individual health care provider varies from other providers by looking
at utilization patterns. We have heard
from a number of providers
that this kind of information is very helpful to them and have encouraged us to
produce more CBRs and make them available to providers.
These reports are not available to anyone but the provider who
received them. To ensure privacy, CMS
presents only summary billing
information. No patient or case-specific data is included. A sample is
provided in this communication. These are tools to help providers
comply with Medicare billing rules and
improve the level of care
they furnish to their patients, our beneficiaries.
Provider Help
Desk
CBR Support Team at 530-896-7080
CBR Services website at
www.cbrservices.com
September
2, 2010 -
The following policy article applies only to claims
made for Medicare Part a or Part B services (not
DMEPOS) but has
some valuable information for all Beneficiaries who have or are contemplating
sending
in claims because their provider or supplier says they are
not covered.
MM6874- Beneficiary-Submitted Claims
This article,
based on Change Request (CR) 6874, clarifies instructions for processing claims
by carriers
and A/B MACs that are submitted by Medicare
beneficiaries. All providers and suppliers are required to
enroll
in the Medicare program in order to receive payment. In addition, Section 1848
(g)(4)(A) of the
Social Security Act requires all providers and
suppliers submit claims for services rendered to Medicare
beneficiaries. The current manual requirement instructs Medicare
contractors how to process claims
submitted by Medicare
beneficiaries when the provider or supplier refuses to submit claims for
services
rendered and/or refuses to enroll in Medicare. Read more
at http://www.cms.
gov/MLNMattersArticles/downloads/MM6874.pdf.
The Amount in Controversy (AIC)
required to sustain Administrative Law Judge (ALJ) and Federal
District Court appeal rights beginning January 1, 2010. o The amount
remaining in controversy
requirement for ALJ hearing requests made
before January 1, 2010, is $120. The amount remaining in
controversy
requirement for requests made on or after January 1, 2010, is $130. o For
Federal District
Court review, the amount remaining in controversy
goes from $1,220 for requests on or after January
1, 2009, to
$1,260 for requests on or after January 1, 2010. That means that when you file
a Medicare
appeal make sure that you combine all the items in a
single appeal. You can combine claims so long as
they are all
within the filing time window. And remember that the Amount In Appeal is the
cost of the
material less your 20% co-pay, so if you want to
eventually be considered by an ALJ your appeal must
be for an
aggragate amount of greater than $163.00 Bob Robert Weiss, M.S. Lymphedema
Patient
Advocate National Lymphedema
Network
-----------------------
May 20, 2010
Therapeutic
Shoes - In-Person Fitting and Delivery
Appendix C of the DMEPOS Quality
Standards published in October 2008 addresses specific
requirements
for orthoses, prostheses, prosthetic devices, and therapeutic shoes. Those
standards
include requirements for "an in-person diagnosis-specific
functional clinical examination" by the supplier
to determine the
need for a particular item as well as "face-to-face fitting/delivery" by the
supplier.
Therefore, in order for therapeutic shoes, inserts, and
shoe modifications to be covered, both of the
following criteria
must be met:
1.Prior to selecting the specific items that will be
provided, the supplier must conduct and document an
in-person
evaluation of the patient; and,
2.At the time of delivery of the
items selected, the supplier must conduct and document an in-person
visit with the patient to ensure that the shoes/inserts/ modifications
are properly fit and meet the
beneficiary' s needs.
In order to
meet these criteria, effective for claims with dates of service on or after
July 1 , 2010, the
following documentation requirements must be
met:
•The in-person evaluation prior to selecting the items must include
at least an examination of the
patient's feet with a description of
the abnormalities that will need to be accommodated by the
shoes/inserts/ modifications. For all shoes, it must include taking
measurements of the patient's feet. For
custom molded shoes (A5501)
and inserts (A5513), this visit must also include taking impressions,
making
casts, or obtaining CAD-CAM images of the patient's feet that will be used in
creating positive
models of the feet.
•The in-person
visit at the time of delivery must include an assessment of the fit of the
shoes and inserts
with the patient wearing them.
Depending on the
items ordered, both the evaluation and delivery could occur on the same day if
the
supplier had both a sufficient array of sizes and types of
shoes/inserts and adequate equipment on site
to provide the items
that meet the beneficiary' s needs. Both components of the visit (criteria 1
and 2,
above) must be clearly documented.
Documentation of
these visits must be available to the DME MAC, PSC/ZPIC, RAC, or CERT
contractor
on request. If one or more of these requirements are not met, the claim will be
denied as
statutorily noncovered.
This information will be
incorporated in a future revision of the Therapeutic Shoes policy. Refer to the
Therapeutic Shoes Local Coverage Determination and Policy Article
for additional information
regarding coverage, coding, and
documentation.
From: NHIC DME MAC A
Robert Weiss,
MS
Lymphedema Patient Advocate
National Lymphedema
Network
__._,_.___
==========================
The
revised Rehabilitation Therapy Information Resource for Medicare Fact Sheet
(April 2010) is now
available in downloadable format from the
Centers for Medicare & Medicaid Services? Medicare
Learning
Network at http://www.cms. gov/MLNProducts/ downloads/ Rehab_Therapy_
Fact_Sheet.
pdf on the CMS website. This fact sheet provides
guidance and resources related to rehabilitation
therapy services,
coverage requirements, and payment
systems.
-------------------
Change in the Amount in Controversy
(AIC) Requirement for Administrative Law Judge Hearings and
Federal
District Court Appeals
MLN Matters® Number: MM6894
Related Change
Request (CR) #: 6894
Related CR Release Date: May 7, 2010
Effective Date:
August 9, 2010
Related CR Transmittal #: R1965CP
Implementation Date:
August 9, 2010
Provider Types Affected
Physicians, providers and
suppliers submitting claims to Medicare carriers, Durable Medical Equipment
Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries
(FIs), Part A/B MACs
(A/B MACs) and/or Regional Home Health
Intermediaries (RHHIs) for services provided to Medicare
beneficiaries are affected.
Provider Action Needed
This
article is based on Change Request (CR) 6894, which notifies Medicare
contractors of the
Amount in Controversy (AIC) required to sustain
Administrative Law Judge (ALJ) and Federal District
Court appeal
rights beginning January 1, 2010.
The amount remaining in controversy
requirement for ALJ hearing requests made before January 1,
2010, is
$120. The amount remaining in controversy requirement for requests made on or
after January
1, 2010, is $130.
For Federal District Court
review, the amount remaining in controversy goes from $1,220 for requests
on or after January 1, 2009, to $1,260 for requests on or after January
1, 2010
Please sure that your staff knows of these
changes.
Background
The Medicare claims appeal process was amended by
the Medicare, Medicaid and SCHIP Benefits
Improvement and
Protection Act of 2000 (BIPA). CR 6894 modifies the Medicare Claims Processing
Manual, Chapter 29, Sections 220, 330.1 and 345.1 to update the AIC
required for an ALJ hearing or
judicial court review. CR 6894 also
expands the background information in the Amount in Controversy
General Requirements, Principles for Determining Amount in Controversy
and Aggregation of Claims
to meet Amount in Controversy sections
250, 250.1, 250.2 and 250.3 in the Claims Processing
Manual,
Chapter 29. The revised portions of the manual are attached to CR
6894.
Additional Information
The official instruction (CR 6894)
issued to your Medicare Carrier, A/B MAC, DME MAC, FI and/or
RHHI
is available at www.cms.gov/Transmittals/downloads/R1965CP.pdf on the Centers for
Medicare & Medicaid Services (CMS) Web site.
A brochure
entitled, The Medicare Appeals Process: Five Levels To Protect Providers,
Physicians
And Other Suppliers provides an overview of the Medicare
Part A and Part B administrative appeals
process available to
providers, physicians and other suppliers who provide services and supplies to
Medicare beneficiaries, as well as details on where to obtain more
information about this appeals
process. The brochure is available
at www.cms.hhs.
gov/MLNProducts/downloads/MedicareAppealsProcess.pdf on the CMS
Web site.
The
brochure is a very well done information source.
Bob
Robert
Weiss, M.S.
Lymphedema Patient Advocate
National Lymphedema
Network
--------------
The topic of Medicare limits on therapy comes
up very often, and I wish to comment. My comments
apply to current
Medicare policy, but to the extent that the principles apply to lymphedema
medical
treatment in general, they may be able to be used for
private insurance too.
Medicare has a policy this year called the
"exception" rule which allows therapy beyond the annual
$1860 limit
when the additional treatments are deemed "medically necessary" by the treating
physician.
The additional treatments might be necessary because
there are other co-conditions which make the
therapy less
efficient, force the therapy to be done slower than usual, extend to multiple
body sites, etc.
This is all assuming that the therapist is
qualified and competent, and is teaching the patient to do home
self-treatment between clinical sessions.
Some of these
co-conditions might be congestive heart failure, venous insufficiency,
peripheral arterial
disease, obesity, lipodema, multiple limbs or
body sites, diabetes, etc.
If Medicare turns you down ask your physician
to write a letter of medical necessity for additional
treatments
because these co-morbidities make the treatment less efficient and therefore
require therapy
exceeding the statutory (policy for insurance)
limits.
Medicare will reimburse ANY physical therapist or occupational
therapist why treats a lymphedema
patient regardless of whether
that therapist has the specialized lymphedema training. This occasionally
results in treatment that may not be effective, and the patient reaches
the annual limits without
experiencing the improvement that would be
expected from a properly qualified therapist.
ALWAYS check whether the
lymphedema therapist has had adequate training and experience, and if
not,
find one who has. The LANA national certification for lymphedema therapists
requires a minimum
of 135 hours of lymphedema training on top of a
current license in physical or occupational therapy plus
one year
of clinical experience overseen by a qualified lymphedema
therapist.
Bob
Robert Weiss, M.S.
Lymphedema Patient
Advocate
National Lymphedema
