DME/Customary Rate/No Fault

Messages
1
Best answers
0
I have encountered a specific situation and am wondering if anyone can offer some advice and/or resource information.

A DME supplier provides a product that is not included in the CPT/HCPCS book nor in the fee schedule of Medicaid, Medicare or Workers comp. The product however, is approved by FDA, therefore it is allowed to provide to patients for therapy.

In such instances you bill the product under HCPCS CODE E1399 durable medical equipment miscellaneous. However, this code doesn't have a maximum reimbursement amount. To the best of my knowledge, as being a coder, in such instances the reimbursement would depend on the acquisition cost (i.e. the line item cost from a manufacturer or wholesaler net of any rebates, discounts or other valuable considerations, mailing, shipping, handling, insurance costs or any sales tax) to the provider plus 50%;

or the usual and customary price charged to the general public.

This specific product is a rental.

However, the no-fault payer denied the payment amount requested by the supplier and wants to calculate the reimbursement with the Medicaid policy and guidelines which equals to 1/6 of the acquisition cost of the product from the wholesaler.

To the best of my knowledge Worker Compensation DME Fee Schedule is not bound to the Medicaid DME provider manual policy guidelines. see section 442.2 subsection (g).


Section 442.2 Fee Schedule

A The maximum permissible charge for the purchase of durable medical equipment, medical/surgical supplies, and orthotic and prosthetic appliances shall be the fee payable for such equipment or supplies under the New York State Medicaid program at the time such equipment and supplies are provided, except that the fee for bone growth stimulators (HCPCS codes E0747, E0748 and E0760) shall be paid in one payment and not split. For orthopedic footwear or if the New York State Medicaid program has not established a fee payable for the specific item, then the fee payable, shall be the lesser of:

1. the acquisition cost (i.e. the line item cost from a manufacturer or wholesaler net of any rebates, discounts or other valuable considerations, mailing, shipping, handling, insurance costs or any sales tax) to the provider plus 50%; or
2.the usual and customary price charged to the general public.

B. The maximum permissible monthly rental charge for such equipment, supplies and services provided on a rental basis shall not exceed the lower of the monthly rental charge to the general public or the price determined by the New York State Department of Health area office. The total accumulated monthly rental charges shall not exceed the fee amount allowed under the Medicaid fee schedule.

C. The maximum permissible charge for the purchase of durable medical equipment, medical/surgical supplies, and orthotic and prosthetic appliances and the maximum permissible monthly rental charge for such equipment, supplies, and services provided on a rental basis as set forth in subdivisions (a) and (b) of this section are payment in full and there are no separate and/or additional payments for shipping, handling, and delivery.

D. Self-insured employers and insurance carriers, including their agents and designees, shall not direct a claimant to use a particular supplier of durable medical equipment, medical/surgical supplies, and orthotic and prosthetic appliances, except as part of a certified preferred provider organization in accordance with Workers' Compensation Law Article 10-A and Subpart 325-8 of this Title. Self-insured employers and insurance carriers, including their agents and designees, may recommend a supplier of durable medical equipment, medical/surgical supplies, and orthotic and prosthetic appliances.

E. Notwithstanding any other provision to the contrary, the Chair may make other adjustments to the durable medical equipment fee schedule as he or she deems appropriate, upon a finding that the reimbursement provided for a particular piece of durable medical equipment, medical/surgical supply or other such item under the fee schedule is grossly inadequate to meet the suppliers' or pharmacies' costs, and following thirty days notice on its website and consideration of any comments provided in response to such notice. Requests for such adjustments to the fee schedule shall be submitted to the Bureau of Health Management, 100 Broadway-Menands, Albany, New York 12241.

F. Hearing aids are not considered durable medical equipment for purposes of this fee schedule and the reimbursement is the provider's usual and customary price.

G. The Medicaid provider manual and the policy guidance for durable medical equipment are not included as part of the durable medical equipment fee schedule used in workers' compensation cases except to the extent such documents contain the Medicaid durable medical equipment fee schedule.
Does anyone have any ideas, suggestions or where I can get resources that address this issue?

Thanks in advance,

Phillip Schwimmer, CPC-A
 
Top