Inconsistent CMS Guidelines Leave Health Providers in Financial Turmoil

Lack of consistent policy guidelines and flawed documentation process could be the reason for Medicare’s denial of many Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), a U.S. Department of Health and Human Services Office of the Inspector General (OIG) report suggests.

The American Association for Homecare recognizes this report and points to its findings as evidence that the technical problems must be addressed. Tyler Wilson, president of American Association for Homecare, says the denial of DMEPOS claims hurts health care providers who pay for products that are crucial to the health of their patients, and are in turn denied reimbursement by the Center for Medicare and Medicaid Services (CMS).

“Providers are paying for products and services that are medically necessary for Medicare beneficiaries. Then, largely for technical reasons, the reimbursements for providers are being denied, and they must go through a lengthy and costly appeals process to receive payment,” said Wilson.

Upon beginning the appeals process, WIlson states that cash flow shortages and government audits can occur and cause care providers to cease the provision of products to patients and potentially go out of business.

A June 4 Mobility Matters article cites the inconsistency of medicare payment guidelines as a contributor to the flawed process of reimbursement for care providers.

The article cites wheelchair providers as those especially affected by inconsistent policy and payment guidelines. Because the process for reporting wheelchair necessity has changed many times in the last decade, confusion among physicians, clinicians, providers and Medicare beneficiaries has occurred, said the article.

The OIG report found improper Medicare payments reported to Congress for fiscal years 2009 and 2010 should have been reduced by $2 billion because many payments originally deemed improper were overturned and paid during the appeals process.

While CMS continues to deny DMEPOS claims, WIlson says the the unfair denials must be addressed and a change needs to occur.

“What’s clear is the underlying problems contributing to the error rate must be addressed,” said Wilson. “It’s absurd for the private sector to have to pay such a steep price because the government can’t implement reasonable reimbursement guidelines.”

Written by Erin Hegarty

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