TPN

Competitive Bidding cont...

As you may be aware, in July, 2008, the Medicare Improvements for Patients and Providers Act of 2008 (or MIPPA) was enacted. This new law delayed Medicare’s implementation of the Competitive Bidding Program (the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies--or DMEPOS--Competitive Bidding Program).

In the interim, supplies that had been included in the first round of the DMEPOS Competitive Bidding Program could be furnished by any enrolled DMEPOS supplier in accordance with existing Medicare rules—and reimbursed using the existing fee schedules. The new phase in date was then set for April 18, 2009.[3] Suppliers urged Medicare to reconsider certain aspects of the bidding program, and this was taken under advisement during the summer months. In August, 2009 CMS issued a statement saying they were announcing a new timeline for bidding, which will occur during 2010, and had initiated a supplier education campaign leading up to the bidding period in those categories listed below.

Oxygen supplies and equipment;

Standard power wheelchairs, scooters, and related accessories;

Complex rehabilitative power wheelchairs and related accessories;

Mail-order diabetic supplies;

Enteral nutrients, equipment, and supplies;

CPAP (Continuous positive airway pressure) and respiratory assist devices (RADs) and related accessories;

Hospital beds and related accessories;

Negative pressure wound therapy pumps and related accessories;

Walkers and related accessories; and

Specific support surfaces (group 2 and 3 mattresses and overlays).

CMS plans to phase the program in, starting with the first nine Metropolitan Statistical Areas, or MSAs. The country is divided into regions so that prices from one area are not used in another area where they would be unrealistic (for example, imagine if the same reimbursement amount paid in rural Pennsylvania was paid to a supplier in Manhattan)!

Now that we have established some basic framework, let’s move on to the various medical supply coverage categories.

Allowable Fee Schedule:

Each of the areas we are going to examine has an allowable fee for every item category, or HCPCS code. The allowable fee is the value Medicare has set for each product category. With ostomy supplies, for instance, the fee amount varies by the type of pouch and skin barrier. Payment of the allowable fee is the shared responsibility of Medicare and the beneficiary:

As we said earlier, Medicare’s responsibility is 80% of allowable fee,

The Beneficiary’s responsibility is 20%.

Suppliers submit claims to one of four insurance companies, called DME MACs contracted by CMS to process Medicare Part B claims. Each of the four DME MACs services a specific geographic area, based on the beneficiary’s permanent residence.[8]