Medicare Update

Important program changes that you need to know about

For Opticians…
Compliance for DME Suppliers
By Pamela Fritz

Change for Medicare DME (Durable Medical Equipment) suppliers has been happening at a steady pace in the past few years. The latest round regarding post-cataract eyewear does, however, have DME suppliers, opticians, dispensing physicians, and optometrists in a flap.

SUPPLIER VS. PROVIDER

Before beginning, it's important to define two key Medicare/DME-related terms terms—provider and supplier. Ophthalmologists or optometrists are labeled as providers; that is, they write the Rx for patients after cataract surgery. The optical dispensary is considered the DME supplier of the eyeglasses because it fills the Rx. Medicare provides a certain amount of coverage for the DME “equipment” (that is, eyewear).

Why do you want to be a DME supplier in the first place? To take advantage of available the post-cataract dollars available and, of course, to take care of post-cataract patients who are in your practice.

More specifically, the benefit—covered by Medicare and available to locations registered as DME suppliers—is a pair of eyeglasses after each (eye) cataract surgery, as long as the surgeries are not back-to-back. And the question: Why would you miss out on providing two pair of eyeglasses for your patients?

NEW STIPULATIONS

That being said, however, the process is confusing. The latest changes, mandated in the Federal Register on Feb 2, 2011, concern provisions that became effective on March 25. For information, you can contact the contractor in your area (see map below) by email: Region A: www.medicarenhic.com; Region B: www.ngsmedicare.com; Region C: www.cignagovernmentservices.com; Region D: www.noridianmedicare.com. Changes include:

■ Provider enrollment screening categories.
■ Submission of application fees.
■ Payment suspension based on credible fraud allegations.
■ Authority to impose a temporary moratorium on the enrollment of new Medicare providers and suppliers of a particular type of geographic area.

This affects suppliers who are new enrollees, opening another supplier location, enrolling one of their present locations, or re-validating an existing location. These suppliers will have to pay an enrollment fee of $505 for each new enrollment application.

There are some rather onerous stipulations that go along with this regulation, including the fact that new enrollees will be scrutinized, may be placed in high-risk categories, and might even be subject to finger printing.

Durable Medical Equipment Medicare Administrative Contractors (DME MACs)

THE COMPLIANCY BUS

It is important to understand where all this is coming from. While it might feel like Medicare is singling out Medicare Providers and DME suppliers of optical goods (eyeglasses and contact lenses), that is not the case. Medicare and DME Medicare face serious financial issues. The vision care industry is a relative small piece of the total picture.

The problem lies elsewhere—in the fact that after Medicare launched an extensive investigation of Medicare DME suppliers, it recovered millions of dollars due to supplier fraud and abuse, notably suppliers of wheelchairs and power mobility equipment. Though eyewear did not even make the top-10 list, optical suppliers have now been thrown under the compliancy bus with the rest of the DME suppliers.

Optical is now struggling with this issue, and some consultants have recommended, “Get out of DME Medicare. It's not worth the hassle.”

THE BENEFITS TO YOU

There are, however, many reasons to be a DME supplier.

■ LOST SALES. First, your patients (post-cataract surgery and aphakics) need to access their benefits. If you are not a qualified DME supplier, you will have to send them elsewhere to get their eyeglasses and contact lenses. Many suppliers are under the impression that they can help the patient with their paperwork and that Medicare will pay the benefits directly to the patient. That's not so if you are not a qualified DME supplier. (For info, go to medicare.gov. Supplier Directory, Supporting Information. It states: “If you go to a pharmacy or supplier that is not enrolled, Medicare will not pay. You will be responsible for paying the entire bill.”)

■ DOLLAR BENEFIT. The DME patient eyewear benefit is substantial, better than most other insurances. The patient can purchase other options, like deluxe frame, AR, photochromics, or progressives. (However, you cannot bill Medicare for covered items and collect from the patient on non-covered unless you are a qualified DME supplier.)

■ COMPETITION. Several large optical chains have made it their business to become DME compliant. Don't lose valuable patients and eyewear revenue to competitors.

One final note: If you are considering opting out, it�s important to know that becoming reinstated with Medicare has become a lot harder than it used to be. EB

Pamela Fritz (pfmdesources@sbcglobal.net) is recognized for her expertise in Medicare Post-op Cataract Eyewear. She gives seminars and webinars on the topic and serves on the Provider Outreach and Education Panel for Medicare's DME

For Optometrists…
Mandatory e-Prescribing NOW
By Brad Rourke, CPA

If you have not started e-prescribing, you should do so now. Why? On Nov. 19, 2010, CMS (Centers for Medicare and Medicaid Services) announced that if you do not electronically submit at least 10 medical prescriptions during the period January 1 to June 30, 2011, you'll be subject to a one percent adjustment penalty to your 2012 Medicare reimbursements.

THE PENALTY

The penalty has snuck up on you and many other doctors because providers have been thinking they need not worry about e-prescribing until 2012. That's not the case at all! The 2012 and 2013 penalties, also known as Medicare payment adjustments, are a function of meeting e-prescribing thresholds in 2011.

Providers should begin worrying about e-prescribing now. Not only do you need to begin worrying about it, you need to start e-prescribing now to avoid 2012 and 2013 reimbursement adjustments.

As a physician, you must electronically submit a minimum of 10 prescriptions electronically during the period Jan. 1 through June 30, 2011, in order to avoid a one percent reduction in your 2012 Medicare reimbursements.

Furthermore, you must electronically submit an additional 15 medical prescriptions electronically, between July 1 and Dec. 31, 2011, to avoid that same one percent reduction in 2012.

Moreover, if you do not electronically prescribe a minimum of 25 medical prescriptions at some point in 2011, you will be subject to a 1.5 percent Medicare adjustment penalty levied against your 2013 Medicare reimbursements.

That's right, your 2012 and 2013 Medicare reimbursements will be affected by your 2011 e-prescribing activities.

AVOIDING THE PENALTY

You can avoid the penalty if you:

■ Are not a physician.
■ Do not have prescribing privileges. You must report this fact on the CMS1500 claim form by way of G-code G8644 (defined as not having prescribing privileges) at least one time prior to June 30, 2011.
■ Do not have at least 100 Medicare patients or 10 percent of Medicare patient visits during 2011 among the office visit encounter codes listed on CMS's e-RX site, cms.gov/ERxIncentive/.
■ Report a significant hardship exemption.

THE E-PRESCRIBING INCENTIVE BONUS

According to CMS, e-prescribing is, “a prescriber's ability to electronically send an accurate, error-free, and understandable prescription directly from the point-of-care.”

If you do e-prescribe, and thereby avoid the payment adjustment penalty, CMS will pay you an e-prescribing incentive bonus for 2011 in the amount of one percent of your total Medicare Part B reimbursements.

The incentive is not limited to one percent of only those encounters where a medication has been submitted electronically, but to all 2011 Medicare encounters regardless of whether or not a medication has been prescribed electronically. There are also one percent and 0.5 percent e-prescribing bonus incentives for years 2012 and 2013, respectively.

HOW TO OBTAIN INCENTIVE BONUSES

For specifics, read the “How to Get Started” page in the e-Prescribing section on CMS's website, cms.gov/ERxIncentive/.

You need to:

■ File a qualifying CPT code along with the G8553 code for a Medicare covered patient, (which represents that you have transmitted a medication electronically) at least 10 unique times from Jan. 1 to June 15, and 15 more times between July 1 to Dec. 31, 2011, on the CMS1500 claim form.

■ Furthermore, at least 10 percent of your Medicare patient visits must have encounter codes among the set of CPT codes listed here at the website, cms.gov/ERxIncentive/.

■ The CMS site states that, “There is no need to register to participate in this program. Simply begin submitting the G-code on your claims appropriately.”

WHAT'S A QUALIFIED SYSTEM?

The e-prescribing system used does not need to be ‘certified’ as do the Electronic Health Record systems for purposes of the EHR Meaningful Use incentive funds.

CMS does, however, outline the following capabilities that the e-prescribing system must have in order for the e-prescribing system to be considered qualified:

■ Ability to generate a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers if available.

■ Ability to select medications, print prescriptions, electronically transmit prescriptions, and conduct alerts.

■ Ability to provide information related to lower cost, therapeutically appropriate alternatives, if any. EB

Brad Rourke, CPA, is vice president of the Practice Director Software, headquartered in Lincoln, Neb.