Medicare is the federal health insurance program for people who are 65 or older, as well as certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD). There are different parts of Medicare that help cover specific services. Medicare Part B covers certain medical supplies.
To learn more about Medicare coverage Click Here.
To learn more about Medicare Supplier Standards, Click Here.
Items billed to Medicare require a physician's order. Supporting documentation relevant to your prescription, such as chart notes from a face-to-face visit, are needed for most equipment and supplies. Some equipment and supplies even require that we, the supplier, receive additional documentation from your healthcare provider before we can deliver your items to you.
Below are some terms you may encounter during this process.
Durable Medical Equipment (DME)
Durable Medical Equipment must meet the following criteria: be durable (long-lasting), used for a medical reason, not typically useful for someone that is not injured or ill, and is used in your home. Some examples of DME include (but aren't limited to) hospital beds, manual wheelchairs and power mobility devices, oxygen equipment, and walkers. DMEPOS- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.
Assignment versus Non-assigned
Assignment: This means Norco will file a claim to Medicare and payment goes directly to Norco. For example, your primary insurance will pay Norco 80% of the allowed amount for a particular item. You or your co-insurance company will be responsible for the remaining 20% of the allowed amount.
Non-Assigned: Norco will file a claim to your primary insurance and the notice of payment will go directly to you. You will be responsible for 100% of the total bill. Regardless of whether your insurance’s criteria is met, Norco may not accept assignment for some items. We emphasize that notice of payment or denial will go directly to you.
Also known as the “allowed amount” or maximum allowable; this is the dollar amount considered by a health insurance company to be a reasonable reimbursement rate.
Advanced Beneficiary Notice of Non-Coverage (ABN)
This is a notice you will receive when we, the supplier, believe Medicare will not cover your equipment or supplies. ABNs are not required for items that Medicare never covers. Your ABN should list the items that Medicare isn't expected to pay, an estimate of the cost of the item, and a specific reason as to why Medicare isn't expected to pay. You will be asked to choose an option on the ABN and sign it to say that you read and understood the notice, and that you may have to accept responsibility for payment.
For more information about ABNs, Click Here.
The face-to-face requirement ensures that the orders for equipment or supplies are based on a physician's current knowledge of a patient's medical condition. This visit should document when the physician or practitioner saw the patient, as well as document how the patient's condition, as seen during the visit, supports the need for the equipment or supply ordered.
This means that the equipment or supplies ordered are reasonable and necessary based on evidence based clinical standards of care. Medicare pays for equipment or supplies that are medically necessary. This necessity must be documented in the patient's medical record.
Competitive Bidding Program
Under the Competitive Bidding Program suppliers submit bids to provide certain medical equipment and supplies to people with original Medicare plans living in (or visiting) Competitive Bidding Areas. Medicare uses the bids to set the amount they will pay for items. This program requires you to use a contracted supplier for certain supplies.
For more information about the Competitive Bidding Program, Click Here.
Medicare Part B Deductible and Co-Insurance
Medicare covers services and supplies that are considered medically necessary to treat a disease or condition. After your deductible is met, you typically pay 20% of the Medicare-approved amount for your durable medical equipment or supplies. If you have a Medicare Advantage Plan or other Medicare plan you may have different rules.
To learn more about Medicare deductibles, coinsurance, and Part B coverage, Click Here.
The amount the insured (customer) has to pay out of pocket for expenses before the insurance plan begins to pay. Deductibles range in price according to the terms set in your specific policy.
Percentage of coverage that a patient is responsible for paying after an insurance company pays the portion agreed upon in the health plan. Co-Insurance percentages vary depending on the health plan.
How can we help?
If you have questions about Medicare, or our billing process, please do not hesitate to contact us.