Home Health & Hospice Week

When doctors up testing, suppliers must provide more data to avoid rejection.

Doctors occasionally stepping up blood sugar testing regimens is a fact of life for diabetics. But that fact also can complicate life for testing-product suppliers because the DMERCs sometimes nix claims for the additional supplies as duplicates.

Fortunately, the Centers for Medicare & Medicaid Services has looked into the problem of rejected test claims and formulated advice for how to avoid them. Agency staff shared their recommendations at the June 23 Home Health, Hospice and Durable Medical Equipment Open Door Forum.

Diabetics' medical condition may worsen, requiring them to test their blood sugar levels more frequently, acknowledged John Warren of the agency's Program Integrity Group. When this happens, the beneficiary will run out of supplies before initially expected.

Suppliers can dispense the additional supplies upon an order from the treating physician. But the DME regional carriers claims system initially will see that extra claim as a duplicate and won't want to pay it.

In previous open-door sessions, suppliers reported that the problem of rejected test claims has been particularly acute in DMERC Region A, which extends from Delaware to Maine. Noting that diabetic supplies are a "significant" area of concern for the agency's comprehensive error rate testing program, Warren reported that CERT has found diabetic supplies present a greater risk of payment error in Region A than in other regions. As a result, Region A DMERC Health-Now NY is closely scrutinizing those claims.

Nevertheless, there is a process whereby the supplier can communicate to the DMERC that a new order exists and that the additional quantities are reasonable and necessary, Warren said.

Play the Text Field to Your Advantage

Suppliers first should indicate in the electronic claim's text field that the patient's condition has changed and there's a new order for the additional supplies.

"That should normally be sufficient to allow the claim to complete processing," Warren said.

If the supplier can't or doesn't provide that information on the face of the claim, the DMERC will send a request for that additional documentation in paper form. Providing the additional information should resolve the issue, Warren noted.

"But in both cases, whether you submit the information on the face of the claim or submit the documentation afterward, we expect that that documentation exists and shows that the patient's condition changed such that these additional quantities are needed," he advised.

Forum moderator Dr. Richard Lawlor offered a few additional tips for suppliers. Because the form offers only limited space, the explanation should be as clear and succinct as possible, he said. Mention that there is an order for the supplies and that there is something in the medical record explaining why the beneficiary needs to test that often, he said.

Including any evidence that the patient is actually testing at that frequency would also be helpful, Lawlor added.

Suppliers that follow these recommendations should have no problems getting paid for additional diabetic supplies. "I don't expect that any properly justified and documented claims will be improperly denied," Warren assured.