Medicare Compliance & Reimbursement

Warning: Manufacturers' sales reps may make vague promises about Medicare reimbursement. For example, they'll promise that Medicare will cover a new technology in most parts of the country. But you walk on dangerous ground if you go solely by the manufacturer's general guidelines.

Find out whether your own Medicare carrier covers a new technology before you make a purchase, experts say. Check on your private payers, Medicaid, and state workers' compensation insurer as well -- with new technologies, your carrier may wait until the evidence is overwhelming before jumping on the bandwagon.

Be proactive: Research the accurate code for the new equipment, and then call your payers to determine the payment guidelines for them before you buy. Make sure you've done extensive research before investing in any costly equipment. Even if you find out that your Medicare contractor will reimburse, read the fine print too -- most payers will only reimburse in limited cases. Don't take a manufacturer's coding advice as the final word either.

Many manufacturers honestly seek to inform their buyers of the latest coding updates, but you're still never 100 percent sure until you check with your MAC first-hand. Other manufacturers may mislead you into thinking you will collect more reimbursement than you realistically can because they want to sell their product.

Not only might the manufacturer erroneously advise you to unbundle codes, but in some cases, use of the device may trigger clinical policies which means there may be limiting diagnosis supporting coverage. For instance, before reimbursing some technologies, the patient must have undergone other treatments and failed, and this must be documented in addition to the limiting covered diagnosis. If the practice is not aware of this, the device will not be covered and they are stuck with cost ramifications or trying to collect from the patient if that's an option.

Do this: You should take the manufacturer's recommendation as a starting point, but look through your coding book for other options.