Moving the HME Industry Forward

Billing/Reimbursement

Billing Part B for Beneficiary Inside a Facility

December 16, 2017

AMARILLO, TX – As all of us are aware, Medicare Part B covers DME furnished to a Medicare beneficiary who is residing in his “home.” Generally speaking, a beneficiary that receives inpatient “rehab” services in a skilled nursing facility (SNF) is not located in his “home.”

Thus, any DME provided to the beneficiary while he is an inpatient in the SNF is covered under Medicare Part A. A SNF can be either (i) an entire facility that is Medicare-certified as a SNF or (ii) a “distinct part unit” (“DPU”), which is in a facility that is not Medicare-certified as a SNF in its entirety, but rather the DPU is Medicare-certified as a SNF.

Let’s look at a hybrid situation. What if a beneficiary resides (i.e., is an inpatient) in a facility that primarily provides skilled nursing services, but the beneficiary is no longer receiving his Part A benefit? Will Part B pay for DME provided to the beneficiary? The short answer is “no.”

If a facility is primarily engaged in providing “skilled care” to patients, and if the facility provides “skilled care” to a Medicare beneficiary, Part B will not cover DME furnished to that beneficiary, even if Part A is not covering the beneficiary’s care (e.g., the beneficiary has exhausted his Part A benefits).

What about DME furnished to a patient who has been discharged from (i) an entire facility that is Medicare-certified as a SNF or (ii) a Medicare-certified DPU to another facility? Part B will only cover DME if it is furnished to a beneficiary residing in a place that qualifies as the beneficiary’s “home.” This is made clear by the definition of “durable medical equipment,” which only includes items used in the beneficiary’s home, including an institution used as the beneficiary’s home. 42 U.S.C. 1395x(n).

What can be considered a beneficiary’s home for DME purposes? An institution is not considered a beneficiary’s home for DME purposes if it is either:

  • An institution that is primarily engaged in providing, by or under the supervision of physicians, to inpatients: (i) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (ii) rehabilitation services for the rehabilitation of injured, disabled, or sick persons; or
  • An institution, or a distinct part of an institution, that is not primarily for the care and treatment of mental diseases but is primarily engaged in providing to residents: (i) skilled nursing care and related services for residents who require medical or nursing care; or (ii) rehabilitation services for the rehabilitation of injured, disabled, or sick persons.

Id.; and 42 U.S.C. §§ 1395x(e)(1), 1395i-3(a)(1).

A long term care facility (LTCF) will not qualify as a beneficiary’s home for DME purposes if it is primarily engaged in providing any of the services listed above, including skilled nursing care or rehabilitation. See also OIG Report on DME Furnished During Non-Part A Nursing Home Stays (stating that “[a] nursing home qualifies as a beneficiary’s home only if it does not provide primarily skilled care or rehabilitation.”). Moreover, Medicare guidance suggests that many states require a facility seeking a nursing home license to provide the types of services listed above, and “[w]hen this is the case, any nursing home licensed in such States cannot be considered a resident’s home for purposes of … DME … benefits.” Medicare State Operations Manual, Ch. 2, Sec. 2164. If a beneficiary is in a facility that is not a SNF or a DPU, and the facility is not primarily engaged in the services listed above, then the beneficiary will likely be considered to be in his home for DME purposes, and Part B will cover DME furnished to the beneficiary, presuming compliance with all other coverage criteria for that item.

If a DME supplier has access to the following, it may be able to determine whether a beneficiary is in a facility or part of a facility where it can furnish DME to the beneficiary and get paid by Part B.

  • Facility’s certification status – Documentation from the facility showing whether the facility or the portion of the facility (that a patient is in) is Medicare-certified as a SNF.
  • Facility’s licensure status – Information regarding whether the facility is licensed as a nursing home in a state that has incorporated the requirements that preclude a facility from being considered a patient’s home.
  • Facility’s primary purpose – Documentation that indicates whether the facility is primarily engaged in the activities that preclude it from being considered a patient’s home.
  • Claims submitted by a SNF – Assume that a beneficiary is in a facility with a Medicare-certified DPU and a non-certified wing. A beneficiary who is in the DPU under a Part A covered stay should be billed using bill type 22x. If the facility moves the patient from the DPU to a non-certified part of the facility, the beneficiary has technically ceased to reside in the Medicare-certified SNF and, thus, is appropriately billed as a non-resident of the SNF using bill type 23x.

 

Jeff Baird and Brad Howard will be presenting the following webinar:

AAHOMECARE’S EDUCATIONAL WEBINAR

What Business Practices Will Get the Department of Justice’s Attention?

Presented by: Jeffrey S. Baird, Esq., Brown & Fortunato, P.C. & Bradley W. Howard, Esq., Brown & Fortunato, P.C.

Monday, December 18, 2017

2:30-4:00 p.m. EASTERN TIME

Health care fraud continues to be a top priority for the Department of Justice.  Brown & Fortunato defends DME suppliers that have criminal and civil cases brought against them by the DOJ.  As such, B&F works closely with federal investigators and prosecutors.  This program will share observations regarding how the DOJ is attacking the problem, and what the DME supplier can do if it is the target of an investigation.  Nationwide, there are nine Medicare Fraud Strike Forces using data analysis techniques to uncover fraud.  This program will discuss the types of activities by DME suppliers, that the DOJ is focusing on.  The program will set out “nuts and bolts” steps that the DME supplier can take to reduce the risk of being targeted by the DOJ.  Lastly, the program will discuss the steps that a supplier should take in the event that it finds that is the target of a DOJ investigation.

Register for What Business Practices Will Get the Department of Justice’s Attention? on Monday, December 18, 2017, 2:30-4:00 pm ET, with Jeffrey S. Baird, Esq., and Bradley W. Howard, Esq., Brown & Fortunato, P.C.

Contact Ika Sukh at ikas@aahomecare.org if you experience any difficulties registering.

FEES:

Member: $99.00

Non-Member: $129.00

Jeffrey S. Baird, JD, is chairman of the Health Care Group at Brown & Fortunato, PC, a law firm based in Amarillo, Tex. He represents pharmacies, infusion companies, HME companies and other health care providers throughout the United States. Baird is Board Certified in Health Law by the Texas Board of Legal Specialization, and can be reached at (806) 345-6320 or jbaird@bf-law.com.