Friday, March 29, 2024

Billing: Hospital vs. DMERC

Joe

Dear List, I was informed that I had omitted my name and credentials on this previously sent post regarding Billing: Hospital vs. DMERC. There certainly was a low rate of e-mail responses. However those that did respond found this an interesting point and asked that they be given the responses and want to know how this all pans out. Either few practitioners want to discuss this issue or perhaps it was due to the anonymity of the post. I apologize for error. So I’ll try it again making sure you all know who I am. And I hope you all put in your 2 cents worth. Or maybe a quarter. Thanks, Joe Harvey Board Eligible Prosthetist

What you see below is the text as provided in the Winter 2002 DMERC Dialogue Region D manual. Followed by my interpretation and discussion.

__________________________________________________________________________________________

Hospitals are required to provide whatever equipment or other items are need by a patient during a Part A covered inpatient hospitalization. Hospitals may provide the item either directly or under arrangement with a supplier. This includes items which are provided prior to hospital admission but whose medical necessity begins during the hospital stay. One example is a custom fabricated spinal orthosis that is needed following spinal surgery. Even if this item is fabricated prior to hospital admission and is given to the patient to take to the hospital, the hospital must be the one to reimburse the orthotist for the item. In this situation, the orthotist is not permitted to submit a claim to the DMERC for that item. Similarly, if an item is medically necessary during an inpatient stay, it must be provided and paid for by the hospital either directly or under arrangement – even if the patient will continue to use the item at home. A supplier may deliver an item to an inpatient during the two days prior to discharge to home and bill the DMERC for the item only if it not medically necessary to use the item in the hospital. For example, if a patient needs a brace following discharge, the orthotist may come to the hospital, do any fitting or custom fabrication that is needed, and leave the brace with the patient to take home. Alternatively, a supplier may bring an item that will be needed at home to the hospital to show the patient how to use it and then leave the item with the patient to take home. If the patient does not wear or use the item in the hospital, the supplier may submit a claim to the DMERC for the item. However, if the patient wears or uses the item in the hospital – indicating that the item was a medically necessary part of treatment or rehabilitation during eh hospital stay – then reimbursement is included in the hospital’s payment for their inpatient admission, even if the patient will continue to use the item following discharge. When the patient wears or uses the item in the hospital, the hospital must pay the supplier for the item; the supplier may not submit a claim to the DMERC for the item. __________________________________________________________________________________________

My interpretation is that if a doctor orders the item and I deliver the item within two days of discharge and the patient wears the item in the hospital either because PT has orders for rehab and wants to get them up an about, or the patient just wants to walk down the hall, get out of bed to use the bathroom, go shower, or look out the window, or the doc want to replace the immediate post-op device with a more durable or stable device, it was and is medically necessary to be used in the hospital and is part of their treatment or rehabilitation so the hospital owes me a purchase order. The manual says that the supplier within two days of discharge can show the patient how to use the item in the hospital so that once they get home they can do it themselves. And if they don’t use it in the hospital then I bill the DMERC. If a hospital staffer instructs the patient on how to use the item, by putting it on the patient then they owe me a PO because the manual says the supplier may show the patient how to use the item. It does not say the staffer may show the patient how to use the item. My boss sees it slightly differently. He feels that if a doctor orders it and it is delivered within two days of discharge whether or not it is worn within the walls of the hospital it is still medically necessary for the patient to wear the item to be discharged then he is owed a PO.

Call it splitting hairs but I disagree with my employer. I say that if the patient did not wear the item in the hospital and is wheeled outside the hospital with the brace in hand and puts it on after leaving the hospital door prior to getting in the car or waits until getting home then I should bill the DMERC. Conversely if patient wears it in the hospital while in the process of being wheeled outside then the hospital owes me a PO.

The hospital we are having trouble with says, just because the doctor wants an item for the patient for discharge it is not medically necessary for use in the hospital then the DMERC must be billed by the supplier even if the patient wears it or not prior to leaving the hospital doors. The hospital says we are the only suppliers doing things this way. Oddly enough they are the only hospital that we work in that does things this way. I agree with the hospital only if the patient does not wear it in the hospital. A discussion with the hospital’s VP for these services is upcoming. I will pass on what I learn in that meeting to all that respond. Again thanks, Joe Harvey Board Eligible Prosthetist

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