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Medicare revalidation, DMEPOS fee still prompt questions among ODs

December 14, 2012

A year after it began, a U.S. Centers for Medicare & Medicaid Services (CMS) program to revalidate the enrollment records of all individuals and entities enrolled in Medicare – including all optometrists – continues to prompt questions among health care practitioners, according to the AOA Advocacy Group.

Of particular concern to optometrists: a new $523 enrollment fee required of those wishing to provide durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) – such as eyeglasses – to Medicare beneficiaries.

Authorized under the federal Affordable Care Act, the revalidation initiative effectively requires all physicians who have enrolled in Medicare prior to March 2011 to re-enroll online or using paper forms (CMS-855).

“The basic response required of optometrists on receiving a revalidation notice is simple: re-enroll as a Medicare physician within 60 days to make sure you can continue providing eye care services to Medicare patients,” said AOA Federal Relations Committee Chair Roger Jordan, O.D.

Medicare Administrative Contractors (MACs) are in the midst of mailing revalidation notices to health care practitioners and institutions, while Medicare’s National Supplier Clearinghouse (Palmetto GBA) mails the notices to equipment suppliers.

Failure to revalidate Medicare enrollment within 60 days of receiving a notice can result in loss of Medicare billing privileges.

After receiving a notice, Medicare physicians – including optometrists – can re-enroll to provide health care services for Medicare beneficiaries with no application fee through the Provider Enrollment, Chain and Ownership System website (https://pecos.cms.hhs.gov/pecos/login.do) or by filing CMS-855 application forms.

Many optometrists receiving Medicare revalidation notices are surprised by the prospect of paying a $500-plus application fee.

“They weren’t required to pay any kind of application fee the first time they enrolled,” Dr. Jordan observed.

The new fee is intended to cover the cost of a new screening program designed to weed out unscrupulous DMEPOS suppliers. Eyeglasses are classified as DMEPOS – specifically, a prosthetic – by the Centers for Medicare & Medicaid Services (CMS).

Optometrists are not required to pay the $523 fee to continue providing professional services to Medicare patients, Dr. Jordan noted, rather the fee applies to facilities and other institutions that enroll in Medicare. The CMS decided all DMEPOS suppliers would be treated like institutions, even individual doctors who provide covered eyewear for Medicare patients.

Medicare covers eyewear only under limited circumstances: one pair of eyeglasses for patients following cataract surgery per eye. A 2010 AOA survey found that among responding optometrists who were enrolled as DMEPOS suppliers, 59 percent received $500 each year in Medicare reimbursement for eyewear.

In authorizing the new DMEPOS fee, Congress intended specifically to target businesses or health care institutions, not health care practitioners, the AOA Advocacy Group noted.

The AOA filed formal comments objecting to the fee when the CMS proposed regulations last year.

The AOA joined with other interested physician organizations to express concerns about the fee to CMS staff over the following months.

CMS officials initially indicated to AOA and other health care practitioner groups that they did not want to jeopardize patient access to health care items by requiring doctors to pay the enrollment fee required for suppliers, but the agency refused to extend the physician exemption to physician suppliers in the final regulations for the re-enrollment program.

DMEPOS options

A number of practitioners have contacted the AOA Washington office or state optometric associations over recent months seriously questioning the DMEPOS application fee, Dr. Jordan noted.

Regarding the fee, practitioners have two options:

  • Become a DMEPOS supplier, pay the $500+ DMEPOS registration fee, and then be able to provide covered eyeglasses to Medicare patients, or
  • Decline to become a DMEPOS supplier and save the $500+ registration fee, but with the understanding that:
  1. Medicare patients will have to pay out of pocket for any eyewear they prescribe, including eyewear that would normally be covered by Medicare following cataract surgery.
  2. They must advise patients that their post-cataract eyewear would be covered if they obtained it elsewhere.
  3. They must issue an advance beneficiary notice (ABN) warning patients that their post-cataract eyewear is not covered by Medicare.

“Medicare covers post-op eyeglasses for cataract patients only if the glasses are provided by a DMEPOS supplier who is enrolled in Medicare,” Dr. Jordan said. “If the optometrist is not enrolled in Medicare for DMEPOS, then the glasses are not covered. Neither the doctor nor the patient can obtain reimbursement for the glasses from Medicare if the supplier is not enrolled. If a Medicare beneficiary wants to pay out-of-pocket for eyeglasses from a supplier who is not enrolled in Medicare, she or he may do so, but the doctor should be sure to explain to the patient that the glasses would be covered if they were obtained from another supplier who is enrolled in Medicare. In addition, the doctor should be certain to have an ABN form signed by the patient acknowledging that although she/he could have these glasses covered elsewhere she/he agrees to pay the doctor out-of-pocket and that he or she cannot get reimbursement from Medicare.”

Patients of practitioners who opt not to become DMEPOS providers cannot independently seek Medicare reimbursement for their eyewear using the health plan’s Patient Request for Reimbursement form (CMS 1490S) form, according to Dr. Jordan.

“The patient will get a denial because Medicare only pays for covered eyeglasses supplied by an enrolled supplier,” he said. “Medicare will never pay when the DMEPOS supplier is not enrolled, no matter who submits the claim.”

In addition, the CMS generally “frowns on” practitioners who charge patients upfront for eyewear and then urge them to seek Medicare reimbursement, he added.

Practitioners whose patients frequently file CMS 1490 forms will generally receive warning letters from the agency reminding them that physicians are expected to submit claims on behalf of the Medicare beneficiaries.

Practitioners who wish to avoid the DMEPOS fee need not cease providing eyewear to patients before receiving a revalidation notice, nor attempt to in advance notify CMS that they no longer wish to provide eyewear, according to the AOA Washington office.

They can continue to dispense and receive reimbursement for eyewear until they revalidate their Medicare enrollment.
Status as a Medicare “participating” physician, who elects to accept Medicare fee schedule reimbursement as full compensation for services, or a “nonparticipating” physician, who does not, is unaffected by a practitioner’s decision to provide or not provide DMEPOS under the health plan. The decision to supply DMEPOS is a separate decision and enrollment than providing professional services (medical eye care), the AOA Advocacy Group emphasized.

For additional information, visit www.aoa.org/Medicare, www.aoa.org/DMEPOS, or www.aoa.org/PECOS.

One comment

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