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Face-to-Face Encounter Required for
DME Prescription
We previously informed you of this new requirement that takes effect on 7/1/17. The notice from Medi-Cal is pasted below.
Effective for dates of service on or after July 1, 2017, Code of Federal Regulations (CFR) Title 42, Section 440.70 requires Medicaid programs to allow reimbursement to providers only for Durable Medical Equipment (DME) items that are signed for by a physician in either written or electronic format. Additionally, a face-to-face encounter administered by a physician, nurse practitioner, clinical nurse specialist or physician assistant, related to the primary reason the recipient requires the DME item, is also required. If the provider performing the face-to-face encounter is not the physician, the provider must communicate the clinical findings of that face-to-face encounter to the ordering physician.
The DME provider manual contains the following requirements for the Face To Face Encounter:
For all DME items a face-to-face encounter with a physician, nurse practitioner, clinical nurse specialist or physician assistant that is related to the primary reason the recipient requires the DME item is required. Face-to-face encounters may be done via telehealth. For all DME items that require replacement or replacement parts, a new prescription written by the physician for the DME item is required annually.
The following conditions must be met in order for the face-to-face encounter to be satisfied:
- The provider performing the face-to-face encounter must communicate the clinical findings of that face-to-face encounter to the ordering physician.
- The clinical findings from the face-to-face encounter must be incorporated into a written or electronic document included in the recipient's medical record.
- The physician prescribing the DME must document that the
face-to-face encounter, which is related to the primary reason the patient requires the DME, has occurred within six months prior to the date on the DME prescription.
- The physician writing the DME prescription must document who conducted the face-to-face encounter and the date of the encounter.
CAMPS has been in dialogue with DHCS on the specifics of implementation and raised the following issues. The DHCS answer is contained in
Red.
- If the provider received TAR prior to 07/01 but deliver after 07/01 does the new requirement apply? If the TAR was already approved, then there would be no effect on the TAR side. However, for any submitted/pending TARs with dates of service on or after 7/1/17 that have not yet been adjudicated, the new requirement would apply since TAR adjudication is date of service driven.
- TARs currently pending (submitted, not reviewed), will they be denied and sent back to meet the new requirement?Please see response to question #1.
- The bulletin indicates the new requirement applies to all DME, does it apply to repairs? The face-to-face requirement only applies to initial orders; it does not apply to repairs.
- Do the new requirements apply to CCS clients? Yes, if Medi-Cal is paying for the DME.
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More Information on Medi-Cal Provider Claw Back
Our last member email blast indicated that DHCS has announced the implementation of the 10% provider rate claw back for DME.
This letter will only be sent to the provider "pay to address" on file so you may want to check that address. The claw back covers DME payment for the period between June 1, 2011 through October 23, 2013. The adjustments will appear on the impacted provider RAD forms beginning about August 24, 2017. It will not include a total of the dollars to be recouped or a complete listing of all impacted claims. Each RAD will only include those specific impacted claims and the amounts being taken back.
We have since learned the following;
- The claw back includes both DME and medical supply claims
- The first RAD will include a complete list of the providers impacted claims. The next RAD will begin the claw back of payments. We were told that the provider will not see a total of their recoupment amount on the RAD but that may not be accurate.
- The amount recouped from each check write will not exceed 5% of the check write amount.
- If a provider seeks to reduce the 5% recoup amount they can contact Xerox (now Conduent) at the Telephone Service Center referenced in the letter, link above.
- The impacted claims are being processed in four batches. We have been told that is possible that an individual provider's total impacted claims may not all be processed at the same time.
We continue to dialogue with DHCS/ Xerox as the August 24th implementation date approaches. We will keep you informed of any additional information.
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Correction: Certification Statement Required for Medical Supply Invoice Attachments
This article corrects information published in the May 2017 Medi-Cal Update. Effective June 1, 2017, regardless of date of service, any medical supply claim with an invoice attachment for documentation of product cost that does not contain a certification statement will be denied with Remittance Advice Details (RAD) code 9556: Either the invoice or the certification is missing or invalid. The previous article is corrected below.
Effective June 1, 2017, the Department of Health Care Services (DHCS) is adopting a policy requiring a self-certification statement on all invoice attachments for medical supply claims. Providers are required to include the following certification statement exactly as written on all invoices and on each invoice page:
"I certify that I have properly disclosed and appropriately reflected a discount or other reduction in price obtained from a manufacturer or wholesaler in the costs claimed or charges on this invoice identified by item number _______________ as stated in 42 U.S.C. 1320a-7b (b) (3) (A) of the Social Security Act and this charge does not exceed the upper billing limit as established in California Code of Regulations Title 22, Section 51008.1 (a) (2) (D)."
The item claimed must be clearly identified on the invoice if the item number is not identified on the statement.
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Help Support Newly Released Senate Sign-on Letter Focused on Rural Relief
Thanks to the efforts of North Dakota and South Dakota HME providers, the Midwest Association for Medical Equipment Services, and the VGM Group, Senators John Thune (R-S.D.) and Heidi Heitkamp (D-N.D.) have released a Congressional sign-on letter focused on relief for rural/non-bid area providers who are now subject to competitive bidding-derived prices.
The target date to close the letter is next week - July 6, so action is needed soon!
We need as many Senators as possible to sign the letter to show the Administration that there is Senate support for relief on rural/non-CB area rates. Please reach out to your Senators and ask that they sign the letter. Senate offices can contact Senator Thune's staff to sign on.
Find the full text of the letter here.
Three Ways to Take Action
- Call your Senators' offices and let the health care staff know that you are a constituent who wants your Senator to sign the letter.
- E-Mail your Senators; you can use our Grassroots Action Center if you don't have an email address for healthcare staff in their offices.
- Share the Grassroots Action Center link with your patients, co-workers, and other individuals who may be interested in supporting this effort.
Contact Gordon Barnes at [email protected] if you need assistance finding healthcare staff contact info for your Senators' offices.
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One Capitol Mall, Suite 800
Sacramento, CA 95814
t: (916) 443-2115
f: (916) 444-7462
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