Protecting Your Practice from Consolidated Billing
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Recently, a client was asked by Noridian (DME MAC A) to repay a few hundred dollars for a DME claim submitted six years ago. The patient had been seen in the office while residing in a nursing home. Fortunately, the outcome was favorable to my client, but it highlights a very common concern when providing DME for nursing home patients.
Why This Happens?
A recent OIG review found that DME is frequently paid incorrectly for patients residing in nursing homes. When a patient is in a Nursing Home under a Part A stay (after a qualifying 3-day hospital admission), Medicare consolidates payment for many services to the facility—hence Consolidated Billing.
What’s Affected (and What’s Not)
Subject To Consolidated Billing:
- Most DME, diagnostic testing and imaging (x-rays), nerve testing, vascular studies, etc.
- Not subject to Consolidated Billing:
- Office visits and surgical procedures by physicians (including podiatrists) and non-covered services (e.g. foot orthotics).
Best Practice To Protect Your Practice from Consolidated Billing:
EHR systems can serve as the first line of defense although they are not the most reliable.
EHR systems rely on checking the Medicare Common Work File to determine if the patient is subject to Consolidated Billing. However, this data may be outdated by up to a month.
What is the most reliable method for verifying whether a patient is subject to Consolidated Billing?
Have staff call the facility’s billing office the day before the visit and ask whether the patient is under:- Part B → DME and diagnostics may be provided
- Part A → NO DME
- Ask when Part A expires (if only a few days your delivery of DME can be delayed), or
- Ask whether the facility will contract with you separately for the item
What About Home Health Agency (HHA) Patients?
Patients receiving care from a Home Health Agency may also be subject to Consolidated Billing.
- If home health services are unrelated (e.g., BP or glucose checks), your DME/services are generally not impacted
- If related, Consolidated Billing may apply.
- If the patient is receiving related HHA services, then contact the HHA billing office for further information.
Bottom Line
Always confirm the patients’ Part A or B Status:
If Part A Stay: Contract with the Facility or HHA and bill them for DME services.
If Part B Stay: Proceed with providing DME and bill as usual.
Make that phone call NOW to protect your DME investment and protect you from recoupment!
