Billing: Hospital vs. DMERC

Billing: Hospital vs. DMERC

Joe

2/18/2002

I know this subject has been tossed about before. However, if you don't
mind allow me to bring up this thorny subject again. First I'll write
out the wording as provided in the Winter 2002 DMERC Dialogue Region D
manual.
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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 t 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.
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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 to walk down the hall, get out of bed to use the bathroom, go
shower or look out the window, it was medically necessary 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. Bill the DMERC. If a hospital
staffer instructs the patient how to use the item they owe me a PO. My
boss sees it slightly differently. He feels that if a doctor orders it
and it is delivered within two days of discharge and it is 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. 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 prior to getting in the
car or waits until getting home then I can bill the DMERC. If patient
wears it in the hospital while in the process of being wheeled outside
then the hospital owes me a PO.
So let the discussion begin.