Billing: Hospital vs. DMERC

Billing: Hospital vs. DMERC

Joe

2/24/2002

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