In the near future CMS will offer the Provider Enrollment, Chain and Ownership System (PECOS) and Provider Statistical and Reimbursement Report (PS&R) online through a secure CMS Website. This will allow Medicare fee-for-service providers to access, update, and submit enrollment and cost report information over the Internet.
Prior to accessing the CMS Enterprise Applications providers and or their designated staff must first register for access to the new online enterprise applications through the new CMS security system, the Individuals Authorized Access to CMS Computer Services - Provider Community (IACS-PC).
Medicare providers and their designated representatives (e.g. clearinghouses, credentialing departments) may request access to CMS enterprise applications. However, CMS notes that Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers should not register in IACS-PC at this time as CMS does not expect any new online services will be available to them in 2008.
CMS uses the IACS-PC security system to safeguard the privacy, security and authorized access to Medicare provider information. Through IACS-PC provider organizations, their staff, and individual practitioners, will be able to access new CMS applications. Provider organizations will also be able to manage users who they authorize to conduct transactions on their behalf, which may include staff and contractors.
Physicians, providers, and suppliers who submit fee-for-service claims to Medicare contractors (carriers, fiscal intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), and Medicare Administrative Contractors (A/B MACs)) should select “Provider Community” when registering in IACS.
CMS explains that the provider community is the first in a series of IACS communities that will be comprised of groups of users who provide a similar service to CMS and who need access to similar applications. According to CMS the next community will be the FI/Carrier/MAC community comprised of users who work within Medicare contracting organizations (FIs, Carriers and MACs).
When registering as a member of the IACS-PC providers have the choice of registering as either an individual or as an organization. An individual practitioner is defined by IACS-PC as a physician or non- physician practitioner who will be conducting transactions with online applications personally and have no staff who will be accessing the applications. An organization includes providers and suppliers such as hospitals, home health agencies, skilled nursing facilities, independent diagnostic testing facilities, ambulance companies, ambulatory surgical centers and physician group practices as well as individual physicians and non- physician practitioners who want to delegate staff to conduct transactions on their behalf.
CMS recommends that providers gather the information identified below prior to beginning the IACS registration process:
For an individual practitioner (who will be conducting transactions with online applications personally and have no additional staff that will be accessing the applications) they will need to know their:
- Social Security Number and
- Correspondence Information
For an IACS-PC provider organization, the Security Official (SO) of that organization will be the first person to register within IACS and create their organization. The SO should have the following organizational information available before they sign on to register:
- Taxpayer Identification Number (TIN);
- Legal Business Name;
- Corporate Address; and
- Internal Revenue Service (IRS) Issued CP-575 hard copy form.
CMS identifies the following necessary steps that provider IACS-PC users must take to access a CMS Enterprise Application:
|The 3 Steps to Access
a CMS Enterprise Application
Be Approved for an IACS-PC Role.
The first two MLN Matters Articles in this series discussed how to register in IACS-PC.
The purpose of the IACS-PC registration process is to:
- Confirm the identity of the person requesting registration;
- Assure registrants have a legitimate business need to access CMS provider systems;
- Provide the registrant an IACS-PC role (e.g., SO, BSO, UGA, or end User) that defines their responsibilities (if any) for approving the registration requests of others in their organization; and
- Provide the registrant a User ID and Password for IACS-PC.
Be Approved for an Application Role
After receiving approval for an IACS-PC role, a registered user in a Provider Organization may then request to be an "Application Approver" or an "End User." (Note: Because Individual Practitioners do work in the application themselves, they do not designate "Application Approver" roles).
This role determines:
- Their responsibilities (if any) to approve application access requests from others in their organization;
- What CMS enterprise applications (if any) they have a legitimate need to access, and
- The appropriate level of access to each application for their job function (which application "role" they require).
Enter the application when it becomes available.
You will be notified as CMS enterprise applications become available. After you have been approved in steps 1 and 2, you will be able to access available CMS enterprise applications using your approved application specific roles via the CMS website.
Prior to registering in IACS-PC carefully read and review all of the CMS information provided in the links below as the process is complicated and the CMS articles and reference guides provide detailed instructions and explanations. Monitor CMS and your Medicare contractor’s bulletins and Web sites for updated information.
CMS MLN Matters articles addressing the IACS-PC:
OIG Report on Medicare Overspending Leads to New Program
The following article provides detailed information on the CMS DMEPOS Competitive Bidding Program and the associated supplier quality standards. These CMS initiatives will impact every DMEPOS supplier including physicians. However, as you read the program information provided in this newsletter please be aware that there remain many unanswered questions about these initiatives and changes to both the Competitive Bidding Program and the quality standards for suppliers are almost certain. In fact, (as detailed below) legislation has been introduced that would delay the start of the program and change a number of the bidding and quality standard requirements.
According to government data Medicare routinely pays twice as much for durable medical equipment such as hospital beds and power wheelchairs as individuals do when ordering the equipment online.
In 2003 in response to these government findings Congress required Medicare to phase out the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule in favor of a competitive bidding system for certain DMEPOS items. The Medicare Modernization Act of 2003 (MMA), Section 302, established these requirements for a new competitive bidding program for certain DMEPOS in order to bring its durable medical equipment costs more in line with market prices.
Under the competitive bidding program, suppliers will submit a bid for selected products through a Web based application process. According to CMS the bids are evaluated based on the supplier’s eligibility, financial stability and the bid price. Contracts are awarded to the Medicare suppliers who offer the best price and meet applicable quality and financial standards. Contract suppliers must agree to accept assignment on all claims for bid items and will be paid the bid price amount. The amount is derived from the median of all winning bids for an item. Additional program information is available in the Competitive Bidding Final Rule.
CMS has contracted with Palmetto GBA to administer the DMEPOS Competitive Bidding Program. Palmetto GBA is responsible for conducting performing bid evaluations, selecting qualified suppliers, setting payments for all competitive bidding areas and overseeing an education program. Palmetto GBA will also work with CMS and its contractors to monitor the program’s effectiveness, access, and quality.
To participate in the competitive bidding program, suppliers are required to meet Medicare's quality and financial standards and the contracted supplier must:
- Be enrolled in and be approved - or accredited - by Medicare based on the specific products and services they offer;
- Be financially sound - as demonstrated by common standards in use by the financial community;
- Fill orders from their own inventory, or contract with other companies that can fill orders for beneficiaries;
- Provide access for beneficiaries to get the items they need; and
- Provide high quality customer service by ensuring that delivery of products is timely and complaints are resolved quickly and appropriately.
In accordance with the MMA the Competitive Bidding Program will be phased in beginning in ten of the largest Metropolitan Statistical Areas (MSAs). The new payment amounts will be effective on July 1, 2008 for these ten areas. In 2009 the program will be expanded into seventy additional MSAs and into additional areas thereafter.
The round one MSAs are:
- Charlotte-Gastonia-Concord, NC-SC
- Cincinnati-Middletown, OH-KY-IN
- Cleveland-Elyria-Mentor, OH
- Dallas-Fort Worth-Arlington, TX
- Kansas City, MO-KS
- Miami-Fort Lauderdale-Miami Beach, FL
- Orlando, FL
- Pittsburgh, PA
- Riverside-San Bernardino-Ontario, CA
- San Juan-Caguas-Guaynabo, PR
The product categories for round one for the 10 MSAs include:
- Oxygen Supplies and Equipment
- Standard Power Wheelchairs, Scooters, and Related Accessories
- Complex Rehabilitative Power Wheelchairs and Related Accessories
- Mail-Order Diabetic Supplies
- Enteral Nutrients, Equipment, and Supplies
- Continuous Positive Airway Pressure (CPAP) Devices, Respiratory Assist Devices (RADs), and Related Supplies and Accessories
- Hospital Beds and Related Accessories
- Negative Pressure Wound Therapy (NPWT) Pumps and Related Supplies and Accessories
- Walkers and Related Accessories
- (Miami and San Juan Only) – Support Surfaces (group 2 mattresses and overlays)
The bidding for round one of the DMEPOS bidding program opened on May 15, 2007 and on May 19, 2008 CMS announced the winning suppliers selected for the first round. In the announcement CMS reported that the amounts that Medicare will pay for the ten product categories included in Round 1 of the DMEPOS Competitive Bidding Program overall average 26% less than Medicare’s previous payment amounts.
The lower payment amounts will also benefit Medicare beneficiaries through lower coinsurance amounts. However, Medicare beneficiaries living in one of the Competitive Bidding Areas (CBAs) will need to choose a new supplier if their current supplier is not either a contract supplier or a grandfathered supplier. Grandfathered suppliers are non-contract suppliers that provide certain rented equipment under the terms of the competitive bidding program and accept the program payment amounts.
Exceptions and Special Circumstances
Under the DMEPOS Competitive Bidding Program, beneficiaries who permanently reside in designated CBAs are required to obtain competitive bidding items from a contract supplier, unless an exception applies. One such exception allows providers, who are enrolled Medicare DMEPOS suppliers, to provide certain types of competitively bid items in a CBA to their own patients without submitting a bid and being selected as a contract supplier. These providers would however still need to meet the new accreditation requirement discussed in this newsletter.
CMS includes DME infusion pumps in the list of items that non-contracted DMEPOS suppliers can furnish to Medicare beneficiaries as long as the following requirements are met:
- The items must be furnished by the physician or treating practitioner DMEPOS supplier to his or her own patients as part of his or her professional service; and
- The items must be billed to a DME MAC using the DMEPOS billing number that is assigned to the physician, the treating practitioner (if possible), or a group practice to which the physician or treating practitioner has reassigned the right to receive Medicare payment.
- If the furnished item is a bid item and the beneficiary resides in a CBA, the physician or treating practitioner will be paid the single payment amount established by this program for the item. This exception does not affect the applicability of the physician self-referral (Stark law) provisions in section 1877 of the Act. All provisions of the physician self-referral law remain fully in effect.
Legislators Seek Delay in Program
The new competitive bidding system is scheduled to begin in the ten Metropolitan Statistical Areas listed above on July 1, 2008. However, a bipartisan group of lawmakers is asking for a delay of the program for at least one year stating concerns that contracts awarded to companies who have no experience in delivering the products they bid on would lead to poor service for their constituents.
On Thursday June 12, 2008 H.R. 6252, the Medicare DMEPOS Competitive Acquisition Reform Act of 2008, was introduced by House Ways and Means Health Subcommittee Chairman Pete Stark (D-CA) and Health Subcommittee Ranking Member Dave Camp (R-MI), along with cosponsors Charles Rangel (D-NY), John Dingell (D-MI), Frank Pallone (D-NJ), and John Boehner (R-OH). As of June 17, 2008 the bill had 28 cosponsors, you can track this bill on The Library of Congress.
In a summary of H.R. 6252 Representative Pete Stark outlined the bill’s provisions. Of most concern to oncology practices are the following items:
Temporary Delay Rounds 1 & 2
- Terminate contracts awarded under Round 1 and restart the contracting process in those areas in 2009.
- Round 2 contracting process would begin in 2011.
- Payment adjustments for DMEPOS in non-competitive bid areas may not take effect until Round 2 is completed.
- Require all suppliers to be accredited by October 1, 2009. Ensure that all suppliers, whether they are billing Medicare directly or are a subcontractor to another supplier, be subject to accreditation.
- Require contracting suppliers to disclose all subcontracting relationships to CMS.
- Exclude physicians and other practitioners from DMEPOS accreditation requirements until CMS develops provider-specific standards. Allow CMS to waive physician accreditation if the agency determines they are subject to other mandatory quality requirements.
- Establish a separate ombudsman within CMS to handle supplier and beneficiary issues related to the competitive bidding program.
DMEPOS Competitive Bidding Web site
Competitive Bidding Program Customer Service Center
Phone: (877) 577-5331
Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal FY 2007;
Provisions Concerning Competitive Acquisition for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); Accreditation of DMEPOS Suppliers; Final Rule
New Accreditation Requirement for DMEPOS Suppliers
Accreditation and competitive bidding are two separate issues. All suppliers of DMEPOS must be accredited by a CMS approved accreditation organization in order to receive and retain a supplier billing number. The DMEPOS supplier will only receive payment for the products and services for which the supplier is accredited. The accreditation process and quality standards for DMEPOS suppliers were required by the Medicare Modernization Act of 2003 (MMA).
CMS states, “Suppliers must comply with the quality standards in order to furnish any Durable Medical Equipment (DME), prosthetic device, prosthetic, or orthotic item or service for which Part B makes payment, and also in order to receive or retain a provider or supplier billing number used to submit claims for reimbursement for any such item or service for which payment can be made by Medicare.”
Read the DMEPOS Accreditation Fact Sheet for more information.
To date the only exception to the rule requiring supplier accreditation is for providers that maintain a Part B supplier billing number only to submit Part B drug claims and administer vaccinations. Currently, these suppliers do not have to become accredited. However, these supplier providers (or pharmacies) must still meet the remaining current 21 national supplier clearinghouse (NSC) standards. See the list of supplier standards in this newsletter.
Current Deadlines for Supplier Accreditation
- New DMEPOS suppliers submitting an enrollment application to NSC on or after March 1, 2008 must be accredited before submitting the application to NSC.
- New DMEPOS suppliers that applied for enrollment for the first time between January 1, 2008 and February 29, 2008 must obtain and submit an approved accreditation to the NSC by January 1, 2009.
- Existing DMEPOS suppliers enrolled prior to January 1, 2008 are required to obtain and submit an approved accreditation to the NSC by September 30, 2009.
DMEPOS Supplier Standards
Below is the abbreviated version of the certification standards included in the CMS 855S supplier enrollment application. Every Medicare DMEPOS supplier must meet these requirements in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. pt. 424, sec 424.57(c).
- A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
- A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
- An authorized individual (one whose signature is binding) must sign the application for billing privileges.
- A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or nonprocurement programs.
- A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
- A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare-covered items that are under warranty.
- A supplier must maintain a physical facility on an appropriate site.
- A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation.
- A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, or cell phone is prohibited.
- A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations. Failure to maintain required insurance at all times will result in revocation of the supplier’s billing privileges retroactive to the date the insurance lapsed.
- A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business.
- A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare-covered items, and maintain proof of delivery.
- A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
- A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries.
- A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
- A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
- A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
- A supplier must not convey or reassign a supplier number; i.e. the supplier may not sell or allow another entity to use its Medicare Supplier Billing Number.
- A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
- Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
- A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.
- All suppliers of DMEPOS and other items and services must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment for those specific products and services.
- All DMEPOS suppliers must notify their accreditation organization when a new DMEPOS location is opened. The accreditation organization may accredit the supplier location for three months after it is operational without requiring a new site visit.
- All DMEPOS supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill the Medicare. An accredited supplier may be denied enrollment or their enrollment may be revoked, if CMS determines that they are not in compliance with the DMEPOS quality standards.
- All DMEPOS suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation. If a new product line is added after enrollment, the DMEPOS supplier will be responsible for notifying the accrediting body of the new product so that the DMEPOS supplier can be re-surveyed and accredited for these new products.
In addition, in August 2006 CMS published the revised Quality Standards for Suppliers of DMEPOS in order to ensure that accredited suppliers provide quality products and services to beneficiaries in a safe and cost effective way.
As mentioned earlier there will almost certainly be future changes and clarifications to the DMEPOS Competitive Bidding Program and the accreditation requirement for DMEPOS suppliers so monitor your CMS and Medicare contractor’s email alerts and bulletins for critical updates.
CMS Approved Accreditation Organizations
The following organizations have been approved to accredit suppliers of durable Medical equipment, prosthetics, orthotics and supplies (DMEPOS):
- Accreditation Commission for Healthcare, Inc (ACHC)
Approved for Categories: All DME, Respiratory, Orthotics, Rehabilitation Technology Supplier and Medical Supply Provider
- Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Approved for Categories: All products and services described in Section 1834(a) (13) of the Act, Prosthetic devices, orthotics and prosthetics described in Section 1834(h) of the Act; and items described in Section 1842(s) (2) of the Act
- Community Health Accreditation Program (CHAP)
Approved for Categories: Diabetic Supplies, Cane, Crutches, Walkers, Commode Chairs, Hospital beds, Traction Equipment
- Appendix A:
Respiratory equipment, supplies, and services, Oxygen concentrators, reservoirs, high-pressure cylinders, oxygen accessories and supplies, oxygen conserving devices, Home Invasive Mechanical Ventilators, Continuous Positive Airway Devices (RAD), Intermittent Positive Pressure Breathing Devices, Nebulizers
- Appendix B:
Manual Wheelchairs and Power Mobility Devices, including complex rehab and assistive technology, PMDs: Power wheelchairs, power operated vehicles and accessories, Manual wheelchairs, standard recliners, heavy- duty wheelchairs, standard lightweight wheelchairs, hemi wheelchairs, armrests, leg rests/footplates
- Appendix C:
Custom fabricated custom fitted, custom made orthotics, prosthetic devices, somatic, ocular and facial prosthetics, and therapeutic shoes and inserts www.chapinc.org
- Healthcare Quality Association on Accreditation (HQAA)
Approved for Categories: All DME and Custom Orthotics
- National Board of Accreditation for Orthotic Suppliers (NBAOS)
Approved for Categories: Orthotics – custom fabricated, Orthotics – non-customized, Orthotics – custom, Custom and non-customized prosthetics
- Board for Orthotist/Prosthetist Certification (BOC)
Approved for Categories: All orthotics, prosthetics, pedorthics; DME, All Respiratory and POV
- National Association of Boards of Pharmacy (NABP)
Approved for Categories: DME Diabetic Products and Supplies, Enteral and Parenteral Nutrients and Supplies, Off the shelf products and supplies – Respiratory, Urological, Mobility Aids, Wound Care, and Medical Non Custom Orthotics and Prosthetics
- Commission on Accreditation of Rehabilitation Facilities (CARF)
Approved for Categories: Wheelchairs, Prosthetic Devices (including those devices (other than dental) that replace all or part of an internal body organ; Orthotics and prosthetics, including leg, arm, back, and neck braces, artificial legs, arms and eyes, and extra depth shoes with inserts or custom molded soles with inserts; therapeutic shoes; DMEPOS covered by Appendix B (ie. Manual wheelchairs and power mobility devices, including complex rehab and assistive technology) and Appendix C (ie. Custom fabricated custom fitted, custom made orthotics, prosthetic devices somatic, ocular and facial prosthetics, and therapeutic shoes and inserts)
- American Board for Certification in Orthotics and Prosthetics, Inc. (ABC)
Approved for Categories: Comprehensive orthotics, comprehensive prosthetics, prefabricated custom fitted orthotics, post mastectomy prosthetics, non-custom therapeutic shoes, comprehensive therapeutic shoes, ocular prosthetics, facial prosthetics, somatic prosthetics, Ancillary assistive ambulatory devices (canes, walkers, crutches) for those suppliers who qualify for O&P accreditation
- The Compliance Team, Inc
Approved for Categories: All mail order and home delivery durable medical equipment, prosthetics, orthotics, and supplies; Home dialysis supplies; therapeutic shoes and inserts
PQRI Reports to be Available Soon
The Centers for Medicare & Medicaid Services (CMS) have announced that the 2007 PQRI Final Feedback Reports will be available online in mid-July. These reports will be available to each practice, identified by Taxpayer Identification Number (TIN), under which at least one eligible professional reported 2007 PQRI quality measures data.
According to CMS the Feedback Reports will include reporting rates, clinical performance, and incentives earned by individual professionals, as well as summary information on reporting success and incentives earned at the practice level.
The reports will be accessed through a secure online system requiring practitioners to register for access through a new CMS security system known as the Individuals Authorized Access to CMS Computer Services - Provider Community (IACS-PC). Because the account activation process may take several weeks CMS is urging practices to set up their online account now. For more information on the IACS read the accompanying article “CMS to Offer New Online Services” in this newsletter.
Risë Marie Cleland
315 W. Mill Plain Blvd.,
Vancouver, WA 98660
Comments and suggestions for future issues are welcome, please forward correspondence to Risë Marie Cleland by email at: Rise@Oplinc.com
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ABOUT THE EDITOR
Risë Marie Cleland is the founder and President of Oplinc, Inc., a national organization of oncology professionals. Through Oplinc, Inc. Ms. Cleland publishes the weekly Oplinc Fax Tracts focusing on the timely dissemination of information pertaining to billing, reimbursement and practice management in the oncology office and Oplinc’s Best Practices Review, which provides a more in-depth look at the issues and challenges facing oncology practices. Ms. Cleland also works as a consultant and advisor for physician practices, pharmaceutical companies and distributors.
Please note that this newsletter is presented for informational purposes
only. It is not intended to provide coding, billing or legal advice. Regulations
and policies concerning Medicare reimbursement are a rapidly changing
area of the law. While we have made every effort to be current as of the
issue date, the information may not be as current or
comprehensive when you review it. Please consult with your legal counsel
for any specific reimbursement information. For Medicare regulations visit: www.cms.hhs.gov.
CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2007 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.