If Suppliers Submit Assigned Claims, Then the Fee Schedule is Adequate Payment?

By Dan Fedor, Reimbursement Specialist, U.S. Rehab

According to the following release from CMS, it appears that their logic is if suppliers submit assigned claims, then the fee schedule is adequate payment. But, we know that is not the case, as the fee schedule is NOT adequate payment for most codes!

Assignment Rates

CMS Releases 2016 Assignment Rates
As part of CMS’ efforts to monitor the impact of the changes to the DMEPOS fee schedule, CMS monitors and publishes assignment rates in an effort to determine whether the fee schedule is sufficient.

The logic is, if suppliers submit claims assigned, then the fee schedule is adequate payment.

For calendar year (CY) 2015, 99.88% of claims were filed assigned. On Monday, CMS posted the assignment rates for CY2016 and found that there was only a 0.7% decrease in assignment rate (99.81%). The data published is segmented by BEA region and DME category. The data for walkers showed the lowest assignment rate at 96.3%, which is 1.33% lower than the rate from CY2015.

You can access all the data on CMS’ page. For your convenience, AAH combined the assignment rates for all the DME categories on one spreadsheet.

What CMS doesn’t realize is that suppliers are not submitting assigned claims because the fee schedule is adequate payment. Suppliers are submitting assigned claims because, for one, all competitive bid contract providers must accept assignment, and when a patient is dual eligible (Medicare primary and Medicaid covering their copay), suppliers also have to accept assignment. In addition, many Medicare beneficiaries don’t have the funds to pay upfront for these items. It’s much harder to ask someone to pay upfront for medically necessary medical equipment and supplies when they truly need the item than for a luxury item (big screen TV, new car, dishwasher, etc.). Many suppliers feel bad putting this additional financial burden on a chronically ill/disabled person, so they don’t ask for upfront payment and they accept assignment. But, this can’t continue as the fee schedule is not adequate for many codes to be able to run a business, and suppliers are now beginning to shift to non-assigned claim to ensure the sustainability of their companies.

Can we keep submitting assigned claims and accepting contract where we are losing money? These decisions will result in CMS believing that the fee schedule is adequate as they’ve stated. While it is a difficult position to ask a person with a medical need to pay upfront for these items, the alternative is to continue accepting assignment (an inadequate fee schedule) and jeopardize the longevity of the business. If your customers don’t understand why or don’t like the fact that they have to pay more and upfront for their medical equipment and supplies, please direct them to People for Quality Care by calling 800-404-8702. People for Quality Care will assist them in making their concerns known to their congressional representative. This document can also help explain why customers may be required to pay more for equipment.

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Dan Fedor
O: 844-794-8459
C: 570-499-8459
E: dan.fedor@vgm.com
F: 844-307-5729