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Chantell Perry

sunMEDchoice.com

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Bailey Mcelvarr

sunMEDchoice.com

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Brad Vaspoli

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Insurance Updates

2/14/2024: A message to clinicians regarding processing of compression garment orders through Medicare:

I wanted to provide you an update on the LTA and its impact on you, your patients, and SunMED as well. It is now about four weeks since coverage began and there is still a lot of unknowns surrounding the new law for both Medicare and Medicare Advantage plans.
First and foremost, it appears we are one of a few providers around the country accepting orders for both Medicare and Medicare Advantage patients. As a result, we are receiving about 3 to 4 new facilities a day reaching out to SunMED inquiring about our services and how we can support their Medicare and Medicare Advantage patients. We are doing our best to help every patient we can, while dealing with a lot of unknowns from the insurance providers.
While we have done our best to prepare for the changes, nobody has nor had what they needed. Manufacturers are working on aligning their products to the new codes, therapists are unsure about what is covered and how to send in orders, and the payers are struggling to develop processes for these new codes. As an example, as of this writing, we have not seen a single Coverage Policy or fee schedule from a Medicare Advantage plan as to what codes they are using, clinical documentation they require, and fee schedules on how they will reimburse, yet we are filling these orders just the same.
We have provided some guidance to what we need from therapists on SunMED Express and will continue to put out updates on that platform as we learn more. Most importantly, we no longer are doing benefit checks for Medicare/Advantage patients. Rest assured, they’re covered, and at minimum 80%.
You may have noticed we are a bit slow in getting back to you all on order status, etc. We are basically having to re-build our entire order process, insurance dashboard, and our workflow to meet the requirements of the “New World” of Lymphedema that we are now in. It is taking some time to smooth out the flow internally. We ask for your patience as we work towards answers from our insurance providers and continue to educate therapists and patients as well.
Here are a few examples that are still holding up orders for which we are waiting for a response from Medicare:
  • If a patient only orders one garment, can they still order two more daytime garments within six months?
  • Can a patient order a RTW and a custom (Made to Measure) garment at the same time?
  • If a therapist orders a knee high and a thigh high for the same limb, is that acceptable?
These are just examples of a few that apply to how you order. We have many, many more of these that are critical to SunMED on the billing side that are unanswered. Still, we press on.
We knew going into this there would be a lot of unknowns and accordingly, SunMED is taking a substantial risk of non-payment on many of these situations, which we are willing to accept.
How can you help the process?
  • Please only send in orders with items (Products) included. The more complete the order (clinical notes, Rx, product selection and measurements) the more rapidly we can process an order.
  • Please don’t request benefit checks unless it is a commercial (non-Medicare/Advantage) plan. Medicare/Advantage plans are at minimum covered for 80% of the garment/bandaging fee schedules.
  • Please start to utilize SunMED Express (SME). We are doing our best to stay current and SME will show you order status, rather than our team needing to take the time to send an email detailing status. If you see the order hasn’t moved, it is because we are behind. In most cases, waiting on guidance on how to advance the order.
My next question is to you, and I’m looking for your feedback- how can we help you with the process?
We’re new at these changes just like you, and we’d like to know how we can improve the process too. We know we’re taking longer than normal. Trust me, we’re aware of it. And often times it is because we just don’t have answers – yet!
If we are not meeting your timeline expectations, we certainly understand and continue to work toward that resolution. While not an ideal solution, are you aware that a patient can pay out of pocket for the items they need and submit their receipt to Medicare or their Advantage plan on their own and be reimbursed directly? We realize not all patients can afford to do this, but if they can, it is a way to ensure during this adjustment phase they get what they need when they need it. The last thing we want to do is hold up garments and treatments for patients. If you simply cannot wait for us to get you a response and to move forward, please, encourage your patients to pay cash and submit their own claims on this first go around. I realize many patients cannot afford to do this, but there are also those that can, and this is an option if they simply cannot wait for us to get caught up.
I am leaving you with this final thought- We are doing our best to get and stay current. There are over 40 SunMED people working behind the scenes to figure all of this out and get this program up and running at high speed. It is my everyday focus and will be until it is resolved. We are here to take care of patients. It’s what we do.
I am leaving my direct email address for you. If you have questions, concerns, anything, please feel free to email me directly. Please do not send orders or order inquiries to my email box. Rather, those requests should go back to your representative. My email is Bill.Lobosco@SunMEDMedical.com.
We have considered holding a webinar with our therapist customers to provide a Medicare overview and an opportunity to ask specific questions about order fulfillment (not about becoming a DME, or any of those processes) – just a webinar to help therapists help their patients. Would this be of value to you, or just continued updates like this and on SME?
Thank you all for reading this and your patience. This act is long overdue, and we are doing whatever we possibly can to get this operationalized and running smoothly as quickly as possible.
Bill Lobosco, President
SunMED Medical

 

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2/7/2024: A message to clinicians regarding the coverage of compression garments through Medicare:

There is no need to request a “benefit check” for your Medicare or Medicare Advantage patients. When you are ready to order, please send over the following information:
 
  • Your product selection and measurements
  • Clinical/treatment notes including stage of lymphedema
  • If ordering a custom garment, clinical notes must indicate why a ready to wear garment is not indicated for this patient
  • Patient Demographics/face sheet
  • If you do not provide a prescription with your initial documents, we will request a prescription once the order has been received
That’s it!
 
Here is what we know:
 
Medicare, both billed to Medicare and Medicare Advantage, WILL cover your patient’s compression garments.
 
Quantity Available per plan year:
  • Daytime garments: 3 garments per affected limb or body part every 6 months (Ready to Wear or Made to Measure).
  • Nighttime garments: 2 garments per affected limb or body part every 2 years (Ready to Wear or Made to Measure).
  • Bandaging is covered.
  • A Prior Authorization may be required for Medicare Advantage patients.
There may be some initial delays in processing a Medicare Advantage order while we work to obtain the information needed to bill these payers. We may also request your patient’s involvement reaching out to their plan if we are unable to determine their new guidelines to help us expedite those orders.
 
For commercial insurance plans, we will continue to perform benefit checks. (Early indications are that these plans are adopting Medicare coverage guidelines and codes, so hopefully benefit checks will go away on these as well.)
 
Have more questions? Please feel free to reach out to your SunMED field representative or send an inquiry to sales@sunmedmedical.com and we will gladly assist you.

 

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11/22/2023: Overview of the key points from the CMS guidance for the LTA.

Who is Covered

  • To be eligible for coverage, a patient must have a diagnosis of lymphedema and a prescription for the required compression supplies.
  • Coverage will commence on January 1, 2024, and it will not be retroactive, meaning that claims for garments or supplies purchased or billed before this date will not be reimbursed.  We will need proof of delivery with a date after 1/1/24.  Proof of delivery prior to 1/1/24 will not be eligible for reimbursement.
  • This coverage will apply to Medicare Advantage recipients as well and is mandatory to be effective 1/1/24 just like the Medicare Fee for Service patients.
  • Lipedema and any other diagnosis other than the specific diagnosis code of lymphedema are not covered at this time and may be addressed in future guidance and changes.

Covered Items

  • The coverage extends to upper extremity, lower extremity, head, neck, and truncal lymphedema, many of which up until now were often not covered based on individual plans and payers, deemed experimental and not covered.
  • Both made-to-measure (custom) and off-the-shelf (ready to wear) daytime and nighttime garments are included.
  • Gradient compression wraps with adjustable straps are covered, as well as bandaging supplies for any phase of treatment (Phase I or Phase II).
  • Accessories, such as donning and doffing aids, padding, foam sheets, and more, are covered.

Frequency Allowances

  • Daytime garments: Three garments per affected limb or body part every six months (off-the-shelf or custom fit).
  • Nighttime garments: Two garments per affected limb or body part every two years.
  • Bandaging supplies have no set limits, and accessories will be determined case-by-case based on patient needs.
  • Lost, damaged, or stolen items will also be covered, beyond the quantity limits, with supporting documentation.
  • There are also provisions for patients who may have received items, but prior to their next opportunity to re-order no longer can fit into their garments, due to comorbidities, and other changes to receive garments prior to the re-order timeframe.
  • Historically, when ordering ready to wear knee highs or thigh highs, the manufacturers generally package those as a pair.  We will need to bill them as each.  Given the quantity limit of three per affected area, we cannot simply send a patient two “pair” as currently packaged and only bill for three items.  This is considered a Medicare inducement and is not a legal billing practice.  More on this as we learn more from the manufacturers.

Deductible and Coinsurance

  • Traditional Medicare will cover these supplies under Part B, subject to the annual Part B deductible and 20% coinsurance.
  • For Medicare Advantage and other insurance plans, out-of-pocket costs will vary based on the terms of the specific plan.

 

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Insurance Expertise Advantage

SunMED successfully submits and manages tens of thousands of medical equipment claims each year nationwide.

As a result, SunMED is today one of the premier national in-home medical equipment claims experts in the country.

We are a Medicare provider and hold over 200 insurance company contracts nationwide.

We use our expansive contract portfolio, and the depth of our claims experience to the advantage of our customers.

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