Insurance Updates
5/1/2024: What Medicare Requires from Your Patient in Order to Cover their Garments
You and our mutual patients may not be aware of the documentation that Medicare requires from your patient prior to any DME dispensing compression products. We understand this is all new to the Lymphedema community, but SunMED has been a Medicare provider for over 20 years and is here to help.
A Medicare Beneficiary must sign an Assignment of Benefits that is a legal document that allows a provider to bill Medicare on the patient’s behalf. It is a requirement that this be signed by the patient as the document confirms to Medicare that the patient chose the listed provider. A DME cannot bill Medicare for the patient without this -. If they chose not to assign their benefit to a provider, they can purchase their products and submit for reimbursement on their own.
Medicare providers are also required to furnish beneficiaries with Medicare Supplier Standards and Notice of Privacy Practices. These do not need to be signed and are Medicare drafted documents.
All providers are required to obtain a signed delivery ticket which we obtain for garments via UPS or USPS.
SunMED has a process in place that emails the required documents to the patient as soon as we receive their order. This is automated and gives the patient time to read, sign, and return the Assignment of Benefits prior to our dispensing of product. This Medicare requirement is our responsibility to manage but if you are willing to assist by providing patient or caregivers email address when placing your orders this will prevent unnecessary delays – we cannot ship garments until we have these items.
SunMED also has a program that patients can sign electronically on their phone or email. We can also furnish you with blank patient packets if your patient is willing to sign and fax the AOB from your office and take their copies home.
We would also request that if a patient is due to re-order garments in six months, they could either opt in for this or not – their choice, but the main purpose is for documentation to prevent the patient from being charged for their items.
We hope this helps clarify what SunMED is asking patients for, these are Medicare requirements and apply to most private insurance as well. This email is not intended for marketing purposes but to be timely and compliant with Medicare and Medicare advantage guidelines, as well as most commercial plans. We have always been in the background obtaining what legal documents allow us to bill on your patient’s behalf and wanted you to understand and assist if you are willing. If you have questions or would like blank patient packets to expedite your patients’ orders, please contact your outside sales representative. The patient document packet will soon be available on SunMED Express.
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2/14/2024: A message to clinicians regarding processing of compression garment orders through 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?
- 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.
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2/7/2024: A message to clinicians regarding the coverage of compression garments through Medicare:
- 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
- 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.
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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.