Improvements to the Adjudication Process of Serial Claims

A major win for DME suppliers was announced recently, as CMS released information regarding improvements to the adjudication process of serial claims. Effective April 7, 2017, CMS has implemented changes to improve the processing and adjudication of recurring (monthly) claims for capped rental and certain inexpensive and routinely purchased (IRP) items.

Prior to April 2017, if a monthly rental claim was denied and then appealed separately, then the claim was adjudicated independently and without reference to the other claims in the series. As a result, one month could pay while claims for other months in the rental period remained denied and pending at various other levels of appeal. Industry leaders have been working hard to get CMS to see the light and make changes that would get all monthly claims in the rental period adjusted and paid following an effectuation for any month. CMS listened and has directed the DME MACs to change their processes for adjudicating serial claims!

What does that mean?

Once the reason for denial for one claim in a series is resolved at any appeal level, the DME MACs will identify other claims in the same series that were denied for the same or similar reasons, and take that determination into consideration when adjudicating such claims.

The DME MACs will also communicate the favorable decision(s) to the DME QIC and the Office of Medicare Hearings and Appeals (OMHA) to consider when adjudicating related appeals pending at those levels.

CMS has also instructed the DME MACs to update the Certificate of Medical Necessity (CMN) in the ViPS Medicare System (VMS), when appropriate, to reflect when a favorable decision has been rendered for a serial claim, allowing future claims in the same series to pay without requiring suppliers to continually resubmit evidence.

Finally, CMS instructed the DME MACs to perform data analysis of all favorable serial claim appeal decisions made over the past 3 years, in an effort to capture all currently pending appeals in the series that could be included in this initiative. Suppliers do not need to take any action and should not reach out to the DME MAC within their jurisdiction to request that their appeal be considered for this initiative.

Will this help me?

Going forward, any claim in a series that denies but is then paid will result in adjustments for payment to other denied months in the series. Remember, the data analysis only applies to recurring (serial) claims for capped rental items and certain IRP items adjudicated during the past three years. For a complete listing of HCPCS codes that are included in this initiative please see the list published in MedLearn Matters article SE17010.

Bottom line

This is a major win for the DME Industry! With 51% of DME claims comprising the ALJ Appeals backlog this new initiative will most certainly help reduce that number! More importantly, this new process will alleviate the burden on suppliers billing monthly rentals.

Kelly Grahovac serves as a senior consultant for The van Halem Group. She can be reached at Kelly@vanHalemGroup.com.