There are frequent updates to DME regulations. Some years will see more than others with changes rolling out each quarter. Even if the regulations are only updated once a year, it can still be a challenge for your practice to keep up.

Here is what you need to know to simplify these regulatory changes in DME. 

It Begins with Medicare

More often than not, the changes to DME regulations begin with Medicare and trickle down to the other plans. They are typically looked to as the primary source of changing compliance, code changes, or anything of the sort. Medicare will make a change first and that change will get adopted by commercial plans over time. 

This is not always the case though. Sometimes, the regulations that are changed by Medicare are not applicable to commercial payers. In these situations, Medicare may have different rules from everyone else. Most of the time, everyone will adopt the same rules—but this is not always true.

Keeping up with these frequent and often complex regulatory changes in DME for every payor and plan takes a lot of time for your practice to compliantly navigate. There are no shortcuts for managing changes or for predicting which changes will be made across the board.

The Frequency of Change Varies

How often can your practice expect to see changes to DME regulations rolled out? Unfortunately, the answer is that it depends. Medicare typically tries to put out larger changes no more than once each calendar year, but they often roll out smaller changes quarterly.

For example, last year saw changes in the second and third quarters. This year, they are starting to implement the need for a prior authorization that started in March. Another rollout happens in July and again in the third quarter, proving that every year is different. This unpredictability makes it difficult for many practices to keep up. 

The Type of Change Varies

While orthopedic practices have no idea what type of changes will come through the year, they are generally one of the following categories:

  • CBA or reimbursement rates
  • Code changes
  • Documentation 
  • Prior Authorization changes 

Let’s take a closer look at how each one may impact your practice: 

CBA or Reimbursement Rates

CBA refers to the competitive bid area, most often referring to the reimbursement rate for high volume items. Medicare will take a closer look at what they are spending on those items and open the market for companies to bid at a new reimbursement rate. 

Companies who want to dispense these items submit a bid for Medicare to review. In turn, Medicare comes up with a new reimbursement rate, usually lower than what it was previously.

Codes

Codes can also change which can have a huge impact on DME. For example, consider the process that you might go through with a patient who needs a brace. Some patients may be able to use the brace as-is, directly off the shelf. Others may require a custom fit based on their anatomy and the issue that they are being seen for, while others may require a custom-made brace altogether.

All of these codes may be different, which leads us to our next regulatory change.

Documentation 

Documentation is the physician’s opportunity to prove medical necessity, showing a patient would benefit medically from the use of a brace. Unfortunately, the requirements for proving this are often a moving target.

Medicare, for example, is implementing prior authorizations. While this change is only affecting a few codes, it means the criteria that must be met and and documentation proving the need is even more crucial. 

For large practices where DME comprises about 10% of their business, it may be extremely difficult to keep up with these changes to documentation and codes. Remaining compliant takes up significantly more time when compared to the percentage of business earned from this major category. 

Keeping Up

The reality is that payors and these frequent changes make it more difficult than ever before to keep up and run a profitable in-office DME program. Even unintentionally being out of compliance with these guidelines can result in a financial risk or loss of Medicare supplier approval.  

If your practice has been struggling to keep up with the constant changes to DME regulations from Medicare and other commercial plans, allow Select Ortho to help you stay compliant and profitable. 

Select Ortho is vendor-neutral, allowing doctors to use their preferred DME products. Under the Select Ortho DME Service LineTM, we staff the clinic and fully manage a profitably compliant DME program allowing more time to spend with your patients.  

Remain Profitable and Compliant