Durable Medical
Equipment
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Myers and Stauffer has significant experience related to durable medical equipment (DME) reimbursement issues, including rate development, modification, and code maintenance, as well as periodic updates and monitoring activities. Our work has involved obtaining and establishing rates based on acquisition cost data or manufacturer suggested retail price (MSRP) data. We understand the implications involved in various types of DME, such as wheelchairs, nutritional supplements, and diabetic supplies as well as reimbursement issues impacting the purchase of DME versus rental.

We provide the following services:

Rate Setting and Reimbursement

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Tim Guerrant, CPA
member
tguerrant@mslc.com

317.846.9521

State Medicaid programs establish reimbursement rates for DME using a variety of approaches, including calculating rates based on MSRP or acquisition cost or updating historical rates by trending for inflation. Given recent federal requirements limiting payments for certain items of DME, many states have adopted Medicare DME rates, or a percentage of Medicare rates, for some or all DME items. Myers and Stauffer assists our state clients with DME policy analysis and rate setting services designed to ensure DME purchase and rental reimbursement rates are appropriate for the DME item. Our services include:

  • Policy and benefit analysis.
  • Rate adequacy studies.
  • Develop or update purchase or rental fee schedule rates.
  • Collect acquisition cost or MSRP data.
  • Analyze payment and utilization trends.
  • Fiscal analyses.
  • Implementation assistance.
  • Socialization planning.
  • State plan/regulation amendments.

Benefit/Program Integrity

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Ryan Farrell, CFE
Principal
rfarrell@mslc.com

512.342.0800

Through our benefit/program integrity services, Myers and Stauffer is able to assist our government health care clients with their review of DME payments to identify: improper payments; areas of non-compliance with applicable regulation and policy; investigate potential fraud, waste, and abuse; and identify payment system and policy weaknesses. Using cutting edge data analytics and subject matter expertise, our reviews, audits, and investigations target areas such as: adequacy of documentation, up-coding, services not rendered, improper add-ons or upgrades, quantity manipulations, medical necessity, rental rate manipulation, improper kickbacks, and providing basic products (e.g., ace bandage) while billing them as complex (e.g., back brace). Our program integrity services include:

  • Claims analysis.
  • Post-pay claims audits – clinical and financial.
  • Pre-pay claims audits – clinical and financial.
  • Medicaid recovery audit contractor (RAC) services.
  • Software modules for surveillance and utilization review subsystem (SURS), fraud and abuse detection services (FADS), and case tracking.
  • Provider compliance.
  • Payment system processing accuracy.
  • Fraud, waste, and abuse detection (FWAD) litigation support.

Medicaid Financing and Reporting

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Tim Guerrant, CPA
member
tguerrant@mslc.com

317.846.9521

State Medicaid Director Letter #18-001 imposed a limit on federal financial participation (FFP) for Medicaid DME. We assist our state Medicaid agency clients with the development of a compliance strategy, which may include adjusting fee schedule rates at or below Medicare or conducting DME upper payment limit (UPL) demonstration analyses. Our services include:

  • Calculate fiscal impact estimates.
  • Analyze compliance options for federal DME payment limit.
  • Demonstrate federal UPL compliance for DME.
  • DME fee schedule monitoring in comparison to Medicare fee schedule.

Managed Care Oversight and Compliance

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Mike Johnson, CPA, CFE
Member
mjohnson@mslc.com
404.524.0775

The extensive services offered by our highly skilled managed care engagement team are generally focused on the oversight of health plans but can impact all provider types, including durable medical equipment providers. These services include:

  • Encounter data reconciliation and validation.
  • Financial audits, performance audits, and program effectiveness audits.
  • Network adequacy assessments and member access compliance.
  • Readiness reviews.
  • Claims payment and denial assessments, accuracy, and timeliness.
  • Medical record review.
  • Grievance and appeals analysis.
  • Contract compliance.
  • Other provider-specific issue review and resolution activities.