- How does Medicare “courtesy billing” work?
- How much will I be reimbursed through Medicare?
- Is courtesy billing for scooters available in my area?
- How does the reimbursement process work?
- Can you bill HMO Medicare Advantage Plans like United Healthcare or Humana?
- What are the reimbursement criteria for mobility scooters?
- What are the reimbursement criteria for lift chairs?
- What are the reimbursement criteria for wheelchair cushions?
- Can you bill Medicare for a power wheelchair?
- Can you bill Medicare for a manual wheelchair, hospital bed, or patient lift?
- How can I find out if my physician has a valid NPI and PECOS enrollment?
- Additional Information Required by Medicare
- Can US Medical & Mobility bill Medicaid for my items?
Submitting claims to Medicare can be complicated and time consuming. To help make the process easier, US Medical & Mobility offers “courtesy billing”. After you purchase an eligible product from US Medical & Mobility, you can request that we file a Medicare courtesy claim. We will then handle all of the documentation required to submit a claim to Medicare on your behalf. If your claim is approved by Medicare, you will be reimbursed directly from Medicare for their portion of your claim.
Please note the following important information about Medicare courtesy billing:
- In order for us to courtesy bill, Medicare must be your primary insurance
- It is important to let us know if we will be billing Medicare for beneficiaries in assisted living facilities as these claims are handled differently
- We are unable to courtesy bill any Medicare Advantage programs or if the beneficiary is in a nursing home, skilled nursing facility, home health facility, or hospice facility
Medicare assigns every eligible item an “allowable amount”. The allowable is the maximum amount that Medicare will consider as the total price of the item. The allowable amount for each item varies slightly by state. Medicare will pay 80% of the allowable amount, or 80% of the cost of the item from US Medical & Mobility, whichever is less. The other 20%, or co-pay, is the beneficiary’s responsibility. Many beneficiaries have secondary coverage through another private insurance company (AARP, Anthem Blue Cross, CIGNA for example) to cover the remaining 20% and will not be responsible for a co-pay. If you have Medi-Cal as a secondary insurance, they will cover the remaining 20%.
US Medical & Mobility’s prices are generally at the Medicare allowable amount for eligible products; therefore, your 20% co-pay may be covered by your private insurance resulting in a significant savings. Below are the allowable amounts for items commonly purchased from US Medical & Mobility:
- Scooters for individuals weighing 300 lbs or less (HCPCS Code K0800): The allowable for Riverside County under Competitive Bidding is approximately $840. Most people upgrade as the allowable only covers the smallest scooter with the fewest features.
- Scooters for individuals weighing 301 lbs to 450 lbs (HCPCS Code K0801): The allowable for Riverside County under Competitive Bidding is approximately $1,605.
- Scooters for individuals weighing 451 lbs to 600 lbs (HCPCS Code K0802): The allowable for Riverside County under Competitive Bidding is approximately is $1,900.
- Lift Chair Mechanisms (HCPCS Code E0627): The allowable range is approximately $350 for Riverside County, which covers the medically-necessary motor lifting mechanism. The beneficiary is responsible for the actual chair. We do not handle lift chair billing for Medicare/Medi-Cal beneficiaries as Medi-Cal does not cover any portion of a lift chair.
- Wheelchair cushions that provide skin protection and/or positioning (HCPCS Code E2605-E2622): The allowable ranges from $195 – $400 for standard sizes, depending on the specific cushion.
Please note the following important information about Medicare reimbursement amounts:
- Any applicable deductibles must be met before Medicare will reimburse their portion of the allowable amount on an approved claim.
- While we can’t guarantee Medicare reimbursement, we will ensure claims are filed accurately and completely.
In Medicare’s Competitive Bid areas such as Riverside and San Bernardino counties, US Medical & Mobility is obliged to accept assignment on Medicare billing and claims for scooters. We do not courtesy bill for residents in these areas. If you reside outside of a competitive bid area, we will be happy to assist you in obtaining a scooter if your doctor completes all the documentation required and indicates that the scooter is medically necessary. In addition, residents of California, Florida, Illinois, Michigan, New York, North Carolina, and Texas must obtain prior authorization from The Centers for Medicare and Medicaid (CMS) before we can deliver a scooter. Effective September 1, 2012, for residents of California, Florida, Illinois, Michigan, New York, North Carolina, and Texas: the Centers for Medicare and Medicaid (CMS) implemented a Prior Authorization Request (PAR) process for beneficiaries with Fee-for-Service Medicare residents residing in these states with high incidences of fraudulent and error-prone claims. The PAR process changed the procedure for billing and delivery. Equipment cannot be delivered to beneficiaries until all the documentation is sent to Medicare for consideration. Medicare typically responds within 10 days of receiving a PAR and will either approve or deny a request. If the request is denied because they required additional documentation, the PAR can be resubmitted. Please contact us if you would like more information. We can provide you with a fact sheet for the CMS Prior Authorization process. For more information on the zip codes included in each competitive bid area, please visit the following website: http://dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home
After purchasing a Medicare-eligible item and requesting that US Medical & Mobility bill Medicare on your behalf, we will complete the required documentation and submit your claim.Step 1: We will send you the four documents listed below or you may print them from our website. You must provide your signature during the intake process or complete the paperwork in the Medicare package that you print from the website or receive from US Medical & Mobility. You may complete these documents and return them to us via fax or mail. If your spouse or relative has power of attorney (POA), we will need a copy of the POA on file at US Medical and Mobility. Documents required:
- Medicare Supplier Standards (we provide you with a copy for your file)
- Receipt of HIPAA Privacy Notice and Medical release (must be signed and returned)
- HIPAA Authorization Form (must be signed and returned)
Step 2: We require that you provide us with the following:
- A prescription from your physician for all Medicare eligible equipment. The prescription must have a date that precedes the delivery date of your equipment. The prescription must be current (not older than 60 days)
- A copy of your Medicare card, both front and back, and a copy of your secondary insurance card.
- Your date of birth
- For lift chairs, your physician will have to complete a Certificate of Medical Necessity (CMN), which we will provide to you or directly to your physician. This document must be signed/dated within 30 days of the date on the prescription and returned to us
- For mobility scooters, power and manual wheelchairs, you must schedule a face-to-face functional mobility examination with your physician. Full details of the process are provided in the Medicare packet we will provide to you (see also “Step-by-Step Consumer Guide to Power Mobility”).
- For cushions, we require the manufacturer name, model number, serial number, and date of purchase of the wheelchair currently on file with Medicare. Medicare will not cover a cushion unless there is a wheelchair on file.
Step 3: After all documentation is received, including the documentation from your physician, we will file your claim with Medicare (power mobility claims required a Prior Authorization Request (PAR). See above explanation.
Step 4: Medicare has between 45-60 days to respond regarding your claim. If your claim is approved, you will receive reimbursement directly from Medicare unless US Medical & Mobility has agreed to accept payment directly.
US Medical & Mobility cannot provide courtesy billing for customers with an HMO Medicare Advantage Plan as their primary coverage (such as United Healthcare HMO or Humana HMO). An Advantage HMO is a Medicare replacement HMO program contracted to manage your Medicare coverage and benefits.
Beneficiaries may qualify for a scooter (also called power operated vehicles or POVs) if the following general criteria are met:
- The beneficiary must have a mobility limitation which prevents them from performing one or more mobility related activities of daily living in the home, including toileting, eating, bathing, and grooming.
- There cannot be other conditions that limit the beneficiary from performing mobility-related activities of daily living at home, such as significant impairments of cognition or judgment and/or vision. This only applies if these other conditions cannot be addressed through other means, including caregiver support.
- The beneficiary must demonstrate the capability and the willingness to consistently operate the device safely.
- A cane, walker, or manual wheelchair will not provide the necessary functional mobility for mobility related activities inside the home.
- The beneficiary’s environment must allow for the use of the scooter in all areas where the mobility related activities of daily living are customarily performed.
- The beneficiary must have sufficient trunk and/or arm strength and postural stability to operate the scooter.
- Medicare will deny a scooter as not medically necessary when it is needed only for use outside the home. A scooter for leisure or recreational activities will be denied as not medically necessary.
Medicare only covers the seat-lift mechanism, not the actual chair/furniture. The reimbursement amount is between $340- $350 depending on the state in which the beneficiary resides.A lift chair is considered medically necessary if all of the following coverage criteria are met:
- The patient must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
- The seat lift mechanism must be part of the physician’s course of treatment and be prescribed to effect improvement or arrest or retard deterioration in the patient’s condition.
- The patient must be completely incapable of standing up from a regular armchair or any chair in their home.
- Once standing, the patient must have the ability to walk, even if a cane, walker or other assistance is required. Medicare will not cover this item if the patient has a wheelchair, scooter, or power wheelchair on file. Medicare/Medi-Cal beneficiaries do not qualify for this benefit as Medi-Cal does not cover lift chairs.
- If the seat height of a chair is too low and the patient is capable of getting up from a seat of appropriate height, Medicare will not consider this sufficient justification for reimbursement.
- Medicare requires that the physician ordering the seat lift mechanism be the patient’s attending physician or a consulting physician for the disease or condition resulting in the need for a seat lift.
For wheelchair cushions to be covered, the beneficiary must have a wheelchair on file with Medicare. When courtesy billing for a cushion, Medicare requires US Medical & Mobility to submit the manufacturer, model, and the date of purchase of the wheelchair on file. If no wheelchair is on file with Medicare, a cushion and wheelchair can be provided to the patient and both items billed at the same time. The beneficiary must also either have a current pressure sore or have a previous history of a pressure sore on record. Medicare will not cover cushions as preventative items. Documentation of positioning requirements and any other risk factors are also taken into consideration and should be submitted to US Medical & Mobility along with the physician’s prescription.
In areas not under the Competitive Bidding Program, Medicare pays for power chairs on a monthly rental basis. Because US Medical & Mobility only sells new equipment and does not provide rentals through Medicare, we are unable to provide courtesy billing for power wheelchair rentals. US Medical & Mobility is contracted with Medicare under the Competitive Bidding Program for Riverside and San Bernardino counties, and we provide Medicare beneficiaries with power chairs under this program. If you want to obtain a new power wheelchair through Medicare, please contact us and request an information packet or speak with one of our equipment specialist regarding the Prior Authorization Request (PAR) process.
Many customers choose to purchase their power chairs to avoid delays and to obtain all of the features they want in a chair. Our equipment specialists can also guide you in choosing the right equipment for your needs.
Ultra Lightweight K0005 manual wheelchairs can be purchased by Medicare. If you choose to purchase your ultra-lightweight wheelchair from US Medical & Mobility, we will be happy to assist you in filing a courtesy billing. We can provide you with an information packet explaining the necessary steps to file for Medicare reimbursement.US Medical & Mobility is contracted with Medicare’s Competitive Bidding Program for power mobility, but not for walkers or hospital beds. There are other suppliers currently contracted with Medicare for these items. Please call us for additional information in locating these suppliers. Standard wheelchairs, lightweight wheelchairs, and patient lifts are considered rental items by Medicare. We can bill Medicare for these items with a doctor’s prescription. They require a monthly co-pay of 20% of the monthly rental amount, which can be covered by a secondary insurance carrier. After 13 months of continuous rental, the item is then “purchased” for the beneficiary and no additional co-pay is required.To save time, many customers choose to purchase items and equipment rather than process a claim through Medicare or insurance. Our equipment specialists can advise you on the options available so that you can make an informed decision.
Effective July 1, 2010, Medicare required that all prescribing physicians have an NPI (National Provider Identifier) number for all Medicare claims. The physician must:
- Have a valid national provider identifier (NPI).
- Be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) program.
If your prescribing physician does not have a valid NPI or PECOS enrollment, your claim will be denied. To view a list of physicians and non-physician practitioners with valid NPI and PECOS enrollment, you can visit this government website and download the PDF document titled Medicare Ordering and Referring File [PDF]. You can also contact your physician’s office for this information.
Warranty Information. Medicare requires that we provide all beneficiaries with the following information.Every product sold by our company carries a warranty which can range from 6 months to more than 5 years. US Medical & Mobility honors all manufacturer warranties and will provide replacement parts free of charge for Medicare-covered equipment that is under warranty. In addition, when available, an owner’s manual with warranty information will be provided to beneficiaries.Medicare Capped Rentals. Capped rental items are paid by Medicare on a month rental fee basis for a period not to exceed 13 months. After 13 months, the ownership is transferred to the Medicare beneficiary. Once the item is beneficiary-owned, it is the beneficiary’s responsibility to arrange and pay for any required equipment service or repair. Examples of this type of equipment includes hospital beds, alternating pressure pads, air-fluidized beds, manual wheelchairs, nebulizers, suction pumps, TENS units, patient lifts, and trapeze bars.
Inexpensive or Routinely Purchased Items Notification. Inexpensive or routinely purchased items include lift chair seat lift mechanisms, canes, walkers, crutches, commodes, low pressure and positioning equalization pads, home blood glucose monitors, pneumatic compressors (lymphedema pumps), bed side rails, and traction equipment. These items can be purchased or rented, although the total amount paid for monthly rentals cannot exceed the fee schedule purchase amount.
US Medical & Mobility can only provide billing for Medi-Cal beneficiaries when the beneficiary’s primary insurance is Medicare with Medi-Cal as a secondary insurance to Medicare.