(Medicare Claims Processing Manual)

 The supplier is listed by the Secretary under 1834(a)(15)(B) of the Act as a supplier who has submitted a substantial number of claims, which have been denied as not medically reasonable and necessary under 1862(a)(1) of the Act or the Secretary has identified a pattern of over  utilization.   In cases in which an advance coverage determination is mandatory, an ABN must be issued to the beneficiary prior to furnishing the item.  If the advance coverage determination has not been received, or if the determination is that Medicare will not pay for th e care, an ABN is required prior to furnishing the requested item.   B.  Optional   A request for an advance determination of coverage of medical equipment and supplies is optional under 1834(a)(15)(C)(iii) of the Act when the item is customized and either the beneficiary or the supplier requests an advance determination.  In cases where an advance coverage determination is optional and the beneficiary requests such a determination, an ABN must be furnished prior to furnishing the requested item.  Every supplier is expected to know whether or not an advance coverage determination is required for Medicare payment.  The presumption of that suppliers knowledge becomes non-rebuttable after a single denial under 1834(a)(15) of a claim by a particular s upplier.   50.13 - ABN Standards for Upgraded Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)                                      (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  Notifiers must give an ABN before a beneficiary receives a Medicare covered item containing upgrade components that are not medically reasonable and necessary and not paid for by the supplier.  DME upgrades involve situations in which the upgraded item or component has a different Heath Insurance Common Procedure Coding System (HCPCS) code than the item that will be covered by Medicare.  Please refer to Chapter 20, Section 120 in this manual for information on billing procedures for ABN upgrades.   ABNs cannot be used to charge beneficiaries for premium quality services described as excess components.  Similarly, ABNs cannot be used to shift liability for an item or service that is described on the ABN as being better or higher quality on an AB N but do not exceed the HCPCS code description.   50.14 - ABNs for items listed in a DMEPOS Competitive Bidding Program (CBP)                                                                                                          (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  Section 1862 (a)(17) of the Act excludes Medicare payment for CBP items/ services that are provided by a non- contract supplier in a Competitive Bidding Area (CBA) except in special circumstances.  A non -contracted supplier is permitted to provide a benefic iary with an item or service listed in the CBP when the supplier properly issues an ABN prior to delivery of the item or service per 42 CFR 414.408(e)(3)(ii).  In order for the ABN to be considered valid when issued under these circumstances, the reason that M edicare may not pay must be clearly and fully explained on the ABN that is signed by the beneficiary.   To be a valid ABN, the beneficiary must understand the meaning of the notice.  Suppliers must explain to the beneficiary that Medicare will pay for the item if it is obtained from a different supplier in the area.  While some suppliers may be reluctant to direct beneficiaries to a specific contracted supplier, the non- contracted supplier should at least direct the beneficiary to 1 -800 MEDICARE to find a local contracted supplier at the beneficiarys request.   50.15 - Collection of Funds and Refunds                                                 (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21) Collection of  Funds   A beneficiarys agreement to be responsible for payment on an ABN means that the beneficiary agrees to pay for expenses out -of-pocket or through any insurance other than Medicare that the beneficiary may have.  The notifier may bill and collect funds from the beneficiary for non -covered items or services immediately after an ABN is signed, unless prohibited from collecting in advance of the Medicare payment determination by other applicable Medicare policy, State or local law.  Regardless of whether they accept assignment or not, healthcare providers and suppliers are permitted to charge and collect the usual and customary fees; therefore, funds collected are not limited to the Medicare allowed amounts.  If Medicare ultimately denies payment of the related claim, the notifier retains the funds collected from the beneficiary unless the claim decision finds the healthcare provider or supplier liable.  When Medicare finds the healthcare provider or supplier l iable or if Medicare or a secondary insurer subsequently pays all or part of the claim for items or services previously paid by the beneficiary to the notifier, the notifier must refund the beneficiary the proper amount in a timely manner.  50.15.1 - Physicians Services RR                                                             (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  The physicians services RR provision, found in 1842(l) of the Act as amended by the Omnibus Budget Reconciliation Act (OBRA) of 1986, requires timely refunds for certain services.  When a reduction in payment, not a full denial, occurs, the physician mus t refund to the beneficiary amounts collected which exceed the Medicare payment for the less extensive item or service.  These RR apply to both participating and non-participating physicians.   When the beneficiary signs an ABN agreeing to accept responsibility for payment before services are delivered, the collected funds can be retained.  A refund is not required if the physician did not know and could not reasonably have been expected to know that Medicare would not pay for the services because they were not reasonable and necessary.   The Medicare contractor must notify the beneficiary in any case in which the physician requests review of the denial or reduction in payment or asserts that a refund is not required.   50.15.2 - DMEPOS RR Provision for Claims for Medical Equipment and Supplies                                                                                                     (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  All suppliers who sell or rent medical equipment and supplies to Medicare beneficiaries are subject to the refund provisions of 1834(a)(18), 1834(j)(4) and 1879(h) of the Act, whether accepting assignment or not.  Medical equipment and supplies are defined in the following statutes applicable to this section:     Durable medical equipment, as defined in 1861(n) of the  Act;   Prosthetic devices, as described in 1861(s)(8) of the  Act;   Orthotics and prosthetics, as described in 1861(s)(9) of the  Act;    Surgical dressings, as described in 1861(s)(5) of the  Act;   Home dialysis supplies and equipment, as described in 1861(s)(2)(F) of the  Act;   Immunosuppressive drugs, as described in 1861(s)(2)(J) of the  Act;   Therapeutic shoes for diabetics, as described in 1861(s)(12) of the  Act;   Oral drugs prescribed for use as an anticancer therapeutic agent, as described in 1861(s)(2)(Q) of the Act;    Self-administered erythropoietin, as described in 1861(s)(2)(P) of the Act;  and   Other items as determined by the Secretary.   If a proper ABN is not issued prior to the receipt of one of the preceding items and the above provisions apply, the beneficiary has no financial responsibility.  The refund provisions of the Act apply to both assigned and unassigned claims.  50.15.3 - Time Limits and Penalties for Healthcare providers and Suppliers in Making  Refunds                                                                                     (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21) A required refund must be made within specified time limits:    The refund must be made to the beneficiary within 30 days after the date the healthcare provider or supplier receives the remittance advice (RA) if the healthcare provider or/supplier does not request review of an initial full or partial denial;  or   The refund must be made to the beneficiary within 15 days after the date the healthcare provider or supplier receives the notice of the review determination if the healthcare provider or supplier requests review within 30 days of receipt of the notice of the initial determination.   Healthcare provider or suppliers who knowingly and willfully fail to make a refund where required within these time limits may be subject to civil money penalties and/or exclusion from the Medicare program.   The beneficiary should contact the contractor or CMS when a healthcare provider or supplier fails to make a timely refund.  If the contractor determines that a healthcare provider or supplier failed to make a refund, it will contact the healthcare provider or supplier in person or by telephone to discuss the facts of the case.  The contractor will attempt to determine why the required refund has not been made and will explain the legal requirements.  The contractor will determine whether referral to the Office of Inspector General (OIG) or C MS is appropriate and will make appropriate referrals OIG if necessary.  The OIG or CMS may impose civil money penalties, assessments, and sanctions if he or she fails to make the required refund.  The contractor will retain a detailed written report of co ntact.   50.15.4 - Suppliers Right to Recover Resalable Items for Which Refund Has Been  Made                                                                                          (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  If the Medicare contractor denies Part B payment for an item of medical equipment or supplies on the basis of 1862(a)(1), 1834(a)(17)(B), 1834(j)(1), or 1834(a)(15) of the Act, and the beneficiary is relieved of liability for payment for that item unde r 1834(a)(18) of the Act, the effect of the denial, subject to State law, cancels the contract for the sale or rental of the item.  If the item is resalable or re -rentable, the supplier is permitted to repossess the item.  Suppliers are strongly discouraged from recovering items which are consumable or not fit for resale or re -rental.   If a supplier makes proper refund under 1834(a)(18) of the Act, Medicare rules do not prohibit the supplier from recovering from the beneficiary items which are resalable or  re-rentable.  When the contract of sale or rental is cancelled on the basis described above, the supplier may enter into a new sale or rental transaction with the beneficiary as long as the beneficiary has been informed of their liability.  If the circumstances which preclude payment for the item have been removed (e.g. the supplier has now obtained a supplier number when that supplier did not have one before), the supplier may submit to the Medicare contractor a new claim based on the resale or re- rental of the item to the beneficiary.  If payment is still precluded, the supplier can issue an ABN.   Under the capped -rental method, if the Medicare contractor determines that the supplier is obligated to make a refund, the supplier must repay Medicare those rental payments that the supplier has received for the item.  However, the Medicare beneficiary mu st return the item to the supplier.   50.16 - CMS Regional Office (RO) Referral Procedure  (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  Prior to submitting any materials to the RO, the Medicare contractor will contact the RO to determine how to proceed in referring a potential sanction case for violation of refund requirements.  When referring these types of cases to the region, the contra ctor should include the following:   Background of the Subject   The subjects business name, address, Medicare Identification Number, owners full name and Social Security Number, Tax Identification Number (if different), and a brief description of the subjects special field of medical equipment, supplies, or services.   Origin of the  Case   A brief description of how the violations were discovered.   Statement of Facts   A statement of facts in chronological order describing each failure to comply with the refund requirements.   Written Correspondence and Written Summaries  Copies of any meetings or telephone contacts with the beneficiary and the supplier regarding the suppliers failure to make a refund.  List of the following for each item or service not refunded to the beneficiary by the supplier (grouped by beneficiary):   Beneficiary Name and Medicare beneficiary identifier;  Claim Control Number;  Procedure Code (CPT -4 or HCPCS) of non-refunded item or service;  Procedure Code modifier;  Date of Service;  Place of Service Code;  Submitted Charge;  Units (quantity) of Item or Service; and  Amount Requested to be refunded.  Additional Information  Any information that may be of value to the RO.