HME organizations struggle with the concept and implementation of informing their customers of their financial responsibilities. This area of patient rights is often misunderstood and sometimes poorly implemented by organizations. To establish an effective procedure and mindset for your staff and to serve your customers appropriately, it is important to understand the rationale for this right and requirement.
For years, it was common practice in the home medical equipment industry to admit customers to service without discussing the cost of an item or how much Medicare and/or insurance would pay and what, if any, co-payment would be due. It was also common to waive co-payments and simply accept the amount paid by a third-party payer as payment in full.
HME organizations are expected to have a good understanding of billing regulations for Medicare and any other third party payer source with which they participate or submit claims to. It is incumbent on the leadership of an organization to make sure that their billing practices are compliant with all regulations. An organization’s compliance plan addresses how the staff is educated and how the organization ensures and monitors billing compliance. The organization must have a process to admit a new customer to service where co-payments are explained and billing practices are discussed openly with the customer. Cost of care, information about co-pays and deductibles and any out of pocket expenses need to be addressed with customers at the start of services. It is a customer’s right to be informed of any amounts due and how their insurance (including Medicare or Medicaid) will be billed.
In the case of a Medicare customer receiving a piece of equipment that the organization anticipates will not be covered, an ABN (Advanced Beneficiary Notice of Non-coverage) should be completed and on file in order to bill the customer directly for the item if Medicare does not pay.
HQAA has several standards that address these issues relating to financial responsibilities. Some important ones to pay attention to include:
- ORG 2—Compliance with permits, licenses, and supplier/provider agreements. This standard speaks to compliance by an HME organization with any law or regulation. Compliance with supplier/provider agreements is included here. Think of this as a ‘catch all’ standard for any requirement by CMS or a payer.
- BC 2—Client charges and collection of payments. This standard addresses the need to have policies and procedures regarding how customers are informed of the charges and how payments are collected.
- BC 3—Compliance with payer requirements & regulations. This standard requires that the HME organization is compliant with any payer requirement. For example, if CMS requires a Certificate of Medical Necessity (CMN) to bill for an oxygen concentrator and you don’t have it, you will be cited at BC-3.
- PS 4—Client/caregiver education & training. This standard requires that customers are educated on all aspects of their care, including their financial rights and responsibilities, and any payer required documents (such as an ABN). Surveyors look for not only a good process, but also for the documentation of a patient education in your charts. Using checklists verify that your organization’s educational process took place and the customer has acknowledged it.
An informed customer is a happy customer most of the time. Solid policies and procedures, along with well-educated staff who understand these policies and procedures are the key to success with keeping your customers informed of their financial responsibilities. While they might not always be happy with the cost of their equipment, supplies, and treatments, keeping them informed up front will go a long way towards having good customer satisfaction with your services and staff.