A Surprise From The No Surprises Act For DME Suppliers
Source: Medtrade Monday 7/04/2022
The Consolidated Appropriations Act ("CAA") has a surprise for DME suppliers. DME suppliers are now being required by payors to re-verify their information in the provider directory every 90 days.
On January 1, 2022, Section 116 of the Federal Consolidation Appropriations Act became effective. This section has commonly become referred to as “The No Surprises Act.”
The No Surprises Act requires payors and providers/suppliers to ensure that provider/supplier information, that is present in payors’ provider directories, is correct.
Payors are required to keep their provider directories up-to-date. Therefore, the provider directory information must be updated and verified every 90 days. If a provider’s/supplier’s information has not been verified within that 90-day window, the payors are required to have a procedure in place to remove the provider’s information from the directory.
Besides it being required by Medicare, what motivates the payors to keep up with this rule?
Let’s look at a hypothetical situation:
An enrollee of the payor, “Patient,” uses the provider directory to locate an in-network DME supplier. The supplier that the Patient chooses from the directory is ABC Medical Equipment, Inc. ABC furnishes items or services that will be covered by the payor if ABC is an in-network DME supplier.
It is discovered that ABC is an out-of-network supplier when it takes assignment and bills the payor. It is also discovered that the provider directory was inaccurate because ABC’s information had not been verified. Because ABC is out of network, the Patient is billed in excess of the in-network cost-sharing amount.
Since the Patient relied on an incorrect provider directory and this item or service would have been covered if ABC was in network, the payor is required to reimburse the full amount paid in excess of the in-network cost sharing amount, plus interest.
To prevent the above scenario, payors have begun requiring providers/suppliers to verify and update their provider directory information at least every 90 days.
Payors have also implemented a process to remove providers/suppliers that are noncompliant with responding to the payors’ attempt to verify the provider/supplier data. Even if there is not a change to the information, the provider/supplier is still required to verify the information.
A DME supplier that has a contractual relationship with a payor to provide items or services under the contract must submit its information to the provider directory in the following circumstances:
- At the beginning of the network agreement with the payor
- When the network agreement terminates
- When there are material changes to the content of the provider directory information of the provider or facility
- When the payor requests it
- Any other time that is deemed to be appropriate by the provider/supplier, facility, or HHS