Author Topic: DME/Medicare "5 year rule"  (Read 6397 times)

jennifer8055

  • Newbie
  • *
  • Posts: 41
DME/Medicare "5 year rule"
« on: October 16, 2014, 07:42:04 PM »
Has anyone that bills for DME products ever heard of Medicare denying a product under the Medicare 5 year rule?  If so, is there any fighting this denial??

This to me has to be one of the silliest things I've ever heard after 20 years.  Medicare HMO plan (Humana) is denying a L4360 for a fracture of the bones on the right foot.  They are stating that the patient had fractures of the same foot less than 5 years ago and was issued the same L4360 by another provider and we will not be paid for the new boot.  If we have an ABN signed by the patient, then we can append that modifier to the claim and they will make the boot patient responsibility, otherwise, we have to eat the cost.

Why can the fact that the patient could have lost the original boot, threw it in the trash, ran over it with a tractor......whatever.....be considered??  I can understand having to wait 1 year between getting replacement DME products, that's what the Medicare guideline is for Diabetic Shoes/Inserts that we issue is.....but 5 years, come on??


kristin

  • Hero Member
  • *****
  • Posts: 703
Re: DME/Medicare "5 year rule"
« Reply #1 on: October 16, 2014, 10:51:44 PM »
I have been doing this as long as you, and I have never heard of such a thing. In fact, with regular Medicare DME, we have had patients get more than one L4360 in a year, due to various reasons, with no problem having them paid. BUT...we are talking about Humana which is bad, and Humana Medicare, which is worse than bad. I pulled my office out of their Medicare plans because they made their own rules, and didn't follow Medicare's rules, and I got sick of it. You could try to go through their appeals process, and keep escalating it if they continue to deny, but I don't know how much success you will have. If they have this spelled out in either the provider's contract, or the patient's benefits manual, you may be SOL.

jennifer8055

  • Newbie
  • *
  • Posts: 41
Re: DME/Medicare "5 year rule"
« Reply #2 on: October 17, 2014, 04:21:18 PM »
Kristin -

You said the exact same thing I was thinking when one of my payment posters brought this to my attention.....it's Humana - which is a pain.....but then it's Humana Medicare - which is a HUGE pain in the you know where.  We're going to try and appeal as many levels as we can - but I'm also going to check with the Insurance Commissioner of our state and the head of the TPMA (TN Podiatry Medical Assn.) and see what they say.

Thanks!
Jenn

Merry

  • Sr. Member
  • ****
  • Posts: 362
Re: DME/Medicare "5 year rule"
« Reply #3 on: October 22, 2014, 11:35:04 PM »
The 5 year rule is for lot of DME supplies.  Example.. Let's say Medicare supplied an assisted walking device for someone and they subsequently had a stroke so needed a different appliance so that they could be mobile.  If Medicare paid for the first device they will not pay for the second within 5 years. 

BWM1

  • Newbie
  • *
  • Posts: 2
Re: DME/Medicare "5 year rule"
« Reply #4 on: March 03, 2015, 07:08:19 PM »
Somebody chime in with more info because I think there is more to this.  You can supply a product to a patient within 5 years IF the product was out of warranty, lost, stolen, etc.  Inside a year its a replacement (see MFR warranty) and from year 2-5 it's a replacement for lost, stolen, or damaged beyond repair and out of warranty.  anyone?

Medical Billing Forum

Re: DME/Medicare "5 year rule"
« Reply #4 on: March 03, 2015, 07:08:19 PM »

ZooxySeno

  • Jr. Member
  • **
  • Posts: 59
    • molecular docking of tamoxifen
Re: DME/Medicare "5 year rule"
« Reply #5 on: November 09, 2022, 04:08:31 PM »
Although it is true that oral steroids normally induce higher liver stress than injectable steroids owing to their slower clearance, the safety of any steroid must be determined on an individual basis <a href=https://nolvadex.one/>tamoxifen usage</a>

unorgobug

  • Sr. Member
  • ****
  • Posts: 330
    • doxycycline ruined my life
Re: DME/Medicare &quot;5 year rule&quot;
« Reply #6 on: November 18, 2022, 04:15:24 PM »
It can also cause androgenic and estrogenic side effects so it s best used in a stack with compounds such as cardarine to increase hardness, reduce fat and improve cardio tolerance and an AI such as Aromasin to lower the amount of estrogen and the resulting effects <a href=http://doxycycline.world/>doxycycline dose for adults</a>

royagma

  • Sr. Member
  • ****
  • Posts: 326
    • generic of furosemide bad for your kidneys
Re: DME/Medicare &quot;5 year rule&quot;
« Reply #7 on: November 22, 2022, 09:47:29 AM »
<a href=https://lasix.autos/>torsemide to lasix conversion calculator</a> First, through a cell autonomous process, repeated and behaviorally relevant activation during EE induces changes in Fmr1 KO neurons that facilitates development of synaptic plasticity during learning, allowing normal memory consolidation to occur

Vogegrorb

  • Sr. Member
  • ****
  • Posts: 334
    • is levitra still on the market
Re: DME/Medicare &quot;5 year rule&quot;
« Reply #8 on: December 08, 2022, 10:42:05 PM »
<a href=https://zithromax.one>imitrex buy u.s canada</a> Therefore, they are extensively utilized in several aspects of cancer diagnosis

lapound

  • Sr. Member
  • ****
  • Posts: 340
    • do you have to use finasteride forever
Re: DME/Medicare &quot;5 year rule&quot;
« Reply #9 on: December 19, 2022, 10:31:22 PM »
The selective D2 dopamine receptor antagonist eticlopride counteracts the ejaculatio praecox induced by the selective D2 dopamine agonist SND 919 in the rat <a href=https://stromectol.mom>stromectol for lice</a> 1, epicatechin EC 4

Medical Billing Forum

Re: DME/Medicare &quot;5 year rule&quot;
« Reply #9 on: December 19, 2022, 10:31:22 PM »

knomype

  • Full Member
  • ***
  • Posts: 168
    • predaj viagra kamagra cialis
Re: DME/Medicare &quot;5 year rule&quot;
« Reply #10 on: January 23, 2023, 01:43:55 PM »
<a href=https://cialis.autos>cialis buy online usa</a> He and the owner of the garden have been with him for many years, and they have received gifts from the owner together, so that he has the realm of today, and he has some sense of each other Not long ago, Margherita Guillemette discovered the secret of the garden owner His soul is very weak, almost on the verge of collapse Sure enough, normal cholesterol but high triglycerides has finally worked As long as the garden owner dies, everything he has will become Rubi Damron thing

paurgefug

  • Newbie
  • *
  • Posts: 17
    • what is stromectol prescribed for
Re: DME/Medicare &quot;5 year rule&quot;
« Reply #11 on: January 24, 2023, 03:31:04 AM »
selegiline transdermal increases toxicity of fentanyl by Other see comment <a href=https://nolvadex.pics>tamoxifen eye side effects</a>

ideorrert

  • Sr. Member
  • ****
  • Posts: 304
    • liquid clomiphene dosage
Re: DME/Medicare &quot;5 year rule&quot;
« Reply #12 on: January 27, 2023, 01:54:06 AM »
Liu Y, Zhang Y, Wu J, et al <a href=https://lasix.beauty>lasix for cats</a>

Medical Billing Forum

Re: DME/Medicare &quot;5 year rule&quot;
« Reply #12 on: January 27, 2023, 01:54:06 AM »