Following the expansion of the Medicaid and Medicare services in 2018, the Medicare coverage beneficiary has increased. In addition, the integration of continuous glucose monitoring (CGM) has resulted in a great turn up of patients, thus improving their lifestyle. Conversely, the establishment of continuous glucose monitoring has posed as a billing challenge to the compliance of pharmacies among other healthcare institutions.
When Was The Continuous Glucose Monitoring Introduced?
The establishment of Continuous Glucose Monitoring can be traced back to 1999. This medical innovation marked the start of a decade that sort to produce advanced monitoring tools that could not invade the user’s body, but still uphold the Medicare coverage standards. In 2017, Dexcom, a medical senor that remits data in type 1 and type 2 patients, was allowed by the Medicaid Services and Centres for Medicare to operate.
Initially, the center for Medicare and Medicaid Services stated that continuing glucose monitoring should not be catered for by the Medicare since it did not provide a stand-alone way for the healthcare personnel to make treatment based decisions. Nonetheless, the current CGM system allows us to replace the monitors fully and sequentially resulted in coverage of CGM under Medicare. Currently, the Medicare services the CGM, among other contributing supplies rather than blood sugar monitors.
Despite the eligibility of Medicare reimbursement, there are challenges that are curbing the billing effectiveness of CGM by pharmacies and other healthcare providers. Likewise, following the high cost of CGM systems as compared to blood glucose monitors, the prescribing doctors receive stringent scrutiny from the CMS and various independent auditors. In this regard, the pharmacies that fail to meet the CGM prescriptions and subsequently deliver the CGM sensors to patients, are set to face legal charges.
What are the Critical Compliance Considerations for Pharmacies?
Notably, pharmacists and pharmacies face numerous potential legal charges when it comes to Medicare compliance and continuous glucose monitoring. If the concerned parties fail to manage the compliance issues appropriately, Medicare investigators and auditors are triggered. As a result, the instigated pharmacies risk recoupments, penalties, and fines. The following depicts what prescribing pharmacies and pharmacists need to know on matters of Medicare compliance and CGM.
Coding and Billing Compliance
Notwithstanding billing Medicare for various CGM devices, you should endeavor to follow the right procedure lest you face the long arm of the law. Physicians who are prescribing the CGM should ensure that the device is certified and legible, as described by guidelines outlined by the Medicare billing. Healthcare professionals affected should be aware of the risks of wrongfully billing a CGM device when it is not in need.
• Besides billing the unnecessary CGM devices, common coding mistakes entail;
• Giving a wrong billing code to the CMS.
• Billing for CGM devices that serve other purposes not indicated in the guidelines.
• Billing private insurance and Medicare at the same time for a single CGM device.
CGM Systems that Fail to Comply with Medicare Regulations
Notably, not all the CGM systems are allowed to access the Medicare reimbursement. Owing to the increasing technological innovations, many manufacturers are producing more CGM systems. As a result, it proves difficult for healthcare to keep track of the devices approved by either the Food and Drug Administration (FDA) or Medicare. Nevertheless, pharmacies hold the responsibility to ensure the facility only bills the CGM devices that meet the Medicare standards.
Designation of the Durable Medical Equipment (DME)
Furthermore, billing for the CGM systems as the durable medical equipment poses a profound mistake. Generally, all the devices billed as durable medical equipment; they are always dedicated to perform work and last for at least three years. Following the nature of the performance and functioning of the CGM systems, the reliance on smartphone applications, and other devices such as watches, the CMS is categorized not as durable medical equipment (DME).
Referral Connection with Healthcare Providers
The referral system from physicians can yield several problems concerning Medicare compliance. The formulation and implementation of the anti-kickback statute target healthcare practitioners who are involved in illicit referral relationships. Despite the possibility of establishing a referral arrangement that is compliant with the regulations, any act of referral that breaches the Anti-Kickback Statute is punishable with law.
Following the emergence of the Continuous Glucose Monitoring as an intervention to aid in the treatment of both Type 1 and Type 2 diabetes, various policies have been formulated to guide the use of devices and corresponding prescription. Remarkably, there are common mistakes that healthcare practitioners should avoid in a bid to maintain their practice licensure and prevent fines and penalties—such common mistakes outlined above. Continuous Glucose Monitoring layers intervene when the respective parties are instigated in Medicare compliance issues.
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