Problem Solvers

Expanding with Medicare in Mind

When a provider expands into a new Medicare product category it must satisfy various requirements, starting with accreditation.

As competitive bidding, audits and consolidation impact the industry, there are many cases in which a provider will expand into a new product category in order to broaden their market reach and revenues. With that new line of service comes a variety of requirements: the provider will need to add product expertise, perhaps even new certifications to the staff, and maybe even hire entirely new team members. Also the provider will need to add billing for those items to its workflow and other back office functions.

And, above all, that provider will need to get accredited in this new line of business — otherwise the provider won’t be able to bill Medicare. And, while getting accreditation for a new category is extremely important, it remains a detailed process. Providers going through accreditation for a new category must strive to ensure all the proper documentation and procedural steps are in place for the DME and services they offer, and then undergo site surveys — and possibly have to undergo them again if they are found to need in improvement in some aspects of their business before they can become accredited.

And of course, the provider must continue to work within the accreditation guidelines so that it will maintain that accreditation and be able to easily renew with its accrediting organization. Suffice it to say that accreditation is an ongoing effort, but when first gaining accreditation, the provider must do a considerable amount of preparation and groundwork to ensure it can properly support the new category.

Start by Working With Your AO

Accrediting organizations regularly help providers prepare their businesses to properly support new categories, so your AO can serve as a solid resource. Your AO will have procedures in place to handle this, but the key is that you will want to work up-front with the accrediting organization.

So start by informing your accrediting organization that your are adding new products that are billable to Medicare to your product line-up. Every accrediting organization has a product code checklist that outline which product categories and codes are covered by a provider’s current accreditation. The accrediting organization will work with a provider to determine if the new products are covered by the provider’s current accreditation, or if a new survey visit is in order.

This initial check is critical because obviously if the provider isn’t accredited for that new line, it likely not get reimbursed for the item. When receiving claims, Medicare performs a cross-reference check to ensure that the provider submitting the claim is accredited for the items being billed.

And that list is regularly updated. Accrediting organizations submit reports weekly to CMS, which includes all the product categories that a provider is accredited for, and if there is any discrepancy in billing, then there is risk of not getting paid.

So, before launching into a new business, each provider should be familiar with their accrediting organization’s process in managing the addition of products.

Policies and Procedures

Obviously, if a provider is adding a DME item for which it provider is already accredited, not much work needs to be done. But if the provider is adding a new product category that falls outside the scope of the provider’s current accreditation, then the provider will have to work with accrediting organization to put into place all the policies and procedures required to ensure proper provisioning of those items.

The provider will have to work with the accrediting organization to put the proper standards, documentation and operations in place. It will have to ensure paperwork is in order, delivery is timely, patient set-up and education about the item is accurate, and that all the right resources are available.

Accreditation and Acquisitions

Sometimes the reason a provider adds a new line is because it purchased another business or service line from another provider. Mergers and acquisitions between providers are becoming increasingly common. The question of whether a provider should get accredited when purchasing another provider business — even if that business was accredited for Medicare — is not always simple.

In basic terms, accreditation stays with the location, just as a Medicare number does, but this rule doesn’t fit every situation. For instance if the provider were to buy a business and keep it at its existing location, then that Medicare accreditation would stand as is. However, if a provider buys a business and then integrates some of its assets into the company without maintaining the original location, then that will almost definitely require getting reaccredited in that category.

Ultimately, determining accreditation for a purchased business must be addressed on an individual basis, so again, the provider will want to work with its accrediting organization at the outset.

Leverage Your Staff

Form a team of key staffers who will approach accreditation renewal with the level of intensity your company probably did when first applying.

Identify an expert on your staff who you can trust to lead this effort in a hands-on fashion. You want someone who is ready to work with your accrediting organization to thoroughly understand the needed documentation policies and procedures and will be familiar with how they fit into Medicare accreditation requirements, as well. That leader should also identify and work with key team members in the business who can help implementing company-wide compliance, review workflows, determine how procedures need to change, and implement those changes.

Once you’ve identified the right people, make sure that not only those staffers, but the entire business understands that the company will be renewing accreditation. Outline why your business is doing this; what any changes will be; review how the process will work; explain how it might be different from before; and specify how the process will impact each department and what will be required of team members in those departments.

Manage Cost

The cost of getting accrediting in new categories depends on the accrediting organization. Some accrediting organizations will charge to add a category, others won’t charge, but when adding standards and subsequently having a site visit survey, those general costs are incurred. Like at the outset of the process, the provider must communicate with the AO to ensure all the costs are understood.

This article originally appeared in the September 2016 issue of HME Business.

About the Author

David Kopf is the Publisher and Executive Editor of HME Business and DME Pharmacy magazines. Follow him on LinkedIn at and on Twitter at @postacutenews.

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