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American Association of Diabetes Educators Government Affairs Department
Special Edition--September 1998

Medicare & DMERCs Release Guidelines
Hospital Programs Impacted As ADA Recognition To Be Required

The Health Care Financing Administration (HCFA) recently released a program memorandum to expand Medicare benefits as authorized by the 1997 Balanced Budget Act. It is the second bulletin setting policies for reimbursement of diabetes education services. The announcements guide intermediaries and carriers who process claims submitted by patients and service providers for outpatient services under Part B of the Medicare Program.

Also released this week was a revised policy issued by the Durable Medical Equipment Regional Carriers (DMERC) setting utilization standards for blood glucose monitors and testing strips for Medicare beneficiaries. The revised DMERC policy permits reimbursement for up to 100 strips every three months for non-insulin using beneficiaries. This replaces an initial policy announcement of only 50 strips every two months. Also relaxed, but not completely repealed, are requirements that beneficiaries supply a copy of their monthly testing log book when the primary care provider prescribes testing of more than once a day.

The latest program memorandum regarding self-management education services was issued without release of the long delayed proposed rule laying out the plan for implementing the outpatient diabetes education benefit. The release date for its publication in the Federal Register is now forecast for late in the year or early 1999.

The full text of both of the program memorandums and the DMERC advisory are available on the Government Relations page of the AADE web site. They are also available on the AADEfax. Please request document #9009 for the program memorandums on self-management education. To receive the DMERC advisory request document #9019.

HCFA Adopts ADA Recognition

Under policies recently adopted by HCFA, certified providers of diabetes self management education must have ADA recognition in order to be reimbursed.

A certified provider is a physician, individual or entities paid under the physician's Medicare fee schedule. This includes non-physicians (e.g. physician assistants, nurse practitioners, nurse midwives, clinical psychologists and clinical social workers). CDE's and dieticians that are employed by physicians or entities that meet ADA standards may serve as instructors of outpatient diabetes self-management training: however, since they are not certified providers, payment may be made only to their employer, (e.g. a hospital), under the incident to provisions.

Hospital outpatient departments that do not have ADA recognition can be certified providers for these services if they were billing the Medicare program for outpatient diabetes self management education services prior to July 1, 1998. They will be reimbursed on a reasonable cost basis without obtaining ADA recognition until the final outpatient diabetes self-management rule is published. These providers must present proof that they have been billing the Medicare program for these services prior to July 1, 1998. Any new hospital for outpatient diabetes self management education programs (e.g. those that provide and bill for services for the first time on and after July 1, 1998) must have an ADA certificate.

Information on how to contact the ADA for details on obtaining recognition, including a telephone number to the Education Recognition Program, is included in HCFA's memorandum.

Diabetes Education Billed by the Hour

The recently released program memorandum issued by HCFA sets an hour as the increment of billing for self management education services. Providers will not be allowed to round up or down. If the training session lasts 1.5 hours, only 1 hour can be billed for that session. The extra 30 minutes for this day is to be counted towards future sessions. According to HCFA, as a basic guideline, it would not be necessary for a Medicare beneficiary to receive more than 10 hours of services for their initial training.

In addition, outpatient diabetes self management education services should normally be provided in a group setting. However, individual training sessions can be provided for a beneficiary if it is medically necessary, for example, because of language or physical challenges, such as severely impaired hearing or sight.

DMERCs Set Strip Guidelines

Earlier this year the DMERCs released a draft medical policy setting utilization limits and guidelines for blood glucose monitors and related supplies.

The AADE joined the majority of the diabetes community in voicing sharp criticism of the DMERCs policy as creating a cumbersome process for patients and providers. Under the old policy if a physician prescribed more than "50 strips every 2 months," the supplier would have had to submit a statement from the treating physician that included the patient's most recent one month log of glucose test results, confirmation that the treating physician has seen the patient within the last 6 months and the specific reason for the higher usage of test strips.

In response to the outcry from groups like the AADE, the DMERCs have revised some aspects of the policy. The revisions include:

Under the revised policy, physicians must still certify that they have actually seen the patient within the last six months when ordering strips and lancets that exceed the utilization limits established by the DMERCs.

Where To Go From Here

Implementation of the new Medicare diabetes self-management benefit is a high priority for the AADE and its members. The provisions of the Balanced Budget Act of 1997 promised expanded access to blood glucose testing and diabetes outpatient self-management training services for all Medicare beneficiaries.

Many are concerned with HCFA's slow pace of implementation and the narrow scope of the policies circulated by the agency that may not fully achieve the goal of increased access to quality diabetes services.

The best way to register your concern regarding this issue is to let your representative in Congress and the Senators representing your state know how you feel.

Due to the short time left to the legislative session before Congress adjourns for the year, it would be best to telephone these legislators to express your concerns. Their telephone numbers are found in your local telephone directory under "US Government".

Email is a particularly quick and effective way to send a message to your Congressional delegation. The House of Representatives and the Senate each maintain a web site specifically devoted to sending correspondence to your legislators over the internet:

House of Representatives:

Posted 3 October 1998

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