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Provider Operations Section
Exceptional Payment Programs
10/3/2017 1
Exceptional Payment Section
Exceptional Payment Section
Durable Medical Equipment (DME)
Ventilator Dependent Resident Program (VDRP)
10/3/2017 2
Durable Medical Equipment (DME)
What types of Durable Medical Equipment are
covered?
Specially Adaptive Equipment – Specially Adapted DME is
DME that is uniquely constructed or substantially adapted or
modified in accordance with the written orders of a physician
for the particular use of one resident, making the
contemporaneous use by another resident unsuitable.
Exceptional Equipment – Exceptional DME is defined as DME
that meets the minimum acquisition cost and is either
Specially Adapted DME or other such DME that is designated
as Exceptional DME by the Department annually in the
Pennsylvania Bulletin.
10/3/2017 3
Durable Medical Equipment (DME)
er Operations Section
Durable Medical Equipment (DME)
Specially Adapted Equipment
Power Wheelchair
Manual Wheelchair
Exceptional Equipment
Assistive Communication Devices
Bed and/or Mattresses (wound care)
10/3/2017 4
Durable Medical Equipment (DME)
Required Documentation
MA97 – Outpatient Services Authorization form
MA97LTC – DME request for nursing facility resident
Physician’s prescription
For specially adapted wheelchair, clinical assessment report from CARF or JACHO certified rehab facility
Required supporting documentation
10/3/2017 5
Durable Medical Equipment (DME)
Overview of Process
Documentation received from the facility
Request is reviewed. For wheelchairs and ACD’s each part is priced individually, using the MA Fee Schedule -
If no code is available we pay 80% of the MSRP
Nursing Facility notified of decision
Nursing Facility orders equipment for the recipient
Notice of Decisions are sent to the Nursing Facility with the Departments decision
If approved, the Nursing Facility bills the Department
The Department does a follow-up with the Nursing Facility to determine that the equipment was provided to the resident
10/3/2017 6
Durable Medical Equipment (DME)
Overview of Process (continued)
The Nursing Facility is required to notify the Department if at anytime the status of the resident needs change, they are discharged or they cease to breath
If the resident discharges from the Nursing Facility then the purchased DME goes with them
Currently, the Departments Field Operations teams do yearly reviews to verify the resident is still in the facility and the equipment is in good condition
The equipment is the property of the resident and will transfer with the resident. However, while residing in the facility if the resident can no longer use the equipment. The equipment will then become property of the nursing facility and the facility can then use the equipment for another MA resident as they see fit
10/3/2017 7
Durable Medical Equipment (DME)
Overview of Process (continued)
The Department will coordinate with the MCO on monitoring equipment purchased after January 1, 2018
10/3/2017 8
Durable Medical Equipment (DME)
Billing
Wheelchairs and ACD’s: each part of the chair/ACD are billed individually. Using the codes and prices shown on the Notice of Decision
Mattress or Bed Rentals are billed on a month to month basis
See handouts
10/3/2017 9
Durable Medical Equipment (DME)
Transition/Continuity of Care
Any wheelchairs or ACD’s approved prior to January 1, 2018, the Department will do the follow-up
Any Bed or Mattress rentals that where approved prior to January 1, 2018 but continue in the new year will be transferred over to the MCO for follow-up
Any request received prior to January 1, 2018 but have not been reviewed by the Department will be transitioned to the MCO for review
10/3/2017 10
Durable Medical Equipment (DME)
Current number of cases to transfer from the Department to the MCO’s for the Southwestern region.
Bed/Mattress Follow-up: Currently 3 cases
New requests: Unknown at this time
10/3/2017 11
Durable Medical Equipment (DME)
Our questions to the MCO’s regarding the Transition/Continuity of Care
What information will you want from us regarding cases the MCO’s will need to follow? (i.e. beds/mattress)
All cases that need to be followed up on and any new cases that will need to be reviewed will be delivered to the MCO through a file that will be created on DocuShare
The Department will need the name of the clinician that we can use as a contact person
10/3/2017 12
Ventilator Dependent Resident Program
Provides additional funding for the care of residents in
participating Nursing Facilities who are determined to be
unweanable and chronically ventilator dependent.
10/3/2017 13
Rental and rent-to-own
ventilators
Reimbursement for the
Department’s approved
list of respiratory
supplies and
frequencies
Tracheostomy Collars
CPAP
BI-PAP
Any moveable
equipment other than
the ventilator
Ventilator Dependent
Resident Program covers…
Ventilator Dependent Resident
Program does not cover…
Nursing Facility Participation Eligibility Requirements-
(The Department will continue to certify ventilator
facilities)
Certified and Enrolled Medicare Provider
Provider Type 03
Operate an existing or proposed ventilator unit that during
onsite inspection qualifies for the VDRP
Favorable standing with PA’s Department of Health
10/3/2017 14
Ventilator Dependent Resident Program
Resident Enrollment Eligibility Requirements
MA eligible residents
Residents 21 years of age or older who require full ventilator
support (mandatory ventilation) for a minimum of 8 hours a
day
Residents 20 years of age or younger who require ventilator
support to sustain life
Chronically Ventilator Dependent - unweanable
Clinically stable
Residents residing in an approved and enrolled VDRP
facility.
10/3/2017 15
Ventilator Dependent Resident Program
Application Requirements for a Ventilator Dependent Resident in an Approved Facility
MA97 – Outpatient Services Authorization Form
Physician’s statement
Respiratory Therapy flow sheets
Required supporting documentation MDS
H & P
Any additional Physician’s orders and progress notes
10/3/2017 16
Ventilator Dependent Resident Program
Overview of Process VDR’s application is received from an approved facility
Request is reviewed for eligibility requirements
Nursing Facility is notified of the decision & a prior authorization number is provided
If approved, Nursing Facility bills the Department on a monthly basis for ventilator rental and actual supplies used
Nursing Facility participates in Bi-Annual Invoice Reviews by submitting current invoices of actual costs from their DME Suppliers to the Department - periodic Ventilator Surveys are also conducted
10/3/2017 17
Ventilator Dependent Resident Program
Overview of Process (Continued)
The Nursing Facility is required to notify the Department if at anytime the resident requires less than 8 hours a day of mandatory ventilation, weans from the ventilator, transfers or ceases to breath
Currently, the Department’s Field Operations teams do annual reviews to verify that each resident is still in the facility and there are no changes to their ventilator status
The Nursing Facility currently completes an Annual Program Survey that provides current statistics to include: ventilator beds per unit and VDRP participants per unit. The Department will coordinate with the MCO for future reporting. (See Handout)
10/3/2017 18
Ventilator Dependent Resident Program
Billing:
Ventilator rental and approved supplies are billed on a monthly basis
See Handouts
10/3/2017 19
Ventilator Dependent Resident Program
Transition/Continuity of Care
All current VDR participants approved prior to January 1, 2018 and active in the Program, will be transferred to the MCO
All VDRP applications received by the Department prior to January 1, 2018 but not yet reviewed for program eligibility will be transferred to the MCO through a file that will be created on DocuShare
The Department will need the name of the clinician that we can use as a contact person
10/3/2017 20
Ventilator Dependent Resident Program
Current number of cases to transfer from the Department to the MCO’s for the Southwestern Region.
Currently 6 Nursing Facilities are enrolled in the Ventilator Dependent Resident Program:
Cambria Care Center: Currently, 8 participants
Forbes Center for Rehab: Currently, 13 participants
Mountainview Specialty Care: Currently, 2 participants
St. John Specialty Care: Currently, 1 participants
Transitions Healthcare Washington, PA: Currently, 5 participants
William Penn Care Center: Currently, 0 participants
10/3/2017 21
Ventilator Dependent Resident Program
Our questions to the MCO’s regarding the Transition/Continuity of Care
What information will you want from us regarding cases the MCO’s will need to follow?
10/3/2017 22
Ventilator Dependent Resident Program
Provider Programs Contact
Stacy Bowman - DME [email protected] 717-772-4120
Courtney Hammond - DME [email protected] 717-772-1471
Jane Snyder - VDRP [email protected] 717-772-0934
10/3/2017 23