As Medbill’s Vice President of Revenue Cycle Management and Automation, Kelsey Kansler connects the dots between frontline policy discussions and the everyday realities of DME billing.
Kelsey is the Respiratory A Team Leader for Jurisdiction C with a front-row seat to the latest regulatory shifts and behind-the-scenes conversations that impact providers across the country.
Here are the most important updates Kelsey brought back from the latest Jurisdiction C Council pre-meeting:
1. Major Shift: QIC Contractor to End Development Letters
Hot off the press: The QIC (Qualified Independent Contractor) responsible for the second level of Medicare appeals—currently Maximus for DME—has announced it will discontinue the use of development letters.
These letters gave suppliers a second chance to correct minor documentation errors after a claim denial. The move signals a shift back to a more rigid appeals process: You either submit a complete, compliant claim up front, or it gets denied—no second chances.
This decision hasn’t been published on the QIC website yet, but keep an eye out for the official update.
2. PTAN Deactivations on the Rise: Avoid Common Mistakes
The NSC (National Supplier Clearinghouse) contractors—NPE East and NPE West—are ramping up deactivations of provider numbers (PTANs), often without suppliers realizing they’re at risk. The most common reasons for deactivations include:
- Missing revalidation deadlines (an easily avoidable but widespread issue)
- Expired surety bonds or licensures
- Outdated management info or state listings on 855s
- Submitting claims to states you’re not licensed to operate in
Suppliers can file a Stay of Enrollment if they’ve missed revalidation, which can speed up reactivation to 10–14 business days while paperwork is processed. It’s wise to review your PECOS enrollment quarterly to catch any issues early.
3. AAHomecare Watch: Reimbursement & Rulemaking on the Horizon
There are two key updates from AAHomecare to keep on your radar:
- An OIG report on CGM reimbursement is expected late summer or early fall. These reports often shape future audit behavior, so be prepared for more scrutiny.
- Language around competitive bidding may appear in CMS’s final rule this June or July.
Stay tuned for more regulatory insights. The Medbill team will continue to share updates that help DME suppliers stay compliant and proactive.
4. Upcoming Rule for NIV/RAD
The proposed rule for NIV/RAD comments is set to be released in June. Once finalized, the DME MACs will be directed to prepare the Local Coverage Determination (LCD) based on the new National Coverage Determination (NCD). Essentially, these updates could influence how devices like NIV and RAD are covered by Medicare on a local level, depending on the final NCD.
5. Challenges with PAP Devices as Secondary Insurance
Medicare as a secondary payer for PAP devices presents a unique billing challenge. When primary insurance requires rent-to-own after the fourth month, there is no option for Medicare to process the claim under the capped rental rules.
This creates a situation where suppliers can’t bill the patient for the cost share of the primary insurance, especially in cases with secondary insurance like UMR. Additionally, for FDA-approved devices like Inspire, eXciteOSA, and oral appliances, concurrent oxygen coverage for nightly use requires proof that obstructive sleep apnea (OSA) has been sufficiently treated with a titration while wearing the device.