Beginning this year, note that only certain kinds of physicians and non-physician practitioners can order or refer a Medicare beneficiary for durable medical equipment (DME), prosthetics, orthotics, and supplies. (Sometimes the acronym DMEPOS is used to describe all these items). These kinds include:
Physicians (doctors of medicine or osteopathy—all specialties,
and doctors of dental medicine, dental surgery, podiatric medicine, optometry, and chiropractic medicine),
Physician Assistants,
Certified Clinical Nurse Specialists,
Nurse Practitioners,
Clinical Psychologists,
Certified Nurse Midwives, and
Clinical Social Workers.
In addition, each ordering / referring practitioner must be currently enrolled as a Medicare approved physician or practitioner. For example, a Department of Veterans Affairs’ doctor can order DME for a veteran that for some reason the VA will not pay for, but that physician must be enrolled in the Medicare system even though they would have no occasion to submit a claim to Medicare.
It is inappropriate for a DMEPOS supplier to use the Advance Beneficiary Notice of Noncoverage (ABN) if a claim is rejected because the ordering / referring physician or practitioner is not enrolled in Medicare. An ABN is appropriate only when a supplier expects Medicare to deny coverage for an item or service under the Limitation on Liability provisions of Section 1879 of the Social Security Act.
Medicare made this change to tighten up on who can OK DMEPOS, as these items have been beset by fraud and abuse.
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