02/14/2024
Message from APT Owner and Vice President, Bill Lobosco:
I wanted to provide you an update on the LTA and its impact on you, your patients, and SunMED as well. It is now about four weeks since coverage began and there is still a lot of unknowns surrounding the new law for both Medicare and Medicare Advantage plans.
First and foremost, it appears we are one of a few providers around the country accepting orders for both Medicare and Medicare Advantage patients. As a result, we are receiving about 3 to 4 new facilities a day reaching out to SunMED inquiring about our services and how we can support their Medicare and Medicare Advantage patients. We are doing our best to help every patient we can, while dealing with a lot of unknowns from the insurance providers.
While we have done our best to prepare for the changes, nobody has nor had what they needed. Manufacturers are working on aligning their products to the new codes, therapists are unsure about what is covered and how to send in orders, and the payers are struggling to develop processes for these new codes. As an example, as of this writing, we have not seen a single Coverage Policy or fee schedule from a Medicare Advantage plan as to what codes they are using, clinical documentation they require, and fee schedules on how they will reimburse, yet we are filling these orders just the same.
We have provided some guidance to what we need from therapists on SunMED Express and will continue to put out updates on that platform as we learn more. Most importantly, we no longer are doing benefit checks for Medicare/Advantage patients. Rest assured, they’re covered, and at minimum 80%.
You may have noticed we are a bit slow in getting back to you all on order status, etc. We are basically having to re-build our entire order process, insurance dashboard, and our workflow to meet the requirements of the “New World” of Lymphedema that we are now in. It is taking some time to smooth out the flow internally. We ask for your patience as we work towards answers from our insurance providers and continue to educate therapists and patients as well.
Here are a few examples that are still holding up orders for which we are waiting for a response from Medicare:
- If a patient only orders one garment, can they still order two more daytime garments within six months?
- Can a patient order a RTW and a custom (Made to Measure) garment at the same time?
- If a therapist orders a knee high and a thigh high for the same limb, is that acceptable?
These are just examples of a few that apply to how you order. We have many, many more of these that are critical to SunMED on the billing side that are unanswered. Still, we press on.
We knew going into this there would be a lot of unknowns and accordingly, SunMED is taking a substantial risk of non-payment on many of these situations, which we are willing to accept.
How can you help the process?
- Please only send in orders with items (Products) included. The more complete the order (clinical notes, Rx, product selection and measurements) the more rapidly we can process an order.
- Please don’t request benefit checks unless it is a commercial (non-Medicare/Advantage) plan. Medicare/Advantage plans are at minimum covered for 80% of the garment/bandaging fee schedules.
- Please start to utilize SunMED Express (SME). We are doing our best to stay current and SME will show you order status, rather than our team needing to take the time to send an email detailing status. If you see the order hasn’t moved, it is because we are behind. In most cases, waiting on guidance on how to advance the order.
My next question is to you, and I’m looking for your feedback- how can we help you with the process?
We’re new at these changes just like you, and we’d like to know how we can improve the process too. We know we’re taking longer than normal. Trust me, we’re aware of it. And often times it is because we just don’t have answers - yet!
If we are not meeting your timeline expectations, we certainly understand and continue to work toward that resolution. While not an ideal solution, are you aware that a patient can pay out of pocket for the items they need and submit their receipt to Medicare or their Advantage plan on their own and be reimbursed directly? We realize not all patients can afford to do this, but if they can, it is a way to ensure during this adjustment phase they get what they need when they need it. The last thing we want to do is hold up garments and treatments for patients. If you simply cannot wait for us to get you a response and to move forward, please, encourage your patients to pay cash and submit their own claims on this first go around. I realize many patients cannot afford to do this, but there are also those that can, and this is an option if they simply cannot wait for us to get caught up.
Here is a link to do so: https://www.cms.gov/.../downloads/cms1490s-english.pdf
I am leaving you with this final thought- We are doing our best to get and stay current. There are over 40 SunMED people working behind the scenes to figure all of this out and get this program up and running at high speed. It is my everyday focus and will be until it is resolved. We are here to take care of patients. It’s what we do.
I am leaving my direct email address for you. If you have questions, concerns, anything, please feel free to email me directly. Please do not send orders or order inquiries to my email box. Rather, those requests should go back to your representative. My email is [email protected].
We have considered holding a webinar with our therapist customers to provide a Medicare overview and an opportunity to ask specific questions about order fulfillment (not about becoming a DME, or any of those processes) - just a webinar to help therapists help their patients. Would this be of value to you, or just continued updates like this and on SME?
Thank you all for reading this and your patience. This act is long overdue, and we are doing whatever we possibly can to get this operationalized and running smoothly as quickly as possible.
