The Truth about Insurance Coverage for VAD Patient Supplies

Decreasing the Risk of Financial Hardship for the VAD Patient at Home

Medicare guidelines – In 2012, CMS made the determination that traditional DME companies could no longer bill dressing supplies for VAD patients and that billing entities must have a “carrier provider” designation.  Many DME companies do not know that the rules have changed and are still trying to bill some of the supplies.   If a Medicare audit indicates that a DME has been billing and receiving reimbursement for VAD supplies, Medicare will most likely ask for repayment.  Because such an event could cause a DME company to financially fail, the DME would likely bill the patient for the amount recouped by Medicare.

Commercial insurance – Traditional DME’s can bill for VAD patients having commercial insurance or Medicaid. However, hospital reliance on an insurance company’s short list of in-network DME suppliers for outpatient driveline dressing supplies can be a costly mistake.  Unfortunately, insurance companies rarely know the limitations of their chosen and usually, long-standing DME suppliers. The truth is that traditional DME suppliers are often unfamiliar with the unique needs of VAD patients and many times will substitute ordered products for inferior ones or different ones.  This practice can ultimately put the patient’s health at risk.  Updates on new, possibly better-qualified in-network providers for outpatient supplies are not always available to the hospital.

In many cases, insurance companies will see the need for a niche provider and allow it into their networks to provide services for unique patients such as those with a VAD.  A supplier company that has insurance company relationships and deals one-on-one with these companies daily can often convince a given insurance carrier to provide appropriate benefits and to even let them into network as a provider for future VAD supply claims.

VAD facilities should seek a VAD-knowledgeable company that understands the unique needs of these patients and that will research each patient’s specific policy benefits and discuss them with the patient before sending out VAD dressings and supplies.  A knowledgeable company has the skill to advocate for the patient by fighting for patient coverage and the insurance carrier’s preauthorized, correct payment for VAD supplies.  This can reduce the chances for unexpected, exorbitant patient copays.

Medicaid – Many DME companies do not attempt to become in-network providers in state Medicaid programs because reimbursements are not always sufficient and are slow to be processed.

  It is illegal for a company to provide products to Medicare patients withot billing for them.  This is considered an inducement and is deemed an unfair business practice under the law.  Patients should receive statements from their insurance provider showing that billing has occurred.  Providers are also required to make reasonable attempts to collect copay amounts