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What is DMERC for Medicare?

Just the essentials...
  • DMERC processed requests for durable medical equipment for home usage
  • DMERC was the name used before the current DME MAC designation
  • Medicare used four DMERC companies to cover the US and territories
  • DMERC companies operated the purchasing lists of qualified durable equipment
  • DMERC companies trained and assisted suppliers of durable equipment

DMERCs were the Durable Medical Equipment Regional Carriers. The name change occurred in 2007. Durable Medical Equipment Medicare Administrative Contractors is the current name of the Durable Medical Equipment Regional Carriers. Prior to the DME MAC label, they were also called Medicare A/B contractors.

The primary role of the Durable Medical Equipment Medicare Administrative Contractors is for health care claims processing, and payment or reimbursement for Original Medicare and Medicare Advantage Plans. The payment and processing is an enormous task involving high volumes of requests for equipment, prosthetics, orthotics, and supplies.

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The Heart of the Equipment System

Disabled man with wheelchair entering car

The purpose of the Durable Medical Equipment Regional Carrier and now the DME MAC is to service the medical equipment needs of beneficiaries in a designated territory. Medicare provides durable medical equipment to beneficiaries on a buy or lease basis.

When deemed medically necessary and prescribed by a Medicare physician, Medicare Part B authorizes the Centers for Medicare and Medicaid to provide the medically necessary equipment.

The Functions of the DME MAC

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Original Medicare and Medicare Advantage Plans carry out the durable equipment processes in Medicare Part B. When medically necessary, medical equipment can be a vital part of outpatient care.

The earlier DMERCs and currently the DME MACs perform customer service for the beneficiaries of Medicare. They review and approve claims for durable medical equipment, prosthetics, orthotics, and supplies.

They promote cost reduction through system efficiency and process management improvements.

The role of the DME MACs includes:

  • Assess providers and review credentials
  • Supplier enrollment, training, and education
  • Reviewing records and determinations medical necessity
  • Pre-approval and post-payment review

The Four DME MAC Regions

Connected world diagram

Medicare has four DME MAC agreements; each establishes authority to oversee Medicare durable equipment transactions in a region of the nation and territories.

The DME MACs have oversight over all medical equipment requests, supplier compliance, and durable equipment payments in their regional territories. A recent change in the law extended the length of contracts to a maximum of ten years.

Region A: Noridian Health Care Solutions

The Noridian is the DME MAC for Region A. Essentially,it processes claims in the Northeast region. Region A includes the states of Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.

Region B: DME MAC is CGS, a Celerian Company

CGS is the DME MAC for Region B. This region consists of the states of Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin.

Region C: the DME MAC is CGS

CGS operates the DME processing system in Region C. The region consists of the territories, possessions, and states of Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia, and West Virginia.

Region D: Noridian Health Care Solutions

Noridian is the DME MAC for Region D. This widespread region consists of the states of Alaska, Arizona, California, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming. It includes the territories and possessions of American Samoa, Guam, and the Northern Mariana Islands.

DME MAC Functions Require Expertise

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The DME MAC works with the essential flow of claims and payments that keep Medicare beneficiaries supplied with medically necessary home equipment. Time is of the essence in every transaction because the underlying situation is one that involves the health and well-being of the beneficiaries.

Many DME MAC companies were MACs and worked in Administration or enrolling suppliers. Many handled other parts of the Medicare program such a Health Hospital and Hospice (HH+H). Medicare reviews the performance of the DME MACs through a detailed assessment and evaluation process.

Processing by the Book

Claims processing is a pivotal part of Medicare services. Outpatient treatment can depend on medical equipment for home usage. The DME MACs process claims, review medical information, review appeals, and process payments. The claims processing manual helps ensure uniform approaches and fair treatment for beneficiaries regardless of location or type of request.

Understanding Terms — Durable Medical Equipment

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Medicare only pays for durable equipment. Home care involves many types of supplies and devices, but the terms of Part B apply to durable equipment. The below-listed criteria define durable for the purpose of Medicare Part B Medical Insurance coverage and Medicare Part C Medicare Advantage plans.

  • The item must be long-lasting, expected life of three years or more.
  • Used in the home for a medical reason, most useful to someone sick or injured.
  • The Item or device must be reusable; things that one can use over and over. They do not get used up and suffer ordinary wear and tear.
  • Must be useable inside the home. The item can be useful outside of the home, but the qualifying language for coverage requires that it be useful inside the home. May items are useful in both settings. A wheelchair can help people with limited mobility inside the home and translates easily into an outdoor device.

Understanding Key Terms — Medical Necessity

Medicare pays for durable medical equipment that a doctor prescribes as medically necessary to treat an illness or condition. The rules require a doctor’s visit within six months of the DME prescription in which the patient discusses his or her need for the item with the doctor. The Doctor must attest to the meeting and the recommendation for the equipment.

DME from Approved Suppliers

The patient must order the durable equipment from an approved supplier. The Original Medicare approves suppliers and each Medicare Advantage Plan as a list of approved suppliers.

The supplier accepts the Medicare price and leaves a twenty percent coinsurance for the patient ‘s payment. Buying outside of the approved suppliers can leave the patient open to additional costs as the supplier can demand a balance from the patient.

DME through Original Medicare

Medicare on chalkboard

Original Medicare suppliers are those that accept Medicare.

Members are free to select any of them, and the pricing should be relatively consistent. In bidding demonstration areas, Original Medicare requires the use of suppliers that participate in the demonstration program. Going outside of this list may result in no cost sharing support.

Original Medicare and Bidding Zones

The competitive bidding demonstration zone is an effort by Medicare to improve competition and lower prices paid for durable medical equipment. The zone requirement applies to all transactions that occur in the bidding zone whether one lives there or is merely visiting will not matter.

DME through Medicare Advantage Providers

Medicare Advantage Plans may require approval before the doctors can approve the DME request.

Members of Medicare Advantage Plans should consult with their plan for procedures and use the preferred resources that the plan recommends. The plan’s recommendations will likely include particular suppliers and preferred brands.

Managing the DMEPOS Schedule

The DE MACs or DMERCs help manage the federal schedule of durable equipment, devices, and supplies. They work to ensure the accuracy of codes and the quality of goods that go to beneficiaries for home use.

The DMERC is Vital to Medicare Part B and Part C

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With jurisdiction over large portions of the US population, the Durable Medical Equipment Medicare Administrative Contractors play an important role in delivering high-quality health care services. The need for medical equipment in the home can be severe. Some equipment assists in basic functions in the home.

The system must respond quickly and consistently to the needs of a large and diverse population. Comparison shopping can help consumers find the best items for their durable equipment needs. They can use this technique to find key features and best quality.

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References:
  1. https://www.medicare.gov/what-medicare-covers/medicare-health-plans/what-medicare-health-plans-cover.html
  2. https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center.html
  3. https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/Downloads/CMS-Internal-HCPCS-Coding-Decisions.pdf
  4. https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/DME-MAC-Jurisdiction-Map-July-2016.pdf
  5. https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs-DME-MAC-Jurisdiction-A-JA.html#DME%20MAC%20Jurisdiction%20A%20-%20DME%20Facts
  6. https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs-DME-MAC-Jurisdiction-B-JB.html
  7. https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs-DME-MAC-Jurisdiction-C-JC.html
  8. https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs-DME-MAC-Jurisdiction-D-JD.html
  9. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html
  10. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c20.pdf
  11. https://www.medicare.gov/coverage/durable-medical-equipment-coverage.html
  12. https://www.medicare.gov/supplierdirectory/staticpages/resources/aboutdirectory.html?activeTab=2
  13. https://www.medicare.gov/supplierdirectory/search.html
  14. https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/What-is-a-MAC.html#DMEMacs

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