Medicare recently updated the refill request requirements with an effective date of January 01, 2024
Medicare recently updated the refill request requirements with an effective date of January 01, 2024. All the applicable local coverage determinations (LCDs) have been updated to reflect the below:
For DMEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products that are supplied as refills to the original order, suppliers must contact the beneficiary, and document an affirmative response, prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are expected to end, and to confirm any changes or modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner than 30 calendar days prior to the expected end of the current supply. For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the expected end of the current supply. This is regardless of which delivery method is utilized.
For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee and document an affirmative response, prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request and an affirmative response from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.
Comparison of the old and new rule:
Existing Rule Ending 12/31/2023 | New Rule Effective 01/01/2024 |
Contact with the beneficiary or designee regarding refills must take place no sooner than 14 calendar days prior to the delivery/shipping date | Contact with the beneficiary or designee regarding refills must take place no sooner than 30 calendar days prior to the expected end of the current supply |
For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product | For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the expected end of the current supply |
For consumable supplies, i.e., those that are used up (e.g., ostomy or urological supplies, surgical dressings, etc.)—you must assess the quantity of each item that the beneficiary still has remaining, to document that the amount remaining will be nearly exhausted on or about the supply anniversary date | No longer need to document quantity of supplies remaining on hand. Instead, suppliers should document an affirmative response from the beneficiary or their designee. Affirmative response means the beneficiary, or their designee affirms the need for the refill; but does not require beneficiaries to count the remaining supplies |
For non-consumable supplies, i.e., those more durable items that are not used up but may need periodic replacement (e.g., positive airway pressure and respiratory assist devices’ supplies)—you must assess whether the supplies remain functional, providing replacement (a refill) only when the supply item(s) is no longer able to function. You must document the functional condition of the item(s) being refilled in sufficient detail to demonstrate the cause of the dysfunction that necessitates replacement (refill). | No longer need to document the functional status of the supplies on hand. Instead, suppliers should only document an affirmative response from the beneficiary or their designee. Affirmative response means the beneficiary, or their designee affirm the need for the refill; but does not require beneficiaries to count the describe the condition of the existing supplies on hand |
Based on CMS’ response to the comment in the DMEPOS calendar year 2024 Final Rule, one of the intents was to eliminate the need for the patients to count the quantity of supplies they had on hand but the change also benefited beneficiary who received non-consumable supplies such as CPAP supplies. The new rule eliminated the need for beneficiary and/or their designee to document the functional status of the non-consumable supplies.
Also noteworthy is the fact CMS clarified in their comments that they do not prescribe the mode of communication for contacting the beneficiary to affirm the need for refills. CMS permits suppliers to use any mode of communication so long as the beneficiary’s affirmation is received, captured, documented, and can be provided upon request. This was in response to industry stakeholder’s comments that CMS permit or even require suppliers to use multiple modes of communication to contact the beneficiaries, such as via phone, text message or email.
Suppliers are reminded this change is binding to Medicare Fee for Service and Medicaid and other payers might have their own refill requirements. Suppliers are encouraged to research the other payers’ guidelines before making operational changes that impacts all payors. If you have additional questions or concerns, please do not hesitate to reach out to your Client Success Manager or me directly.