Refusal of Suppliers to File Medicare Claims Is Illegal

I have been advising lymphedema patients to appeal every denial of reimbursement for the compression bandages and garments used in the treatment of their lymphedema. Some suppliers do not file claims, claiming that these items are not covered by Medicare.

This refusal is illegal since these items have been found to meet the coverage criteria for "prosthetic devices" by several Administrative Law Judges, and the decision that they are not covered is not a decision that a supplier can make. CMS has recently published a clarification of the rule that requires Medicare-enrolled Suppliers to file a claim on behalf of a Beneficiary. This educational article can be downloaded as follows:

Mandatory Claims Submission and its Enforcement http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0908.pdf

The Social Security Act (Section 1848(g)(4)) requires that claims be submitted for all Medicare patients for services rendered on or after September 1, 1990. This requirement applies to all physicians and suppliers who provide covered services to Medicare beneficiaries, and the requirement to submit Medicare claims does not mean physicians or suppliers must accept assignment.

Compliance to mandatory claim filing requirements is monitored by CMS, and violations of the requirement may be subject to a civil monetary penalty of up to $2,000 for each violation, a 10 percent reduction of a physician’s/supplier’s payment once the physician/supplier is eventually brought back into compliance, and/or Medicare program exclusion. Medicare beneficiaries may not be charged for preparing or filing a Medicare claim.

For the official requirements, see the following:

Social Security Act (Section 1848(g)(4)(A); "Physician Submission of Claims" at http://www.ssa.gov/OP_Home/ssact/title18/1848.htm on the Internet.

Requirement to file claims – The Medicare Claims Processing Manual, Chapter 1, Section 70.8.8: http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf on the CMS website.

Robert Weiss
Lymphedema Patient Advocate