Patient Claim Development & Medicare Audits

Q-University

Module 1 Introduction

Welcome to Q-University! (6:19)
The QPI Story (5:59)

Module 2 Administration: Corporate Structure

Corporate Entity Formation & Legal Requirements
Physical & Operational Requirements
Core Insurance Requirements
Automobile Insurance
General Liability Insurance
Worker’s Compensation Insurance
Quiz: Corporate Entity Formation & Legal Requirements

Module 2 Administration - Accreditation

Accreditation
Accreditation Process Overview
Supporting Documents
Quiz: Accreditation Process Overview

Module 2 Administration - Policies and Procedures

Why Are Policies & Procedures Important?
Accreditation Compliance
Regulatory & Medicare Compliance
Operational Consistency & Training
Continuous Improvement
Section 1: General Compliance & Accreditation Alignment
Section 2: Human Resources & Employee Training
Section 3: Risk Management & Quality Control
Section 4: Patient Experience & External Quality Control
Section 5: Administrative & Operational Compliance
Section 6: Updates Based on Recent Survey Findings
Quiz: DME Provider Policies & Procedures Checklist

Module 2 Administration - CMS Supplier Standards

Summary of DMEPOS Supplier Standards (42 CFR 424.57)
Purpose & Requirements
Application Certification Standards
Surety Bond Requirements
Prohibited Business Practices
Compliance Enforcement
Quiz: Purpose & Requirements for DMEPOS Suppliers

Module 2 Administration - CMS Quality Standards

Summary of CMS DMEPOS Quality Standards  
Section I: Supplier Business Services Requirements
B. Financial Management
C. Human Resources Management
D. Consumer Services
E. Performance Management
F. Product Safety
G. Information Management
Quiz: DMEPOS Supplier Standards outlined in 42 CFR 424.57
Section II: Supplier Product-Specific Service Requirements
B. Delivery & Setup
C. Training & Instructions
D. Follow-Up Services
Quiz: Section II: Supplier Product-Specific Service Requirements of the DMEPOS Quality Standards
Appendices: Respiratory
Appendix B: Mobility Devices (Wheelchairs & Assistive Technology)
Appendix C: Prosthetics, Orthotics, & Therapeutic Shoes
Quiz: DMEPOS Quality Standards Appendices

Module 2 Administration - Purpose of the DMEPOS Supplier Manual

Introduction
CMS DMEPOS Jurisdiction C Winter 2025 Supplier Manual
Supplier Enrollment & Compliance
Supplier Documentation & Orders
Billing & Claim Submission
Medicare Coverage & Fee Schedules
Medicare Secondary Payer (MSP) Rules
Fraud & Abuse Prevention
Appeals & Overpayments
Resources & Education
Quiz: DMEPOS Supplier Enrollment & Compliance

Module 2 Administration - DME Payer Sequence

Introduction
Understanding the Beneficiary 20% Co-Pay
CMS Guidelines on Billing the 20% Co-Pay
Policy on Not Sending Separate Statements to Patients
Best Practices for Compliance
Primary Payer (First to Bill)
Secondary Payer (If Applicable)
Tertiary Payer (If Applicable)
DME Payer Sequence Illustrated Flowchart

Module 2 Administration - Introduction to Insurances

Introduction
Medicare
Medicare Advantage Plans
Medicaid
Medicaid | Managed Care Organizations
Commercial Insurance | In Network
Commercial Insurance | Out of Network

Module 2 Administration - Medicare A-B-C-D Explained

Medicare Part A, B, C, & D Explained
Medicare Part A (Hospital Insurance)
Medicare Part B (Medical Insurance)
Medicare Part C (Medicare Advantage Plans)
Medicare Part D (Prescription Drug Coverage)
Quiz: Medicare: Understanding Parts A, B, C, & D

Module 2 Administration - Medicare Provider Enrollment - Part 1

Introduction to Medicare
Why Medicare Part B Matters for DME Providers
DME Provider Enrollment
Tips for Successful Enrollment and Ongoing Compliance
Summary

Module 2 Administration - CEDI - Medicare Provider Enrollment - Part 2

Step 1: Common Electronic Data Interchange (EDI) Transactions with NGS (National Government Services)
Step 2: EDI Transaction Codes
Step 3: Trading Partner ID
Step 4: Crosswalk Your NPI to CEDI
Step 5: Submit the CEDI NGS Submitter ID Application
Step 6: Wait for Approval & Obtain Your Submitter ID
Step 7: Complete Required Testing (If Applicable)
Step 8: Start Submitting Claims via EDI
Final Notes & Pro Tips:
Supporting Documentation

Module 2 Administration - DMEPOS MAC Web Portals - Medicare Provider Enrollment Part 3

DMEPOS Jurisdiction Web Portals & Provider Enrollment
Key Functions Available on MAC Portals
Step 1: Registering for DMEPOS Jurisdiction Web Portals
Step 2: Gather Required Information
Step 3: Register for a Provider Portal Account
Step 4: Request Access to Portal Functions
Step 5: Log In & Start Using the Portal

Module 2 Administration - Medicare Advantage Plans

Introduction to Medicare Advantage Plans
Steps to Ensure Reimbursement for Medicare Advantage Plans
Reimbursement Challenges for Medicare Advantage Plans
Best Practices for Success with Medicare Advantage Plans
Enrollment Steps
Credentialing and Contracting
Managing Claims and Appeals for Medicare Advantage Plans
Resources to Help with Enrollment and Claims
Step 1: Introduction to Enroll with MAP’s Timeline
Step 2: Credentialing & Contracting (Week 3-8)
Step 3: Preparing for Patient Services (Week 9-12)
Enrolling with Medicare Advantage Plans & Managing Claims

Module 2 Administration - Medicaid - Managed Care Organizations

Introduction to Medicaid
Understanding Medicaid Managed Care
Step1: Enroll with a Medicaid MCO – State Medicaid License Required
Step 2: Complete Medicaid Provider Enrollment
Step 3: Credentialing & Contracting with the MCO
Step 4: Verify Network Participation & Training
Managing Claims & Compliance
Quiz: Medicaid Managed Care Organization (MCO) Provider Enrollment

Module 2 Administration - In Network Commercial Insurance Carriers

Introduction to In-Network Commercial Insurance Carriers
Step 1: Becoming an In-Network Provider
Step 2: Credentialing & Contracting
Step 3: Verify Network Participation
Step 4: Credentialing & Contracting with the Commercial Payer
Step 5: Claims Management & Compliance
Managing Claims & Compliance

Module 2 Administration - Introduction to Out of Network Insurance Carriers

Introduction
Step 1: Verify Out-of-Network Benefits for Patients
Step 2: Obtain Payment Upfront or Have an Assignment of Benefits (AOB)
Step 3: Submit Out-of-Network Claims
Step 4: Monitor Reimbursement & Appeal Denied Claims

Module 2 Administration - Insurance Enrollment Changes

Change of Ownership
Reenrollment (Revalidation)
Deactivation and PTAN Revocation

Module 2 Administration - Competitive Bid

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

Module 3 Human Resources - Human Resources Department

Introduction
CMS Requirements for HR Records
Accreditation Standards (ACHC, BOC, Joint Commission, etc.)
State HME Licensing Requirements
Licensed Providers (Pharmacists, Respiratory Therapists, etc.)
Human Resources Department Checklist
Background Checks & Compliance Training
Provider Vaccination Requirements
Quiz: CMS Requirements for HR Records & Compliance
Bonus Lesson - Equipment Overview, Fee Schedules, Cost, ROI Video

Module 3 Human Resources - Job Descriptions

DME Provider Job Descriptions: Importance & Key Roles
Ensuring Compliance & Best Practices
Essential DME Provider Job Descriptions
Essential DME Provider Job Descriptions | Compliance Officer
DME Technician
Respiratory Therapist (if applicable)
Customer Service Representative (CSR)
Billing & Reimbursement Specialist
Delivery Technician
Warehouse/Inventory Manager
Quiz: DME Provider Job Descriptions & Compliance

Module 3 Human Resources - DME Evaluation and Skills Assessments Examples

DME Evaluations & Skills Assessments: Ensuring Competency and Compliance
DME Technician Competency Checklist
Respiratory Therapist (RT) Competency Checklist
Customer Service Representative (CSR) Skills Assessment
Billing & Reimbursement Specialist Assessment
Warehouse/Inventory Manager Assessment
Performance Evaluations & Competency Review Process
Quiz: DME Evaluations & Skills Assessments

Module 3 Human Resources - DME Equipment Training

Key Components of DME
Patient Education & Instruction
Regulatory & Accreditation Compliance
Documentation & Record-Keeping
Equipment Cleaning, Maintenance & Troubleshooting
Risk Management & Safety Protocols
Insurance & Billing Requirements
Quiz: DME Equipment Training & Compliance

Module 4 Risk Management - Introduction to Risk Management

Understanding Risk Management and DME Billing
Regulatory Compliance
Internal Controls and Fraud Prevention
Patient Safety & Quality Assurance
Financial Risk Mitigation
Overview of DMEPOS Billing Process | Patient Eligibility Verification
Patient File Documentation Requirements
Claim Submission and Coding
Denials, Appeals, and Audits
Best Practices for Risk Reduction in Billing

Module 4 Risk Management - Medicare Fee Schedule

Overview of the DMEPOS Medicare Fee Schedule
Key Components of the DMEPOS Medicare Fee Schedule
“Ceiling” and “Floor” Reimbursement Limits
Payment Methodologies
Rural vs. Non-Rural Reimbursement
Beneficiary Cost-Sharing
Adjustments & Annual Updates
How to Access the DMEPOS Medicare Fee Schedule
Quiz: DMEPOS Medicare Fee Schedule

Module 4 Risk Management - Billing - Local Coverage Determinations (LCD's)

What is an LCD?
Why LCDs Matter
How to Read an LCD to Ensure Patient Qualification
Example: Reading an LCD for a CPAP Machine
Quiz: LCD Compliance Quiz: Ensuring Patient Qualification for DMEPOS

Module 4 Risk Management - Pricing Data Analysis and Coding (PDAC)

PDAC – Pricing, Data Analysis, and Coding: Purpose and Use
Purpose of PDAC
How to Use PDAC for DMEPOS Billing & Compliance
Key Benefits of Using PDAC
How to Use DMECS for Same and Similar Verification:
Quiz: PDAC – Pricing, Data Analysis, and Coding Quiz

Module 4 Risk Management - Billing - State License Directory

Billing - State License Directory

Module 4 Risk Management - Patient Eligibility

How to Verify Patient Eligibility for DMEPOS Products and Services
Step 1: Verify the Patient’s Insurance Coverage
Step 2: Confirm HCPCS Code Coverage
Step 3: Review Local Coverage Determinations (LCDs) & Medical Necessity
Step 4: Check Prior Authorization & Documentation Requirements
Step 5: Verify Patient Financial Responsibility
Step 6: Document & Maintain Compliance Records
Prevent Billing Issues with Pre-Verification
Quiz: DMEPOS Patient Eligibility Verification

Module 4 Risk Management - Patient Documentation Requirements

DMEPOS Patient Documentation Requirements & Supplier Responsibilities
Key Documentation Requirements for DMEPOS Suppliers
Required Documentation Before Claim Submission
Advance Beneficiary Notice (ABN) – When to Issue
Delivery and Pickup Documentation
Backup Equipment Policy
Supplier Record-Keeping Requirements
DMEPOS Fee Schedules & Billing Rules
Medicare Participating vs. Non-Participating Suppliers
Quiz: DMEPOS Patient Documentation Requirements

Module 4 Risk Management - Patient Order Intake

Patient Order Intake Form
Patient Information
Insurance Information
Prescribing Licensed Independent Practitioner Information
Equipment Ordered
Insurance & Billing Verification
Required Documentation Checklist
Compliance & Documentation Requirements
Use QPI Healthcare Services LLC’s Pre-Billing Checklist
Quiz: Patient Order Intake Form

Module 4 Risk Management - Patient Pre Billing Checklist

Pre-Billing Checklist
Key Components of the Checklist
Order Validation
Medical Necessity & Documentation Compliance
Competitive Bidding & Supplier Compliance (if applicable)
Pre-Delivery & Billing Verification
Proof of Delivery & Refill Requirements
Compliance with Medicare Guidelines
Quiz: Pre-Billing Checklist

Module 4 Risk Management - Patient Claim Development

Patient Claim Development & Medicare Audits (1:53)
ADR – Additional Documentation Request (3:11)
SACU – Supplier Audit Compliance Unit (1:23)
UPIC – Unified Program Integrity Contractor (5:44)
TPE – Targeted Probe and Education
New Quiz Added: Audits

Module 4 Risk Management - Provider Responsibilities - Fraud Waste and Abuse

Fraud Waste and Abuse (10:36)
Comprehensive Summary: Medicare Fraud and Abuse
Quiz: Medicare Fraud and Abuse

Module 4 Risk Management - Provider Responsibilities -Incident Reporting

CMS & Accreditation Organization Regulations on Incident Reporting
Incident Report Supporting Documentation
CMS Regulations on Incident Reporting
Mandatory Reporting of Serious Incident
Incident Investigation & Root Cause Analysis
Incident Reporting System & Record Retention
Reporting to CMS & State Agencies
Accreditation Organization Requirements on Incident Reporting
BOC (Board of Certification/Accreditation) Standards
The Joint Commission (TJC) Standards
Consequences of Non-Compliance with Incident Reporting Regulations
Best Practices for CMS & Accreditation-Compliant Incident Reporting
Quiz: CMS & Accreditation Organization Regulations on Incident Reporting

Module 4 Risk Management - Provider Responsibilities - Annual Performance Improvement Reporting

DMEPOS Annual Performance Improvement Report
Key Components of the Report
Performance Measures (Ongoing Monitoring)
DME Quality Review Numbers (Quality Assurance Checks)
Patient Rights & Responsibilities / Patient Surveys (Patient Feedback Mechanism)
Patient Abuse Reports / Patient Complaints & Grievances (Risk & Compliance Monitoring)
Board of Directors (BOD) Meetings (Governance & Compliance Oversight)
Importance of the Annual Performance Improvement Report

Module 4 Risk Management - Provider Responsibilities - Risk Management Activities

Introduction to Risk Management Activities
Billing & Coding Error Logs
Emergency Drills & Fire Drills
Facility Safety Inspections
Hazard Vulnerability Analysis (HVA)
HIPAA Assessments
In-Service Training for Staff
OSHA Assessment
Patient Experience Surveys
The Joint Commission - Root Cause Analysis (RCA) – Required for Sentinel Events
Quiz: CMS Risk Management & Compliance

Module 5 Patient Outcomes - Building DME to Healthcare Provider Relationships

Building Local Provider Relationships as a DME Provider
Home Health Agencies (HHA) (2:07)
Assisted Living Facilities (3:29)
Skilled Nursing Facilities (SNFs) (5:49)

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Patient Claim Development & Medicare Audits

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