Who Pays for DME? Medicare, Medicaid and Commercial

0:00Intro: payers decide everything

Assalamu alaikum. So after a few weeks, we're starting this course again that we had formally begun, and I just got a notification here. Is anyone else going to join the meeting? No, it's just us. Okay. Okay, so okay. So we are formally restarting this course. And basically, sorry, I got a bit busy, because of which I couldn't continue it, but after that I got a few messages and some people even called me and said that I should continue it. So anyway, I told you earlier that even if just one person is watching this course properly, we will complete this course InshaAllah, and the special thing about this course and basically my idea is that we take each topic and each segment and do a deep dive into it.

A lot of things are everywhere automatically, but to understand the concepts, we need to go into those layers and details where they sink into your mind. For that, I have added two people. One is Ansar Ali, who is our company Next RCM's Product Manager and is also a Director. And with us for this, Ansar Ali is here, both of them are here with me. So Ansar, how are you, how are you doing? Alhamdulillah, I'm fine, and you? Let's start with the tag line then. Yes, yes.

So basically we will try, I have prepared a slide deck, to go through it a bit by discussing it, so it will go well and it will be enjoyable InshaAllah in this discussion. So in the coming time we will keep bringing more guests too. If we do, though there is no guest right now, but let's start with this. So today our topic is basically who pays for DME, where it gets its money from, and in the United States healthcare, the durable medical equipment, prosthetics and supplies provider, basically, where its revenue comes from, and how many payer programs it is involved in.

So in this slide we will try to understand that I will tell you from the start that one big payer is Medicare, which is a federal payer, and it is federally regulated, and Medicare also, basically there is a federal body called CMS, which basically regulates the programs of both Medicare and Medicaid, of both programs, but Medicaid is a state program, but it is regulated federally, and its budget is roughly seventy to seventy-five percent from the federal side and twenty-five percent is what the states bear. We will understand this in detail later, we'll try.

And besides this, in the US health structure there are also commercial payers, which are basically private plans, and those exist too, which means healthcare, there's Humana, Aetna, Blue Cross Blue Shield. Basically this is the structure of insurance, in which there is a federal plan, Medicare, and a state plan, Medicaid, and besides that commercial ones, in which all the private insurances come, okay, and the second thing is that basically basically for healthcare there are two models. One model is that you render a service to the beneficiary and after that you bill their insurance.

And the second model is that you do the work in which you bill the customer or the patient directly, out of pocket. So these are the two options. Now how big is their market, how much is out-of-pocket, what is the market size of out-of-pocket, and besides that what is the market size of insurance, we will understand this later. So basically, these are the four questions above. These six indicators that are here, basically, basically whether the product is covered or not, meaning whether the item is covered or not, and whether it is covered today or not, meaning whether the insurance policy is active or inactive, and whether the documentation is complete or not.

And besides that, basically what its prices are, and what the patient pays, what the patient responsibility is, how to collect it and where to bill it, okay. So here, Ansar, or Ilham, do you want to add anything that comes to your mind? No, not right now, but InshaAllah if I need to add anything, I will definitely add it in this. Okay, now we move ahead, okay. Now this is basically an insurance map of the United States, which says that one hundred fifty million people basically in the states have employer coverage, meaning people who are doing jobs, the insurance they get from their company as an employee, so that is employer coverage, roughly over one hundred fifty million people's policies, one fifty million plus policies exist.

5:36The U.S. insurance map

Besides that, the second number is in the size of this market, in Medicare sixty-eight million people are enrolled in the Medicare records, meaning they have Medicare, so what I mean is that I already told you that Medicare is basically for people who are sixty-five and above, but besides that there are two or three things through which such a patient gets it before sixty-five. One is if they have Lou Gehrig's disease, another is if they have some renal disease, okay, and besides that, now another thing that they added recently, in 2026, is that if someone has a spinal injury, they also get Medicare, no matter whether they are sixty-five or not.

So basically what I mean is that out of sixty-eight million, most of them, I think about 90% of the beneficiaries will be 65 and above, so we'll start from there, it also reflects how many senior citizens there are in the US. Besides that, Medicaid plus CHIP, basically CHIP is the Children's Health Insurance Program, and Medicaid is basically a low-income program, and basically people below sixty-five also have it, and basically those who are not 65 are eligible for it. Low income, for those who have it, basically there is an income scale, if your income is under that scale, so basically you qualify for Medicaid, and for its age, basically it is not necessary that you are 65, even anyone above eighteen years old gets this, and below eighteen they come under other plans, okay, and from eighteen up to a fairly old age you can qualify for Medicaid, and I told you there is an income scale, if your income is below that income scale, you will automatically qualify.

Within Medicaid too there are plans, there is Plan N, there is Plan G, we will understand about this in detail later. Besides that, this is the Affordable Care Act market, it is roughly 24 million people. I will tell you in a separate topic, million people. This means basically twenty-six million people, which I'm talking about when I mention out-of-pocket. You are marketing those segments in out-of-pocket too. So you will see, you will see, meaning for instance, you can target people who want to gift their parents or grandparents, and who want to share the out-of-pocket cost.

You have health insurance, Medicare, which is subscribed under the Social Security Act, then when you apply for it, you have two or three options. Either you take straight Medicare, which is called traditional Medicare, also Medicare FFS, or the second option is Medicare Advantage or Medicare supplement, whichever you want, you can take that too, and if you have Medicare, you have the option to take a Part D plan, for qualified Medicare, it will be Medicare as well, it will be Medicare as well. Okay, so these are your options, and of course in these options the premiums, deductibles, coinsurance and copays are basically different for each, but for now, basically when we understand each topic one by one, we will go deeper into it, okay.

Ansar, do you want to add something here? Yes, in this you mentioned that Medigap plan, that if a patient is 65 plus, within six months if they activate a Medigap plan. Yes, that is a very good point, a very good point. Okay, when the patient, this is a very good point, I just remembered, let me add it. That there is a bracket for the Medicare supplement plan, when Part C, basically Medicare has four parts, Part A, Part B, Part C, Part D. Part A is for inpatient hospital, Part B is for outpatient facilities, for clinics, for DME labs, Part C is basically Medicare Advantage, which is Medigap.

This is Medicare supplement. Medicare supplement and Medicare supplement. Part D is that the patient has an option. And for senior citizens, the patient, the patient may be healthy, or may not be, besides that they have the option of whether they want straight Medicare or Medicare supplement, or Medicare Advantage. I will actually tell you that with Medicare, is Medicare Advantage or a supplement really needed? Medicare Advantage and Medicare supplement are needed, because you know that healthcare in the United States is very, very expensive. So they have to maintain coverage for it.

Now the patient responsibility is there, and the third patient responsibility is also there. And besides that there is one more thing, Medicare was designed in 1965, basically. If you want to see what it is, if you want to see what it is, diapers and pants and such are not covered at all, because those are items of daily dues, okay, so Medicare does not cover diapers, Medicaid covers diapers, so basically to close the coverage gap, that works as your secondary, it stays in your primary, the 20% that you owe, it takes care of that, through your supplement plan, you can get that supplement plan basically from any commercial carrier, but if you first sixty, five, if you take it within that, you get it at a very good premium, because basically there is a policy in it that if you have a severe or critical or chronic disease, or any disease, your premium can become more expensive.

So in the first six months' window, in that your chart notes and your progressive medical notes are not checked, you directly get a flat-rate premium for it. So the first six-month bracket is difficult to pass up, then the second bracket, if you changed the role, the second bracket comes on your age, some on your age. In that, if you subscribe to the policy, you still get very good premium rates, so basically, take it as 20 percent of the insurance, the patient responsibility, then that Medicare plan and Medicare supplement plan covers it, and Medicare automatically sends the 20 percent bill to it.

For this, among the things coming up, there is also this point that the Medicare plan will have a premium, the Medicare plan will have a premium, and in the Medicare Advantage plan, because it is with commercial, the Medicare Advantage plans are there, in that you bill the commercial plan, and Medicare pays a flat fee for each patient to the insurance company, saying that if treatment happens within it, the money that's left is yours, and if not, the loss that happens is also yours, meaning by making it fiscally capitated this way, Medicare pays them, the commercial insurances, they serve the patient this way, so DME companies like us, the ones we billed, I say DME companies like us because we have some partnerships with our clients, so basically we run the whole DME, we run the whole DME.

So that's what we are, a revenue cycle management company, our resume that is burning, on that, on that, and besides that, basically what we run on a partnership basis, for that we do duty, for that we do duty, for that we do duty, we do commercial duty, for that we do duty, for that we do duty, Is there anything you want to add here? No, not right now.

15:10Medicare: who gets it and the four parts

Okay, now let's basically read ahead, and as I already told you, it is given, and those who are 65 become eligible, or they have a disability, or they have end-stage renal disease, meaning they have had kidney failure and are on dialysis. Here they call it an age restriction, and Lou Gehrig's disease is basically one where coverage also starts automatically, and this is basically a muscle disease too, basically the nerves behind the spinal cord, some of the nerves are affected, because of which your mobility gets affected over time, and over time this increases very quickly.

So may Allah keep everyone in safety and well-being. So anyway, about 68 million Americans, every member has in ... basically an 11-character alphanumeric number, and this is basically their Medicare number, it has their name, and below it, basically, it is written Part A for hospital, Part B for medical, okay. Now let's turn ahead, and I told you that Medicare has four parts, Part A, Part B, Part C, Part D. Part A is for hospice, hospice is basically a place where the patient goes, who is said to have no more than this much time to live.

For that, hospice care is needed for the patient. Basically, with Part B benefits, they can also get home medical nurses at home, in which there are skilled nurses, and in that they basically get the speech therapy or physiotherapy. Besides that, they can also get skilled nursing facilities, but besides that, what is not even skilled, such as moving the patient or bathing the patient, that facility too, there are also episodes of a home health agency, that are also available, so basically home health agency and DME, basically home medical supplies, in this, basically both of them fill in, both, and the home health agency also, so the home health agency also bills Part B, and when home health is active, then basically some supplies can only be given to the patient by home health and cannot be given by the DME, in that episode period, DME's many products are bundled under Part B, if the patient's home health segment is going on, okay.

So home health basically goes to the patient's home and provides skilled nursing facilities, and there are some unskilled facilities too, which come with Part B benefits. Okay, so Part B is basically for outpatient, and labs too, the high-complexity labs, for tests, Part B is billed in that too. Part C, basically this is a choice, the patient has it when the patient turns sixty-five and above, then they have the option, either they take original Medicare, which is also called traditional Medicare, also called Medicare Part B, okay.

The second is that they have the option of moving toward Medicare Advantage, or they can also take a Medicare supplement. Medicare Advantage is also an option, in Medicare Advantage it is basically that the commercial payer, the private plan, basically gives the benefits to the patient, but the money, the main money that comes, comes from behind, Medicare gives directly to the commercial, but a DME company like us, if we bill a Medicare Advantage beneficiary, we will bill that plan, meaning Humana, UHC, Aetna, Aetna, okay, in the same way it works in Medicare supplement.

Medicare supplement, as I told you earlier, has Medicare as the primary, and the secondary, basically that is commercial, so we don't need to bill it. So we don't need to bill it, so we don't need to bill it, and we will see when we make the detailed video to explain this, then I would like, InshaAllah, whichever guest Ilham, we bring with us, then in that, basically we can't show live PHI, because we have to be compliant, patient health information, so of course we can't show it on videos, but basically we will show you an illustration of it, where we had a patient and they had a Medicare supplement plan, and we first billed Medicare, and Medicare automatically crossed over, and we also got the primary payment, so one hundred percent got billed, the deductible and coinsurance were also billed to the supplement, basically the supplement plan was made for this reason, the reason supplement plans are made, Medigap plans exist for this reason, to close the coinsurance gap, the patient responsibility that the patient has.

19:56How Original Medicare pays for DME

The patient has to pay some transactions from their own pocket: premium, coinsurance, and deductible, and copay. These four are the transactions they have to pay from their own pocket, and there is an out-of-pocket maximum, combining these four transactions there is a threshold, that if it is reached, then coverage becomes one hundred percent, but that is a fiscal year, meaning it is within the policy year, the policy is renewed every year, so deductibles are also renewed every year, which means that if you have taken it, if you have taken it, if you have taken it, so its deductibles will also be for that year, okay, meaning if the deductible is met in two or three months, after that basically what will happen is that next year the deductible will start again.

Ilham, now how much was the Medicare Part B deductible? What are the deductibles? What are the deductibles? The deductibles are basically to unlock the plan's coverage, meaning to go into the coinsurance system, where 80 percent the payer basically the payer will pay, and 20 percent will be the responsibility, for that, to unlock the plan, there are deductibles, $283 in Medicare, and these deductibles are in Medicare, in Medicare, so you paid $283, after that they unlock. That is why DME companies, now at the start of the year, January, February, March, we tell the patient, brother, wait for now, two or three months, wait until this deductible gets met on its own, then we will give you the services.

If the patient is ready to give us the deductible as out-of-pocket, if they give it to us, we will give them the services. If they want to wait, they will go to the hospital, to a doctor's office, and there their deductible will be taken, basically, and they will have to pay it, and they will have to get the deductible deducted, so as soon as the deductibles are met, then we give the services, so that it doesn't happen that whatever we bill, the deductible gets subtracted from it.

If you want to understand a bit about deductibles quickly here, insurance starts paying when you complete it, as soon as you complete it, whatever services you provide to that patient, then their insurance starts paying. I hope you understood it well. Now basically we will understand how Medicare pays DME. Medicare pays DME at eighty percent. For this, for DME, for DME, what is it, along with this, Medicare automatically creates a table of its benefits, and in it there is the whole calculation of everything, based on that, whatever eighty percent is theirs, they pay it, and the twenty percent is called the patient's liability, and you can charge that to the patient.

Okay, in this there are two things to understand in the slide, one is NCD and one is LCD, these are very important things in healthcare, and besides that, there are 4 DME MACs, these are Medicare's administrative contractors, and basically there are four Medicare jurisdictions across the US, in which 52 states are divided into four jurisdictions, A, B, C, D, and basically these administrative contractors, Noridian and CGS, each of them gets two jurisdictions, Noridian has D, and CGS has B and C, meaning for instance, Illinois, meaning our DME is here, and we have patients coming from Illinois, so who will we bill, we will bill Noridian, in the same way if there is a patient from Texas, we will bill that one there, we will bill in Jurisdiction C, that also is Jurisdiction C, CGS, in the same way, the northern states, meaning those will come under another jurisdiction, we will bill them, Medicare's administrative contractor, Medicare's administrative contractor is Noridian, do you want to add anything?

No, Usman bhai, you clarified it well, that's right, so basically if you have an order coming for a patient, basically you have an order coming from the doctor's office, and the patient's medical necessity is not met, and you bill it, then your bill will be denied, you won't get paid, if medical necessity is met and you bill, if medical necessity is met, it will be paid. I mean the bill will go through, the bill will go through and no denial will come, and yes, if for instance, medical necessity is not met, you haven't seen the LCD, and you billed it, your bill will be denied, so what happens is that when Medicare audits after some time, and they come to their audit clinics, then they recoup the amounts, okay, they recoup them from the payment, the paid amount, so it is important that whatever you bill, check medical necessity, according to the policy, whatever insurance the patient has, look at the insurance policy, look at the LCD, and if it is an Advantage plan, then you have to look at the National Coverage Determinations too.

After that you bill it, billing before that would be dangerous, and medical necessity, because this is R&N, it is R and M, okay, reasonable is also one thing that comes in, meaning it's not necessary that if medical necessity is met you bill it, meaning it also has to be reasonable, meaning there is a patient, okay, and their medical necessity is met, it is met, for instance for a wheelchair, but now they are in such a condition that in that condition they can't even sit in a wheelchair, meaning they have some issue, then it's not reasonable, so if it's not reasonable, then you still can't bill.

Okay, so I explained this to you with a small example to understand this, and Medicare has a timely filing limit, meaning for billing them there is a timely filing limit, which is twelve months, meaning after twelve months you cannot bill them, twelve months, whatever service you provided, on the date on which you serve the patient, from that date you bill, meaning within one year you have to bill Medicare, but if for instance a patient was missed, whom you didn't bill by mistake because of a big flow, then if it has been twelve months, you can still bill them, you can bill Medicare then, but there is a process for that too, then you do an appeal, if you want to understand, appeals have 5 levels, I will explain that to you, so now let's move ahead.

Okay, in this we will basically understand that Medicare Advantage plans have now become major, the reason for this is that, meaning when we started work ten years ago, I remember well that when orders were coming to us, in that the ratio was ninety-ten percent, meaning 90% of people had traditional Medicare and 10% of people had Medicare Advantage plans.

29:07Medicare Advantage: the majority now

They had. These Advantage plans were made because there was a very big gap in the market, because Medicare doesn't cover some things, Medicare doesn't cover them, so I told you about absorbent supplies, because Medicare was not designed to cover daily routine items, that's why it doesn't cover diapers, but Medicaid does, because it is an affordable health program, so that's why basically there are other coverage gaps too, in which there is dental, so basically to close that gap, Advantage plans were made by Medicare together with commercial carriers, with the carriers, so that their services also expand, so that the patient gets more coverage, and the main reason for Medicare is that Medicare's budgets were getting so stressed, so that the budget flows very well, basically.

So now what happened is that as inflation kept rising, Medicare's original plan kept going beyond people's affordability, because of that, Medicare Advantage plans kept increasing, so over time Medicare Advantage plans have reached 54 percent. Yes, yes, go ahead. Yes, that's what I was going to say, regarding Medicare, earlier it was that more, as you said, Medicare was ninety percent, Medicare, we also, in our language, used to say Part B, now we say what you said, now when we are doing views and so on, now sixty-two to seventy percent of people have Medicare Advantage, and I see more commercial insurances, I will tell you the reason, basically this is a very good point, one is that we sometimes some terminologies are such that we start taking them on our own, because of which it happens that we understand something basically with the wrong terminology, but the industry's terminology for that thing is different, so it is very important that everyone's terminology be such that we can understand what the payer is saying, the provider who is speaking, we can understand them, basically, Part B was also a wrong terminology, straight Medicare, original Medicare, Medicare, FFS, traditional, all these names are for original Medicare, so those are wrong, and the terminology for it is what I told you, the other point is, you spoke about the percentage, area-wise also it differs, for example if a DME of ours takes from a financial, a DME of ours, if there is one financial, then of course all the patients that come to us will be Medicare, I may have said it wrong, they will all be Medicare, but if these statistics are CMS's own statistics, then we find out that basically now this Medicare market is 54% and the Medicare Advantage market is 46%, so it is something like this, as it was a long time ago, basically now it has only become 10%, okay?

The patient gets it, the insurance gets it, from Medicare, saying that within this budget you have to serve the patient, and if you go beyond it, the loss is yours, and if money is left, the gain is yours, okay, this is easy to understand, one thing, Ilham wants to add something, yes, I wanted to ask you, that Medicare Advantage and as we also talked about, the Medicare plan, can both be together, for the same patient can both plans be together, say the question again, what is the question, Medicare Advantage and the Medicare plan we also talked about, they cannot be together.

It can be that the patient has it can be that in this the patient has Medicare too, the patient has Medicare, so these are both Medicare, Medicare these can be Medicare Advantage and these can be Medicare, MCO, okay, okay, and the MCO market, I'm telling you, the Medicare market the Medicare market is small, the Medicare market is big, and in Medicare, this Medicare Advantage market is also smaller than the MCO, because in the MCO, meaning meaning those who have Medicare are only twenty percent, the rest all are with the MCO, the rest are with the MCO, the rest are with the MCO, okay, and one thing to understand in this is that in Medicare Advantage plans basically everything is covered, whatever Medicare covers, but the network is its own, when we understand the DME network, InshaAllah we will explain this, and there is prior authorization, that for whatever service you want to bill, for whatever product you want to bill, you first take permission from the insurance, you submit forms about the patient's diagnosis and the patient's situation, and after that you if it is accepted, you bill with the prior authorization number, if it gets rejected, the limit of prior authorization was placed from that time, so that unnecessary products can be stopped, unnecessary products can be stopped, unnecessary products can be stopped, and as many frauds as there are, they can be stopped, those who bill without medical necessity, to constrain the budget, because the purpose of bringing prior authorization was that the budget had become very strained, so this prior authorization came just a few years ago, before that it wasn't there, you just check eligibility, check eligibility, check same and similar, check coverage, check the LCD, check medical necessity, bill, those days are in front of us, okay, so it happens that Medicare went into that, in 2019, and in 2019 itself, basically that same year, it got its provider DME onboard, meaning DME, meaning you understand, within one day, a billion-dollar market was being made, because before Medicare, basically there were federal and state plans, I will tell you about them in detail, their infrastructure was not organized like Medicare and Medicaid, and durable products were not covered that much either, so its market cap was also very small, the volume was also very small, so in one day this million-billion-dollar market was made, when Medicare onboarded its provider, so whoever is watching this video, whichever one of you, in 1965, now, anyway, if you want to ask something, go ahead, oh no, no, today's things are clear, okay, now we move ahead.

37:50Read the card: a costly intake mistake

What I, what I will tell you first, which I talk to the patient, the patient says I have Medicare, he gave his Medicare, for his Medicare, at one time he had original Medicare, we made it together, and he had Medicare Advantage, and the Medicare Advantage's five percent, then an Aetna, a Dual Choice plan, so first it will get rejected because whoever are with Medicare Advantage, in them while billing it is important to see, it is important which policy the patient has, which plan the patient has, whether the patient has original Medicare or a Medicare supplement, so if it is Medicare Advantage, then Medicare Advantage, meaning we will bill the commercial, if it is a supplement, we will bill Medicare, the 20% coinsurance bill will be automatically crossed over by Medicare to the supplement, okay, and if it is Medicaid, then of course we will bill Medicaid, and if there is a supply that is 20% dual, meaning the patient has Medicare and also has Medicaid, they will...

Okay, now we move to the next slide, okay, Medicaid's 50 rule book is very important, okay, one thing about Medicaid that you all should remember is that it just as in California they will call it Medi-Cal, just as in California they will call it Medi-Cal, they will call it Medi-Cal, in the same way in California they will call it Medi-Cal, just as in California they will call it Medi-Cal, just as in California they will call it Medi-Cal, they will call it Medi-Cal, they will call it Medi-Cal, in the same way they will call it, they will call it Medi-Cal, they will call it Medi-Cal, I told you that in the budget 70-75% comes from the federal side, meaning CMS gives it, and the state basically, the state, twenty-five percent of the expense, basically fulfills that, and basically whoever is its beneficiary, and the card that they have, the policy number on it, is called the Member ID, okay, one thing is this, do you want to add something in this, no, I hope it's right, so ask, okay, now I told you something that in managed care, in this too, it happens that There is straight Medicaid, and there is managed care, meaning MCOs.

39:06Medicaid: fifty rulebooks

In the MCO market, it has come up that 75% of the members are in private MCOs, meaning only 25% have straight Medicaid. All the rest are in managed care organizations. And roughly 75 to 80 million people with CHIP. I told you earlier that it can apply even under 65, and we discussed the reason in the earlier slide, but Medicaid basically starts from age 18. So there are 75 to 80 million people in it, and roughly 75 to 80 million people in the Children's Health Plan, and in this too the federal government pays some and the state adds some, and this Children's Health Plan is separate from Medicaid, okay?

By enrollment, this is the largest plan, and I made a mistake here. I said this wrongly, that basically it is not part of Medicaid. It is part of Medicaid. Sometimes mistakes happen with this, so you can double check too. I told you that this is a joint federal-state program. In this, the federal government shares 70 to 75% of the budget, and 20% basically the state basically contributes. And since this is the case, here you have to look at local coverage determinations and you also have to look at national coverage determinations, okay?

Okay, now let's move ahead, and remember one more thing: the rules of Medicaid have changed. In Medicaid they have now changed the eligibility criteria, and they have added that you have to complete certain hours per week or per month, and you have to have answered for those particular hours, and even then, if you have income, you will be eligible. Basically they did this to manage the budget, because their budget grew a lot, so they did this to control it. And according to their research, basically seventy-five percent of the, I am saying seventy-five percent, one trillion dollars or so, by around 2028, I had seen that these people will save, because of these new rules.

So okay, let's quickly move ahead. And basically, today's session of ours is now heading toward the end. So in this slide, basically, what is the major coverage in Medicaid? It is about what Medicaid basically covers of DME supplies. Basically they are incontinence supplies.

43:29Medicaid and DME: incontinence, EPSDT, and more

There are two kinds of supplies in incontinence supplies: one is basically catheters, meaning urological supplies, and the other is diapers and briefs, and so on, and in urological supplies there are urine bags and catheters, all of these. Incontinence supplies are not covered by Medicare. Medicare does not cover them. The patient wants them, the patient wants them, if the patient has Medicare, Medicare does not have it, so incontinence supplies are not covered. And only in some Medicare Advantage plans is it available. For that, diapers and incontinence products, but those are very few, and a special permission is also an option which you can talk about.

Okay, pediatric DME, which is also covered under Medicaid, is under Medicaid. The DME supplies for pediatrics are covered by Medicaid. And of course, Medicaid, but it is under Medicaid. The timely filing limit of Medicaid, for sending claims to Medicaid and filing claims, is 92 or 180 days. Meaning, read it, if it is six months, then for Medicaid it is. Earlier it was one year, and it is 92 or 180 days. For Medicaid it is even less than half, ninety days, less than half. And they cover supplies for daily use.

That is how I told you. Incontinence is the main DME product. Meaning, understand that DME gets a good share of its revenue from incontinence DME products. Okay, now basically let's understand dual eligibles, those who have Medicare and also Medicaid.

45:19Dual eligibles and the QMB rule

They are also called duals. About eight million people have it. In the United States there are Q&B plans, and in a Q&B plan it works like this: just as it works in a Medicare Supplement plan, you bill Medicare and the 20% bill goes to your supplement plan. In the same way in a Q&B plan, the bill you submit to Medicare automatically gets routed for the 20% to Medicare, and if Medicare does not have coverage for it, the whole bill goes to Medicaid, and if there are Medicare deductibles, Medicaid covers those too.

In this dual coverage, Medicaid is the payer of last resort, okay? Okay, in this there is one thing: if a patient is going to a doctor's office and has dual coverage, then they cannot charge any copay, coinsurance or deductible bills to them, which we call patient Medicare deductible bills and coinsurance, federally prohibited. And it is said that the name of this program is not coming to mind right now. It will come to me and I will tell you. The provider cannot charge anything to the patient out of pocket.

Okay, so that is the dual plan, and coverage is under discussion. Now let's move ahead. Now, in the same way, commercial plans. Basically I told you these are private insurances. And the patient, basically the patient's bag of expenses, as it is called, in this there are these four transactions, and the fifth one forms from these together. One is the premium, meaning you have bought a plan, so you have to pay a monthly premium to the insurance, okay? And it depends on your plan, which plan you have and how much coverage it has, and the premium is decided accordingly.

I told you that just like Medicare has 283, in the same way commercial plans also have deductibles but they can vary by plan. A copay is not in Medicare Part B, DME, because the patient, the patient has a face to face encounter, which happens in the doctor's office. We get the order, so there is no copay in that. In DME, there is a copay. There is a copay in Part C, and in Part B there is a doctor visit copay, but there is no copay for DME.

That is the coverage of the insurance at 80 percent. Okay, but this coverage is like that for some people on Medicare Advantage. And you are billing out-of-network, so it is 60-40 and 70-30 and 50-50, that happens sometimes, and 80-20, this is the coinsurance, and these four transactions together make up an amount, and if you reach it, that is the out-of-pocket maximum. After that, the whole plan for that fiscal year, your coverage out-of-pocket will end for you. Then you do not pay anything out of pocket, no premium-related bills.

But this happens very rarely, but the thing is that Music. The expense for the patient, the expense for the patient, the expense for the patient, check? This is a good option. Sometimes people have a severe issue where the expense becomes so large that the out-of-pocket maximum is hit, and after that it refreshes again. That is a very big benefit for beneficiaries. But this happens rarely, but it is noted. Okay, employer plans.

48:50Commercial insurance: plan types and networks

Two kinds are fully insured plans, and the other is self-funded. It is self-funded. These are called ERISA plans. They have identical cards, but the benefits are different. Roughly two hundred million plus people have commercial insurance. And most of them play in the DME market. And this is the Affordable Care Act market, in which there are twenty-four million people as of 2025, and the major carriers on this, UnitedHealthcare is the largest commercial plan, then Humana comes, in the same way Aetna, Cigna, Kaiser, and Anthem, this is also a major plan.

For plan types, basically for commercial plans, there are four plans. Most commonly HMO and PPO show up, but EPO and POS also show up. Now in these plans there are two switches. In all four, HMO, PPO, POS, EPO. Let me quickly tell you in brief, and later when I tell you in detail in a video, I will explain it. In this, it is like there are two switches. Imagine there is a security guard at the door, and there is a switch, one. Now what happens is that the security guard, imagine a security guard who says, brother, you, basically, other than this preferred doctor, other than this preferred provider, you cannot go anywhere else, meaning you can only take service.

Imagine a security guard standing at the gate. The other switch is the network switch. Meaning in this, if it is open, then you can go outside the network, and if it is closed, then you stay basically inside the network, and you will see only a provider from within that same network. And this is in commercial plans, to control the budget, these four plans. You have a preferred physician, who is the gatekeeper. Meaning any specialist or doctor you cannot see without his referral. Meaning you cannot even get any DME supply without his prescription, unless it is referred by him.

And the second switch, I told you, is the network one. That is, in the way that now we are a DME, if someone has an HMO, they can take service from us, and if they do, they will have to pay out of pocket, okay, but if we are contracted with the HMO, with UnitedHealthcare, then any beneficiary of theirs can come to us. The coverage of an HMO is, the coverage of an HMO, if you are out of, basically, it can be seventy-thirty too, okay, it can be seventy-thirty too, but a PPO is different, but even if it is a PPO, if it is a PPO, then that patient.

There is a patient, and we are not contracted with Humana or United Healthcare. The out-of-network calculation will be different. They would pay us seventy percent and thirty percent becomes the patient's responsibility, so we have a doctor, you cannot see any other doctor without his referral, and you cannot go outside the network either. And in a PPO, it is that basically there is no gatekeeper doctor. You see any doctor within the network, go to any DME, there is no preferred doctor. You can see any doctor within the network, go to any DME, but if you go out of network, to any doctor who is out of the network, or any DME, or any lab that is out of the network, then basically the insurance you have will not be fully paid, the insurance will change.

It can be 70-30 and 60-40. And what happens in an EPO? In an EPO and a POS it is this. In a POS, in a POS you in a POS and an EPO the difference is that in a POS you the doctor is the one who in one you get a preferred provider, and in one you get a preferred provider, and in one you get a preferred provider. If you have one thing, then these are two switches, one the guard one that I gave you as an example, and the other the other is the provider one.

But I told you about HMO and PPO, and EPO and POS, basically, one thing is different in these, so they become unique plans. Should I tell you in a minute? Yes, absolutely. Yes, so an EPO plan is an exclusive provider organization, in an EPO usually only in-network providers are covered. We cannot take patient service, and what a POS is, it means point of service. A POS plan is a mix of HMO and PPO, and in this it is mixed like HMO and PPO, meaning a referral is required, in-network has better benefits, out-of-network First of all, the DME will contract with the commercial plans, will contract with them, if the panels are open.

55:10How to get paid by commercial plans

If the insurance company says that our panel is not taking more, they are not contracting, we already have many providers, then in this case they give you permission to bill out-of-network, and then you can bill them, and you can bill their payments, and you can bill your payments. And through a single case agreement, you can bill them at some times, for some emergency cases, if you get their permission, but contracting is most important with commercial, and number two, basically, comes the DME benefit. Separate DME benefit, separate DME benefit, separate DME benefits are there, and they are different from Medicare, within Medicare Advantage and commercial plans, so you will have to verify the benefits.

Benefits, you will have to verify. It should not be the case that you are providing a product but its fee schedule is so low that when you get paid, basically your cost is not even covered. So you have to bill after looking at all these things, and accordingly you then have to put in the bill amount, okay? Prior authorization portals, okay, prior authorization will have to be taken, the insurance company has it on some products, on some codes, on some HCPCS codes. The difference between HCPCS and CPT is that CPT codes are procedures, these are in doctor offices and hospitals.

In DME there are only HCPCS codes, in DME there are no procedures. That is why billing in DME is done with HCPCS codes. In a doctor's office, billing is done with procedure codes too, okay? So the idea of prior authorization is that for some products, in which the insurances have required prior authorization, you first get the prior authorization, and when the prior authorization number comes, then you will bill. If there is no prior authorization, then you will not bill, okay? You will bill after delivering. You will not bill before delivering.

If you bill, it is not compliance. It is not compliance. This is basically a very In DME you can never bill before rendering the service. Okay. There is a prior authorization, and there is a prior authorization. I will tell you all about this. Timely filing, I told you, 90 days and 12 months, whichever the payer's policy is, whatever the payer's policy is, meaning whether it is a UHC plan or Humana. So you will have to see what that payer's policy is, what the timely filing limit is, so that it does not happen that ninety days pass and then you bill.

So you people may be thinking, why would we wait this long? Meaning the product was delivered to the patient, we will bill, why would we wait? Ninety days will pass anyway. But in some conditions it happens that some of your documentation has expired, so you cannot bill yet. You have to wait for it to be renewed. And besides that, it can also happen that sometimes a claim gets missed, sometimes some claim is applied, or there is some claim attached to it, okay? Things like this, and yes, it can also happen that besides this too, you, besides this, it can also happen, because besides this too, it can happen.

So during that time, you billed some patient and you were stuck. I will go into contracting details, basically I will wait a bit and then bill. But it depends. In this too, you have permission that you can bill if there is no plan. If you can bill, then you can bill without that date of service, in which you do not have a contract with the insurance. You have to proceed by looking at this, you have to proceed by looking at this, you have to proceed by looking at this.

How much is the responsibility of the commercial plan and how much is the responsibility of the patient, Okay, so from the patient you collect after delivery, and from the patient before delivery you can also collect. You can also collect payment based on confirmation, that you made a confirmation call and asked that this product order has come to us from the doctor's office, confirm it with the provider, and this is basically your responsibility, you pay it, and after that you deliver. Deliver, after delivering, after delivering, before delivering.

Before delivering, but after delivering, before delivering, there is no problem. After delivering, always bill the insurance. You cannot bill the insurance before it is delivered. This is a bad billing practice. If you billed, and because of this the order and the item got lost, you can get a good penalty. Okay, DME billing is basically very easy. DME credentialing is very easy. DME compliance is very easy. They are very easy steps. If you follow them and integrate them with the system, then you will be fully compliant, fully, you will be following six steps, the same six steps we are discussing.

After that, you bill, and no problem will come. And bill only the ones whose coverage is there, and for which you have the order, and basically if there is no medical necessity, the patient wants to pay out of pocket, the patient will pay out of pocket. Let's move ahead, and this is the same slide, the money table.

1:00:32The four-payer comparison

Original Medicare, I told you, 65 or 65 plus, or someone with a disability, or ESRD, or it is given to them. Music. can have it, can have it, families can have it. Seniors can have it, buyers can have it, okay? And the card is red, white and blue card for Medicare. Really, you can look at the slide yourself further ahead, that the card of Medicare Advantage is whoever took Humana's, it will be like Humana's. If someone took UHC's, then, meaning, it will be their branded card, okay?

And on pricing, the pricing is that here DME POS works on a fee schedule, and in Original Medicare. And in a plan it is contracted. In Medicare Advantage, I am telling you, from Medicare revenue, you will have to contract with the plan. So in this you get contracted rates. Meaning there is a whole set of rates, that brother, which one code you will charge at which fee schedule. So the DME company then negotiates, saying no, we want these rates, so then it gets those rates flexibly.

But let's see what the confusion is, this is the thing. Many people have confusion in this, and the confusion people have is this. The confusion people have is this, about us, that basically they think we, we got confused, can we bill every HMO? No. When your confusion comes, when confusion comes, when confusion comes, in which the insurance tells you that you are in-network in these PPO plans and you are in-network in these HMO plans, meaning you can bill only those plans, but if some other plan comes, then its coverage can change.

And in an HMO you may not have coverage, so you will not bill it. Okay, keep this in mind because the thing is that if a person goes to get insurance, goes to get Medicare, there are three to four options. Meaning one, if they have Medicare, then they have the dual plan option, a dual option, that they can take Medicare Advantage as well, meaning take it from UHC, and also say for Medicaid, as dual coverage, say, make UHC an MCO, so then their plan will be different.

Okay, it will become a dual plan. But this is a complexity, but it is not that difficult, it is an easy thing to understand. As for prior authorization, from the payer there is prior authorization on some products, and there is prior authorization. Prior authorization on Medicare is for selected items only. And on Medicaid there is no prior authorization, it can be on some products. And in commercial plans, you have to look at the policies. And besides that, the filing window below is a twelve-month filing window.

Original Medicare, Medicare Advantage, depends on the plan. And for Medicare it is within ninety-two or ninety days. That, the DME matter, and commercial ninety days to twelve months is within it. It depends on which commercial plan you have. Okay, the biggest risk of Original Medicare is documentation, because Medicare is very strict about the rules, it is very compliant. If you have, in Medicare, you are enrolled, you are billing commercial, you are billing commercial, so some commercial plans, and some commercial In working with it, a DME does not need accreditation, does not need validation, but Medicare enrollment cannot happen without accreditation validation.

1:04:06Back-office playbook and key takeaways

Meaning Medicare has partner accreditation firms which basically to you one accredits that you are able to bill, to bill that product, meaning in this way your, there is a whole validation list for it, okay? And that is how it is best. Accreditation used to be for three years. Now the rule has changed, it is every year, and another rule has been added, that now Medicare surprise audits will also happen in every DME once in six months or twice a year, okay? So this is new, which has happened, because within this provider, within health care, there are many scams.

I would not say that the most scams have happened, very big scams have happened, a phishing scheme, and different, meaning one billing and forward billing, and ten thousand things. I will make an episode on that, I know that many people will be interested in listening to that episode, because I will tell you what kinds of things happen in it. How Medicare catches, whom Medicare has caught, how many Pakistanis are in it, how many are in it, and pointing is not a good thing, but there are others in it too, it is not that only Pakistanis are in it, but the thing is that whoever validates the rules, Medicare has strict rules.

It is healthcare, it is no joke. Any documentation is a big risk. If documentation is not complete, even if the money has come, I am telling you that the money will go back. When an audit comes and you do not fully comply with it, then repayment and recoupment will happen, and in Medicare Advantage the biggest risk is that if you billed without prior authorization, then forget about the money, because where advantage plans, the commercial ones, they do not cooperate with you as much as Medicaid does, and Medicaid has an eligibility eligibility risk, because basically its, eligibility is easy, it is not that big a risk, but in this there are one or two complexities that you have to look at.

I will tell you about the Medicaid details further ahead, okay? And in commercial, the point is that if any one benefit is not verified and you billed it, then of course it will not be billed, of course it will not be paid, okay? Okay, this is The Back Office Playbook. Meaning now you keep my words in mind. After this, this is the last slide. After this, our, this is our one class. And in this I will tell you one thing, look, those DMEs are very successful, and in Pakistan there are many such DMEs, meaning those of the States, who do not have much in Pakistan, but few.

But there are some that are very successful, so there it is very cost effective. If you have a back office in Pakistan, then understand that there is cost advantage. Here you can give very good benefits to employees too. Even if you hire very good employees, you will get an employee at 60 to 70%, okay? Your cost goes down a lot. This is a very flexible back office structure, but the trickiest and most challenging part is being compliant. If your back office is not compliant, then you can face a lot of trouble.

You cannot stay in business if your offshore, your offshore your back office is, and you are not compliant, and patient health information, because it is being transferred, so CMS, DOJ, and all the federal agencies, HHS, health and human services, all of these have a lot of concern about this. If there is no paper, if there is no proper enforcement, no proper compliant enforcement of your back office, it can become a very big problem and end up with cancellation of your license, and if you don't have a license you can not bill Medicare.

Identify the payer, brother, the back office's very first job is to identify the payer, identify that which insurance the patient has, then check the eligibility of that insurance, see which the patient has, which is the patient's, after that check that the patient has, the patient's, after that check whether that patient has the DME benefit or not, and then check whether authorization is required or not before delivery, because if the delivery is made and the authorization is not there, then there will be a problem, because the date of service will go in first. before that.

Prior authorization has to be taken first. If it is required, then after that deliver, and after that before that, all the documentation you have, the patient's WOPD, which is the written order prior to delivery, the medical notes, chart notes, the proof of delivery, and any additional document, any additional document, any additional document, any additional document, you have to keep it safe. InshaAllah, we will teach you the way to keep it safe as well, and tell you how to keep it safe like this, for seven years, because Medicare's rule is seven years, so you will have to keep these documents saved with you, okay?

So it is a very easy task. Now AI has also come, so it has become child's play, it has become very, very easy. Okay. Okay. And after that, of course, if your bill is approved, then you have to do the payment posting. Appeals have stages. Stage 1, stage 2, stage 3, stage 4, stage 5. It will be denied at stage 1 too, then go to 2, then stage 2 will be denied, then go to 3. And that is how the infrastructure of appeals basically is, and in this, if you have an amount that is such that at one level there is an eligibility for the level, that your amount is a certain amount, at the level, that if your bill is not for that much, then you cannot appeal it, okay?

Meaning below the second appeal you cannot come. Meaning there should be a particular amount. And when it goes above that level, you then fix it, rework it, if there is some claim issue, then fix those patterns completely, and look, with billing, I am not talking about billing, because the billing role in the back office is very different, its compliance is very different, and I will explain that to you, it is not that difficult. I will have to explain it in detail. I will explain it to you well, step by step.

Then offshore back office can do billing too, and a back office is different, and a revenue cycle management company is different. Meaning we are a DME's back office too, but for some DMEs we are revenue cycle management too, because within DME billing, within medical billing, you have two options. One option is that you bill under the DME, and the other option you have is that you take your own billing license, and after that you become a billing provider yourself and you do the revenue cycle management, okay?

So these are two options, and they each have separate compliance. I will explain this to you as well when we get there, InshaAllah. I hope that you people understood things very well. And there may have been some confusions, some things may not have been understood properly. I deliberately came out with a fast speed. With these slides, and behind them I have a whole plan, and I have an idea. Do not worry at all. If you do not understand, then watch the video a second time, do your own research too, and as this course moves ahead, I am literally telling you, the processes will start to come to you.

When we reach the process half, I am literally telling you that you will be ready, for the life of a fortune teller. I am literally telling you, but before that you may need one, two, three months of hands-on training, and InshaAllah I will try to do every day or two or three videos every week, because many people are also getting disappointed. And look, the benefit is, I was saying that we have trained many people in hands-on training. Our back office is in Karachi, we have two offices in Karachi, in Shamsi Society, Kashir Center, behind Mehran Hotel, in Saddar, and in the US our office is in Carrollton, Texas.

We have trained many people in Karachi, and, Mashallah, they have gotten very good jobs. Yesterday, one of them, I was offering Fajr prayer, and after the prayer I was sitting in the mosque, and I saw that a boy came and sat next to me, and when I turned my salam, I saw that he was one of those boys, who did an internship with us, and after doing the internship he got a very good job. Mashallah, may Allah bless his sustenance, and it was Hassan. If he is listening too, may Allah bless your sustenance, and progress, make a lot of progress.

My dua is with you. So this is the point, InshaAllah, the benefit of this whole program is, as I told you, that if you understand the whole US healthcare well, its background, its history, all of its stakeholders, providers, networking, credentialing, compliance, if you understand all these things, then your level will go to the next level. And in the industry, the people who are in person, who have next level information, they have no shortage of opportunities. And I will keep learning too, that is not the main point for me, but InshaAllah, along with you, I will also keep getting trained, and my level will also keep going up, and thank you so much.

And thank you for staying with us for the whole session. And you discussed many things, many things. At the end, if you people want to say something, or you have any idea, I just wanted to say, thank you very much to you. You are guiding youngsters, because in our time, when I came into this field, we had no one to guide us. So we got hit around for about three or four years and learned a few things. Our effort is to spread awareness so that youngsters go to a good side.

And thank you to you too for inviting us to this video. Just this one thing I want to say, which I will thank you for, yes, yes. I just say that for the youngsters, basically, this course is for them, it is a benefit for those who have recently finished matric or inter. They will benefit the most from this, because it is very strong for this. If I talk about myself, I too joined you right after matric and inter, and you gave me the full training, hands-on.

And thank you to you, that you invited me to the video, and gave me the opportunity to join the meeting with you. So I would just tell everyone that it is very strong for this. Today I know where I was standing one or two years ago and where I stand today, Alhamdulillah. So thank you so much. It is true, like call centers, you all know that if you tell someone today that you have a call center, the other person will think first that this must be doing some shady work.

So basically the youngsters who are now going in that direction, the reason for them is us, those who basically have such gigs, who can give such skills to youngsters in that kind of segment, and they won't, and my aim with this program I see a huge gap in the market, that in Pakistan there is very little work that can come from US healthcare, meaning it is only in person. There are very big players in the market, among them MTBC, and there are other companies, very big players, Zycon, and I am telling you that the work that can be done here in back office support and US healthcare is very little.

And if we keep sessions like this, it can grow a lot, youngsters will come toward something good, they will get good skills, good jobs, networking will be good, and the better the market and the better the experts, the clients and the providers, they will then give their work to Pakistan. The Philippines has a very big market in US healthcare. So with this same dua that may Allah bless our sustenance, and the Messenger of Allah, peace be upon him, used to make dua after the Fajr prayer, that O Allah, I ask You, peace be upon him, and beneficial.

Now we will wrap up. And InshaAllah we will be back soon with the third episode and the third session. And InshaAllah, as time goes on, I will keep adding more people too. InshaAllah, the fun will keep increasing for you all. JazakAllah to all of you for sitting with us till the end. May Allah bless us and you through the Noble Quran, and benefit us and you through its verses and the wise reminder. Amin.