CMS Durable Medical Equipment (DME) Claims Processing

The CMS Durable Medical Equipment Claims Processing System is a critical component of the Fee-For-Service (FFS) program, processing over $6.5 billion dollars of Medicare claims a year, supporting Medicare's mission to provide quality health care to beneficiaries. CMS Durable Medical Equipment Claims Processing System also known as the ViPS Medicare System (VMS) is the shared systems used to process claims for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) to one of four Durable Medical Equipment Medicare Administrative Contractors (DME MACs). The DME standard claims processing system also processes the National Council of Prescription Drug Programs (NCPDP) claims. The DME claims processing software will be furnished to, and maintained by, the DME SSM contractor as Government Furnished Software. The DME performs processing functionality for claims collection, editing, pricing, adjudication, correspondence, on-line inquiry, file maintenance, financial processing and reporting. The DME also includes DME MAC-specific requirements related to claims pricing, Certificate of Medical Necessity (CMNs), claims processing, supplier interfaces with the Provider Enrollment, Chain and Ownership System, Common Electronic Data Interchange (CEDI), and CWF interfaces. The VMS claims processing system is one of the shared systems used to process claims for physician services, diagnostic tests, ambulance services, DMEPOS and other services/supplies that are not covered by Part A. It interfaces directly with the Common Working File (CWF) for verification, validation, and payment authorization. VMS includes much of the Part B functionality for claims collection, editing, pricing, adjudication, correspondence, on-line inquiry, file maintenance, financial processing and reporting. VMS also includes Certificate of Medical Necessity requirements and supplier interfaces. The VMS claims processing system has four quarterly releases that control, implement, and update software changes due to legislative mandates that dictate the amount of payment for services or coverage levels. Additionally, VMS must also implement changes needed to support the Medicare Administrative Contractors (MACs) authority for the Medicare FFS Program. VMS is in continual gap analysis. System/maintainer performance is reviewed on a monthly basis as a part of the Program Management Review meeting. The VMS Maintainer implements quarterly releases that reflect legislative mandates that may be meant to correct gaps in enterprise performance. The VMS Maintainer, also, implements system correction Change Requests (CRs) from CMS that are meant to tweak system sustainability. On an annual basis, the Scope of Work (SOW) for the maintainer is reviewed and modified to enhance system performance. The maintainer engages workgroups to improve performance; CMS uses the CR process to integrate changes and requires the maintainer to submit an annual enhancement plan which details proposed fixes which can be folded into the CR process for operational improvement. This investment is a steady state investment which is approximately 30 years old and will continue to function into the foreseeable future.

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