Your Voice in Washington Spring 2011
Published by the american association for Homecare Spring 2011
A word from the Incoming chairman
Joel Marx 2011-2012 AAHomecare Chair
Why Do the Good Guys Get All this #!&%? I’m not going to take it anymore!
ho among us hasn’t taken a replacement concentrator out at midnight because the family said “it didn’t sound right?” What about the plug on the bottom of the hospital bed that comes out or the respiratory therapist who rides in the ambulance home from the hospital to assist the patient with oxygen on their final journey? Or the family who calls Christmas Eve to remove equipment because the patient passed away that morning? We keep patients in their home where they prefer to be. Studies show that they often are better cared for and enjoy other health benefits, and the cost is less than facility care. So why do we go through all of this? I believe what we do is noble. Our patients come first and more than 99 percent of our companies do the right thing. Competitive bidding has been handled wrong. It is wrong for patients, unfair to providers and ultimately will result in increased cost to the system as service has to suffer. CMS has acted like amateurs, making up the rules as they went along. This isn’t rocket science, yet the way the program and regulations are set up for oxygen and other home medical equipment, rocket science sounds easy. CMS could have consulted with the HME sector to reduce costs and maintain service. There are suggestions that have been made by our sector in the past that would 2
meet everyone’s goals – including the patients. The path CMS has chosen (citing pressure from a Congress that is overwhelmed by budget issues) is unfair in the short term and unsustainable in the long haul. We are the good guys. What we do is serve the patient within a framework of erratic and often unwarranted rules, regulations, audits and policies. Imagine, defining a legible physician signature? Because our cause is just – because we provide care when no one else will come out, because patients and families
I believe what we do is noble. prefer our care – we have a voice. The challenge we have is making this voice heard in our communities, our state capitals, and in Washington DC. AAHomecare speaks for the entire home medical community – I’m mad as &$%^ and not going to take it anymore. Do the right thing, follow the rules, don’t forget the patient and let’s make a difference – together.
American Association for Homecare
In this issue
Table of Contents
AAHomecare Executive Committee Joel D. Marx Medical Service Company Cleveland, OH Robert Steedley Barnes Healthcare Services Valdosta, Ga. Scott Meuser Pride Mobility Products Exeter, PA Alan J. Landauer Landauer Metropolitan, Inc. White Plains, NY
AAHomecare President Tyler Wilson discusses bad regulations causing the industry heartburn
Miriam Lieber covers the essentials of competent, compliant and composed customer service
New AAHomecare Members
Mary Ellen Conway explains how to focus on your accredication renewal
A. J. Filippis Wright & Filippis Rochester Hills, MI
A. Malachi Mixon, III Invacare Corporation Elyria, OH
12 Flawed GAO Study Calls for Oxygen Cuts, Praises Bidding Program
Lisa M. Getson Apria Healthcare Group Lake Forest, CA Carol Napierski NY Medical Equip. Providers Assoc. Albany, NY
Patients Find Fault With Bid Program
MK Battery Helps to Fund Advocacy Efforts
14 CMS Fails Medicare Mobility Beneficiaries
Get Social With AAHomecare
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Featured Section: Competitive Bidding
Patients Find Fault with Bid Program After the January 1 implementation of Medicare’s controversial “competitive” bidding program in nine regions across the U.S., Medicare patients are reporting problems receiving home medical equipment and services that were prescribed by their physicians.
• Confusing or incorrect information provided by Medicare. The Association has logged more than 250 complaints during the first eight weeks since the bid program was
The bidding program was implemented on January 1 in nine metropolitan regions: Charlotte, Cincinnati, Cleveland, Dallas-Fort Worth, Kansas City, Miami, Orlando, Pittsburgh, and Riverside, California. The program is scheduled to start up in another 91 regions later this year. The bidding program affects millions of Medicare beneficiaries who require oxygen therapy, enteral nutrients (tube feeding), continuous positive air pressure (CPAP) and respiratory assistive devices, power wheelchairs, walkers, hospital beds and support surfaces, and mail-order diabetic supplies. By design, this new Medicare program severely restricts the number of companies that are allowed to provide the equipment and services subject to bidding. Since the bidding program began on January 1, patients, clinicians, and homecare providers have reported: • Difficulty finding a local equipment or service provider; • Delays in obtaining medically required equipment and services; • Longer than necessary hospital stays due to trouble discharging patients to home-based care; • Far fewer choices for patients when selecting equipment or providers; • Reduced quality; and 4
patients only to those equipment providers that won contracts for multiple categories under the bidding system, effectively excluding those companies that only won contracts for one or two service categories. This further shrinks the pool of homecare providers available to serve Medicare beneficiaries who depend on home medical equipment and services and does nothing to protect small providers. »» Home medical equipment providers in Cincinnati, Cleveland, and Dallas have laid off staff because of the bidding program. »» A patient in the Charlotte area was required to stay in the hospital for several extra days because of delay in delivery of oxygen equipment to the patient’s home, reports the North Carolina Association for Medical Equipment Services.
implemented, including more than 100 from patients. Among those complaints are the following: »» A CPAP user in the Orlando area could not find the right supplies from the reduced number of local providers contracted under the bidding system. “I don’t like that the local people were cut out. In our area, there are very few suppliers to choose from.” »» A provider of home medical equipment and services in the Kansas City area reports that hospital discharge planners are sending
»» A director of case management at a Dallas hospital said the bidding program has caused problems and burdens with respect to coordination of equipment and services. “Medicare is making it more difficult to provide services to people in need.” The American Association for Homecare shared a number of problems with CMS earlier in January including: • Companies awarded Medicare contracts that are bankrupt. • Companies awarded Medicare contracts that are not licensed to provide items or services. • Companies awarded Medicare contracts that have credit problems. • Incorrect information distributed American Association for Homecare
by Medicare about the contract winners and which beneficiaries need to change their home medical equipment providers. MARKET EXPERTS, CONSUMER GROUPS OPPOSE THE BID SYSTEM In November, more than 160 leading economists and auction experts, including two Nobel laureates, warned Congress in several letters that Medicare’s bidding design for medical equipment will fail. Those experts, who design market-based auction systems and do not oppose the concept of using a competitive bidding system to set Medicare prices, found that this particular bidding program designed by the Centers for Medicare and Medicaid Services has irreparable flaws that will prevent it from achieving its objectives of low cost and high quality equipment and services. “It’s just weeks into this program and we have received complaints from more than 250 patients, providers, and hospital administrators who have expressed grave concerns about this approach to healthcare,” said Tyler J. Wilson, president and CEO of the American Association for Homecare. “We agree with the many patient advocacy groups, the 167
economists, and the 259 members of Congress who have called for an end to this misguided pricing mechanism. Homecare is already the most cost-effective setting for post-acute care, and this bid system is merely a badly designed solution in search of a problem.” Under the CMS-designed system, the bidding companies are not bound by their bids, which undermine the credibility of the process and encourages “low-ball” bids that create an unsustainable process and threaten the long-term viability of the program. Ultimately, the experts told Congress, the bid design provides “strong incentives to distort bids away from [actual] costs,” and lacks transparency, which is “unacceptable in a government auction and is in sharp contrast to well-run government auctions.” The experts’ letters conclude, “This collection of problems suggests that the program over time may degenerate into a ‘race to the bottom’ in which suppliers become increasingly unreliable, product and service quality deteriorates, and supply shortages become common. Contract enforcement would become increasingly difficult and fraud and abuse would
grow… Implementation of the current design will result in a failed government program.” Also opposing the controversial bidding program are more than a dozen national consumer and patient advocacy groups including the ALS Association, American Association of People with Disabilities, Muscular Dystrophy Association, National Council on Independent Living, National Spinal Cord Injury Association, and United Spinal Association. Last year, a bipartisan group of 259 members of the U.S. House of Representatives supported legislation to repeal the misguided bidding program. Medicare beneficiaries, family members, caregivers, hospital discharge planners, and clinicians can report problems, concerns, and feedback about this bidding system by calling a toll-free number, 1-888-990-0499, or by visiting the website: www.biddingfeedback.com. To learn more, visit www.aahomecare. org/competitivebidding.
History of Cuts to HME
A snapshot of the reimbursement cuts and freezes that have occurred over the past 8 years savings associated with this payment reduction was approximately $4 billion over 10 years.
• Last year’s health care reform enactment cut between $6 and $8 billion over 10 years by accelerating the bidding program, eliminating the previous option under Medicare for beneficiaries to purchase from providers a standard power wheelchair in the first-month; and eliminating a two percent increase in scheduled reimbursement for 2014.
• In 2006, CMS revised power wheelchair coding, resulting in an approximate 26 percent cut in reimbursement rates.
• In 2008, payment rates for items subject to bidding were reduced by 9.5 percent, nationwide. The total
• In 2003 home medical equipment payments were reduced across
• In 2005, Congress implemented a 36-month cap on oxygen payments saving approximately $5 billion over 10 years.
the board by $7 billion and competitive bidding was mandated by Congress. CMS was instructed to reduce home medical equipment reimbursement rates to the median prices paid in the Federal Employees Health Benefits Program. This policy reduced payment rates by more than 8 percent for HME providers. It also included five years of freezes thereby precluding increases that would have occurred under adjustments coming from the consumer price index. 5
From the desk of the president
A Bad Program Producing Bad Results Competitive bidding must be repealed.
A letter to the homecare community Six weeks into Round One of the bidding program and AAHomecare has seen enough. Competitive bidding for home medical equipment must be abolished. The homecare system should not be characterized and viewed merely in terms of the lowest cost and who can provide it most cheaply. Providing valuable healthcare services is much more than that. The Medicare system should not ignore matters of quality, access, and beneficiary satisfaction.
Tyler J. Wilson, President American Association for Homecare
Congress must consider the aging U.S. population (the first baby boomer hit age 65 on January 1), the rising incidence of diabetes and other chronic conditions, the cost of treatment in hospitals and nursing facilities, and the long-established preference among people for care at home. All of these factors argue for a stronger approach to providing homecare – not a tearing apart of the system. The philosophy behind bidding as a way for Medicare to manage, deliver and reimburse for home medical equipment is simply wrong-headed and misguided. For that, we can blame Congress. Lawmakers can be roundly criticized for mandating the program that is now causing such terrible financial hardship and economic dislocation. Congress bears the responsibility and we should let them hear our anger. At the same time, the CMS program design is faulty and its administration has been a lesson in poor planning, arrogance, and clumsiness. For this, the Agency bears the blame. Repeatedly, CMS has shown itself incapable of putting together and getting right basic elements of the program. Auction experts, economists, homecare companies, patient groups and stakeholders from across the homecare spectrum have repeatedly advised CMS they’ve gotten it wrong on a number of fronts – from program development through implementation and beneficiary education.
Congress needs to act fast – while there is still a community of homecare providers that can put the pieces of a robust homecare system back together.
And looking ahead, nothing about CMS’ handling of the program should give anyone comfort. The Medicare agency has been alarmingly dismissive toward a host of issues and completely unwilling to do any of the self-examination that are necessary. With a growing list of problems being reported from the nine initial regions, complete intransigence on the part of CMS, and every indication that Round Two will be implemented without proper analysis or insight into the failings of Round One, the alarm bells are sounding – loudly. The only way to stop the problems is to stop the program. Congress 6
American Association for Homecare
must step in and enact legislation that ends bidding for home medical equipment. And Congress needs to act fast – while there is still a community of homecare providers that can put the pieces of a robust homecare system back together. If Congress fails to act, the economic fallout and harm to the homecare system and those that rely upon it will be irreversible. AAHomecare is focusing all of its energy on convincing Congress that it must act to repeal competitive bidding. A full court press is underway to get the House and Senate to consider legislation to end the program.
What Does Medicare Spend on HME?
Durable or Home medical spending
b i ll i o n
In 2009, total Medicare spending was
$502.3 = b i ll i o n
of total medicare spending
Source: National Health Expenditures data from the CMS Office of the Actuary, published January 2011
This effort needs the full support of everyone in the homecare community. Whether in a Round One or Two, whether a bidding loser or “winner” of one or several contracts, whether a full line HME provider or a specialized supplier, the fight to repeal bidding is a cause for everyone. AAHomecare will lead the fight but the Association needs all of its members engaged and it needs the full involvement of everyone else in the homecare community. There is no better opportunity to make our case than to walk the halls of Congress. Everyone with an interest in good and financially sound homecare should be on Capitol Hill letting the House and Senate hear our call for repeal. The alternative is to take a front row seat and witness the dismantling of the homecare system as we’ve known it. I urge all of you – member and non-member alike – to take up the cause and fight to repeal bidding. The time is now because homecare can’t wait.
Education: Customer Service
Customer Service â€“ Competent, Compliant and Composed by Miriam Lieber
he role of the intake coordinator/ customer service today is daunting, at best. The combined ability to gather referral information in an expedient and efficient manner via fax or phone, ensure that the information obtained meets compliance requirements, and exhibit courteous behavior simultaneously is a definite challenge. How can we nurture customer service staff with just the right amount of a bright personality, knowledge, and technical skill required to take a viable order? Seemingly impossible, here are some suggestions: Hiring Filling a customer service position today would seem easy as joblessness is still hovering around 9.4 percent (per the Bureau of Labor and Statistics
for December 2010). Despite this staggering statistic, many HME companies still canâ€™t find people who are willing to work, especially in the area of customer service. The issue is that finding someone with experience in HME is scarce and finding someone with good experience is even more unrealistic. Thus, you typically have to train the candidate and hope that they can quickly learn the ins and outs of an industry that is always changing. During the interview process, provide a sample case scenario where the customer service person is faced with a multitude of tasks to juggle all at the same time. For example, use a scenario such as an insurance company calling in while a customer comes into office for a mask fitting and all the while you
have a referral source on the phone. Ask the candidate what they would do first and why. You are not necessarily looking for a right or wrong answer but rather you are looking for how they think. Training Once you have made the decision of who to hire, it is time to train the customer service person. Although there are many training tools available online today, there is still no better way to train than on the job with a peer/supervisor. Have the new hire observe the trainer first and then have the trainer watch the new hire. This should be done until the trainer feels comfortable having the new employee work on their own. In addition, you should explore online training or other training programs offered through manufacturers, buying groups and trade associations such as AAHomecare. Compliance Once the employee is trained and skills are honed, it is expected that your staff should know the basics of compliance for Medicare, Medicaid and other major third party payers. They must know, among other things, the various reasonable useful life limitations, supply replacement/ replenishment requirements, proof of delivery requirements, medical necessity requirements, covered and noncovered products and much more.
American Association for Homecare The Newsletter for the National Homecare Association
Welcome New AAHomecare Members! Apex Medical Supplies & Equipment Holiday, Fla.
J & L Medical Services Middlebury, Conn.
Monroe Medical Supplies, Inc. Cranbury, N.J.
Arkray USA, Inc. Edina, Minn.
Kaye Martin Consulting Fort Worth, Texas
Mountain Home Care Equipment Ellijay, Ga.
Aronson Medical & Respiratory Services Baltimore, Md.
Law Office of Asela M. Cuervo Washington, D.C.
Omnicare Medical Supply Services Naperville, Ill.
BlueDot Medical, Inc. Charlotte, N.C.
Linco Medical & Supply Ruidoso, N.M.
Otto Bock Healthcare Minneapolis, Minn.
C & C Homecare Plainview, N.Y.
Medlife Homecare Farmington Hills, Mich.
Peoples Home Medical Covington, Ga.
Care One Home Medical New York, N.Y.
Medstar Surgical & Breathing Equipment College Point, N.Y.
Professional Medical Administrators Boca Raton, Fla.
CJPS Medical Systems, LLC Auburn Hills, Mich. CTM Homecare Product, Inc. Chino, Calif. Hall-Moore Medical Supplies Jacksonville, Fla. Health Law Center Greenville, S.C.
To determine if they are meeting all of these requirements, conduct an internal chart audit of a random sampling of patient accounts. Use an audit checklist (or Medicare’s documentation checklists) and record your scores. This type of regular internal audit will bode well for you when you are audited by the payer, especially if they do not find the results they want. You can always outsource this function if you do not have the manpower to handle it yourself. Collecting your Cash Despite your interest in patient quality care, it is critical that you collect all of your copays and private pay dollars up front. Lingering private pay A/R is the hardest to collect and Spring 2011
Michigan Independent Providers Association Lansing, Mich. Mike’s Medical Clinton, Okla. MJE Consultants, LLC Port Matilda, Pa.
often gets written off to bad debt if you are not vigilant about working it. To avoid mounting patient receivables, when a patient calls for additional supplies or product, train your staff to always check for outstanding balances before dispensing additional product and teach them to always ask for the money up front. As you can see, there are many tasks associated with customer service – from order intake, to insurance compliance and cash collections – this job function takes a versatile person who is extremely flexible and able to wear many different hats simultaneously. The ability to function amid chaos, to think on their feet and to multi-task are three essential
Roscoe Medical Strongsville, Ohio Sunrise Medical Longmont, Colo. Valley Home Medical Supply Canoga Park, Calif.
characteristics of a successful HME customer service representative. As the front line person and the first impression for the referral and customer/caregiver, the intake personnel are your key staff. Make them your best by providing the tools and resources they need to succeed. This in turn will allow you to prosper now and into the future.
About the author Name Miriam Lieber Company Lieber Consulting focus Reimbursement, operational and compliance audits, staff and software evaluations web lieberconsulting.com
Education: Accreditation renewal
Focusing on Your Accreditation Renewal
ver the past three years, ninetyeight thousand plus suppliers who planned to continue to file Part B claims for identified DMEPOS became accredited or re-accredited. The majority of these suppliers became accredited for the first time in the last few years, but even those who have been accredited multiple times tend to put their accreditation requirements on their “back burner” until it’s time to look at renewal. The majority of renewals are due in 2011 and 2012. What should your “accreditation maintenance” program look like? What are the common problems found on survey? And most importantly, when do you need to get started on renewal? Accredited suppliers have daily, weekly, monthly, quarterly and annual requirements to maintain. You can’t sit down when renewal time arrives and get all of your requirements accomplished at once. No matter who your accreditor is, here are some of the tasks you should be maintaining as a component of your daily operations to prevent common deficiencies:
by Mary Ellen Conway in their files. Competency evaluations should be performed with all staff, upon hire and annually. One area that I find problematic with suppliers is that they often do not have completed Annual Employee Evaluations in the files. Your Personnel Files can easily get out of control, but they also can easily stay in control if you pay attention to them each month and with each new hire. Documentation Audit your documentation. Ensure that you have signed copies of the complete paperwork customers receive. Ensure that you have complete orders for all items and when physician notes are required that you have the complete documentation from the physician on hand, which includes all required elements within that documentation because physician notes have now become part of the audit process.
Performance Improvement (PI) Program Do not let your PI requirements get away from you. Ensure that you are tracking the required indicators listed in the Final Quality Standards, which include: • Customer satisfaction and complaints (daily and weekly) • Frequency of billing/coding errors (monthly and quarterly) • Adverse events to beneficiaries due to inadequate service(s) or malfunctioning equipment and/or item(s) (as they occur) • Documentation of patient and staff infections (monthly) Make sure that you are tracking these items ongoing, evaluating them monthly or quarterly (as needed) and
Human Resources Keep up with your Personnel Files. Make sure all of your newly hired employees are completing your orientation program and that all of those requirements have been met. Ensure that you have signed job descriptions and completed orientation checklists for these new employees 10
American Association for Homecare
Advocacy efforts summarizing them annually as you make improvements in the services you provide. Your Accreditation Timeline Another change that has occurred in recent years is when you can expect to see your surveyor for re-accreditation. CMS is enforcing an accreditation “expiration” date. Since the mandatory accreditation requirement, the accreditors now need to conduct your re-accreditation visit well in advance of your “expiration” date, so that if there are deficiencies found, the supplier has adequate time to correct them, file a plan of correction, have the plan approved, complete a re-visit (if needed) and successfully be reaccredited in adequate time so that there is no lapse or gap in your accreditation status. A supplier MUST begin their renewal process 9-12 months prior to their
“expiration” date in order to have adequate time. Be sure to contact your accreditor early for their guidance on your expected timeframe. Using a Consultant A consultant can help you efficiently review and evaluate whether you have any deficiencies that need to be addressed before your accreditor arrives for your on-site visit. But a consultant should NOT be your sole means of meeting your requirements. I explain to potential customers that if you are asking that I, or a member of my staff, complete and monitor all of your accreditation requirements, it would be the same as asking someone to take a college course for you and pass the test, but then you would be responsible to know the material and implement the requirements into your daily operations. We work with
our clients to assist them in creating simple and effective ways to meet their accreditation and regulatory requirements as well as perform on-site evaluations to evaluate their survey readiness. Use a consultant to ensure that your process is complete and thorough so that you do not have any unexpected trouble renewing your accreditation, and do it WELL in advance of your required renewal.
About the author Name Mary Ellen Conway Company Capital Healthcare Group focus Accreditation, home care, hospice and DME web capitalhealthcaregroup.com
MK Battery Helps to Fund Advocacy Efforts at AAHomecare, NCART, and NRRTS AAHomecare member MK Battery conducted a “Power for Funding” campaign designed to “provide a financial boost to those national advocacy groups that are working tirelessly to navigate the industry through the current healthcare crisis.” The Power for Funding program offered to contribute $1 for every MK Gel battery sold to HME providers in the U.S. during a six month period, to be divided equally among AAHomecare, NCART and NRRTS. During the six month campaign, the program brought in a total of nearly $75,000. MK Battery’s HME Category Manager Dennis Sharpe stated, “We were delighted with the high level of provider participation and interest, and proud to support our industry advocates with this initiative.” AAHomecare President Tyler J. Wilson thanked MK Battery, stating, “We deeply appreciate MK Battery’s commitment and leadership, which help the Association to fight our near-term battles in Washington and help preserve the long-term health of the HME sector.” For more information, visit www.mkbattery.com. Spring 2011
REgulatory concerns : oxygen
Flawed GAO Study Calls for Oxygen Cuts, Praises Bidding Program In an oxygen payment report issued by the Government Accountability Office (GAO), the agency recommended that Congress further reduce Medicare home oxygen therapy reimbursement rates. GAO also recommended that the Centers for Medicare and Medicaid Services (CMS) remove payment for portable oxygen refills from the payment for stationary oxygen systems. AAHomecare strongly disputes a number of flawed comparisons made in the report as well as the conclusion reached by GAO, and the Association will issue a rebuttal to the agency which we will share with Congress. The report states, “Based on the experiences with the VA and CMS, the use of competitive bidding holds promise as a way to contain costs for Medicare home oxygen. Payment rates from the competitive bidding program would have resulted in significant savings if they were implemented nationwide.” The GAO’s comparisons between Medicare rates and the very different VA payment model and the low-ball rates from the poorly designed bidding program raise numerous questions about the reliability of the GAO conclusions. The report does recognize the necessary services inherent in the provision 12
of home oxygen therapy, and it relies on the only comprehensive report on the service and overhead costs related to oxygen therapy – the 2006 Morrison Informatics study, “A Comprehensive Cost Analysis of Medicare Home Oxygen Therapy.” Some of the key findings of the GAO report include: • Between 2001 and 2008, beneficiary utilization of portable oxygen equipment and liquid oxygen systems decreased while stationary concentrator-only utilization increased. The Agency concluded that this change in utilization could indicate beneficiary access issues. The GAO also suggested that the decrease in liquid oxygen utilization may be due to the modality-neutral payment system and the more frequent deliveries that liquid oxygen systems require. • The GAO’s analysis found that only a small percentage of beneficiaries (less than 2 percent) relocate to a different service area in the months prior to the 36-month rental cap. However, the report notes that the analysis does not factor in the beneficiaries who temporarily relocate such as “snowbirds” who spend
winters in Southern states. • In 2009, the 1-800-MEDICARE telephone line received only 20 inquiries from beneficiaries who had trouble finding an HME provider, and CMS said that caseworkers were able to find new providers for the patients in a matter of days. CMS stated that the Agency may consider requiring providers at the month-18 threshold to be responsible for providing oxygen for the remainder of the reasonable useful lifetime if access becomes a problem for patients nearing the 36-month rental cap in the future. • The Department of Health and Human Services (HHS) concurred that oxygen payments are excessive. However, HHS did not agree with the recommendation to remove portable refills from the stationary payment rate, arguing that oxygen expenditures would not change as a result and bidding savings would likely be delayed. The GAO disagreed, stating that “the recommendation was not intended to generate savings but to manage resources to help ensure” beneficiary access. The study is disappointing and the Association will make sure that policymakers get the whole story with respect to oxygen therapy. American Association for Homecare
Don’t Leave Your Fate to Chance National Competitive Bidding Invacare is your partner to survive national competitive bidding. From financing options like the Consumer Power Rental (CPR) Program, to non-delivery oxygen methods, to value added services, Invacare offers providers a full range of products and services. For more information visit www.invacare.com or call 1.800.333.6900.
©2011 Invacare Corporation. All rights reserved. Trademarks are identified by the symbols ™ , sm and ®. All trademarks are owned by or licensed to Invacare Corporation unless otherwise noted.
110301NCB AA Homecare.indd Spring 2011
3/1/11 11:17:48 AM
CMS Fails Medicare Mobility Beneficiaries Frustrated mobility providers ask White House to address CMS gross mismanagement of Medicare mobility benefit.
s the Obama administration embarks on improving the efficiency of government agencies, attention must be focused on the Centers for Medicare & Medicaid Services’ (CMS) supervision of the Medicare power mobility benefit. The White House would be hard pressed to find a government operation more outdated, mismanaged and wasteful of taxpayer dollars. In fact, recent audits by the government’s own contractors demonstrate the extent to which CMS has failed to provide proper administration of this important benefit. Power wheelchairs save taxpayer funds by curtailing emergency room visits caused by fall-related injuries, while also allowing Medicare patients to age at home rather than being admitted into costly nursing homes. Yet, CMS policies and guidelines continue to make it more difficult, rather than easier, for seniors and people living with disabilities to obtain mobility assistance. While problems associated with competitive bidding and ending the first-month purchase option for beneficiaries have dominated headlines over the last few months, other issues also plague providers, physicians and beneficiaries: the process for documenting a Medicare beneficiary’s medical necessity for a power wheelchair and the claim approval process remain in total disarray. The most frustrating part for stakeholders is that these problems are not new. Over the last decade, CMS 14
has failed to design a system that adequately documents the medical need for senior citizens and people living with disabilities to receive power wheelchairs. CMS has continuously tinkered with the process, but each change has resulted in more confusion and headaches for the stakeholders – providers, physicians and beneficiaries. At question is what method should be utilized to document medical necessity. The second, and related issue, is what criteria CMS contractors should use when reviewing reimbursement claims presented by medical equipment providers after delivering power wheelchairs to Medicare patients. With the level of technology available today, neither of these objectives should be major hurdles. Unfortunately,
the government hasn’t delivered workable solutions. In fact, recent audit reports by their Durable Medical Equipment Medicare Administrative Contractors (DME MACs) demonstrate not only the extent to which the government has failed to provide a reasonable process, but also call into question the competency of Medicare’s payment system for medical equipment providers. From December 2008 until November 2010, the DME MACs, who administer Medicare claims for CMS, conducted 11 industry-wide audits of reimbursement claims from their four geographical regions. The results were astounding. In their published reports, the DME MACs said that out of 7,309 claims, 5,977 were denied for an error rate of 82 percent. American Association for Homecare
In a November 2009 executive summary of an improper payments report, CMS specifically stated that the error rates are not related to fraud, but “may be an indication of a program weakness that requires more oversight and diligence by CMS.” That is a gross understatement. The reimbursement process for the mobility benefit is so riddled with subjectivity and confusion that providers and physicians don’t know how to comply with the criteria that is established, and frequently changed. The long history of the documentation and audit issues clearly pinpoint CMS as the culprit, while providers, physicians and beneficiaries have been the victims. The denial rate for claims has been high not just in DME MAC audits, but also for most audits conducted on mobility assistance providers, such as those conducted by the US Department of Health and Human Services’ Office of Inspector General. At times, CMS has introduced new criteria for submitting claims and then absurdly applied the changes retroactively to deny previously approved reimbursements for power wheelchairs delivered before the new standards were even applied. Another key indicator of how poorly the claims are processed is that providers are often successful when appealing denials to Administrative Law Judges, allowing providers to eventually be paid. But this has created cash flow nightmares for providers, who now face severe financial ramifications from the controversial competitive bidding program, as well as the end of the firstmonth purchase option. As a result, some providers are no longer selling standard power wheelchairs or going out of business, making it more difficult for Medicare beneficiaries, especially those in rural areas, to obtain the medical equipment prescribed by their physicians. At the heart of the issue is the role Spring 2011
of physicians. CMS has requested that doctors make handwritten progress notes on their patients, documenting over time the increasing need for mobility assistance. This documentation must be presented to prove medical necessity. But physicians vary widely in what they write on patient progress notes, leading to broad discrepancies over what patient chart notes will be available in individual cases. While health care reform is supposed to give patients better access to physicians, as well as better care, CMS claims process creates an unhealthy environment where claim review contractors are overruling the clinical assessments made by physicians. Doctors prescribe power wheelchairs after mandated face-to-face examinations of their patients, yet CMS treats the doctors as if they don’t know what they are doing. Even more absurd is that many claims are denied, not because of questions related to medical necessity, but because the physician documentation was presented in a format deemed undesirable by CMS. For instance, physicians are encouraged not to submit prepared forms to help describe why their patient needs a power wheelchair to ambulate in their home, despite the fact that such forms are universally used in medicine. Physicians must “write” their prescriptions and not even a beneficiary’s name can be pre-printed. Claims are also being denied if the physician’s signature is not legible. More importantly, CMS has ordered that “clinical inference” can’t be considered by claim reviewers, meaning that physicians must document every specific element of the algorithm in patient clinical records or claims will be
denied. This change, as well as the others cited, are being applied retroactively during audits and are contributing to the high number of denials. The entire claim review process is far too subjective, when objectivity is needed. Physicians are not trained to document information the way that CMS is requesting it, they aren’t compelled to change and what CMS is asking is contrary to their common practices. Furthermore, the rules of the game keep changing, and mobility providers, Medicare beneficiaries and physicians become more and more frustrated with the process. “Instead of helping me in my mission to keep my patients functional at home, CMS or Medicare, throws stumbling blocks in my way at every turn it seems,” laments Dr. Jerald Winakur, M.D., F.A.C.P., C.M.D., a Clinical Professor of Medicine at the Center for Medical Humanities and Ethics at the University of Texas. Tyler Wilson, president and CEO of the American Association for Homecare, said that CMS can’t expect physicians to follow rules and regulations that they don’t understand. “Two things are apparent,” Mr. Wilson said. “Some of the things that CMS is asking of the nation’s physicians are unreasonable considering the technology that we have available today, and there absolutely must be broader and more effective outreach that educates physicians on how to comply with the rules. The doctors are refusing to buy into a system that doesn’t make much sense to them.” Wilson noted that if the White House is serious about reinventing government, reviewing how the power mobility benefit is administered is the place to start.
Conference" April 12–14, 2011Expo" April 13–14, 2011 Sands Expo and Convention CenterLas Vegas, NV
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