Oxygen Cap Remains a Threat
In a tough battle over the 2006 Budget Reconciliation Bill, the HME industry is pushing hard to persuade legislators to vote against a proposal that would make home oxygen equipment a rent-to-purchase item, forcing transfer of ownership to beneficiaries after 36 months. “It’s an uphill battle but one that absolutely must be fought,” says Ann Howard, director of federal policy, AAHomecare. “We are pulling out all the stops in grassroots efforts to get calls from both providers and beneficiaries to their Congressional offices on the House side. We raised the volume level and Congressional offices are definitely hearing it.”  Bob McCoy, RRT
The House and Senate approved the bill in December, but the House must vote on the bill again due to changes to the bill that were made by the Senate. Although it is going to be a struggle to convince Congress to vote “no” on the budget bill, the outcome of the proposal is imperative. “If it passes as is, in 3 years, there will be a major problem,” says Bob McCoy, managing director, Valley Inspired Products, Apple Valley, Minn. “That’s what everyone is trying to educate—that you don’t know what problems you are going to have if this goes through. People will not get ambulatory oxygen and they will become more sedentary; then they will go back into Part A or be hospitalized, costing the government more than what they think they are saving.” If passed, the bill would deal a blow to home care patients and providers alike through changes to capped rental and home oxygen policy. “I think this is a wake-up call to the industry that we need to be more proactive than reactive,” says McCoy. “This to me has been coming for a long time, and we haven’t done outcome studies and we don’t have one voice.” The next vote on this bill is tentatively scheduled to occur February 1 when House members return from their holiday break. “The capped rental policy and home health freeze in this bill represent a step backward, but we won’t take it sitting down if it passes,” says Howard. “We will be looking for remedies and we will only increase the volume on the Hill in 2006 if this bill gets signed into law.” |
PMD Rule Pushed Back
The president recently signed into law HR 3010, which includes a provision preventing CMS from using any resources to implement or enforce the power mobility Interim Final Rule (IFR) before April 1, 2006. The bill includes Senate language that instructs CMS to publish a proposed rule by January 1, 2006, followed by a 45-day transition period, with final implementation no earlier than April 1, 2006. Because the approval of the bill took more time than anticipated, CMS should have some flexibility as far as meeting some of the time frames outlined in the bill; however, it is prevented from implementing or enforcing the IFR until at least April 1. The final bill does not include the 1.5% payment reduction for power wheelchairs that was included in the original Senate version.
The retraction of the IFR should alter the 30-day time frame for the face-to-face examination requirement, provide the transition period that suppliers have been requesting to thoroughly educate physicians, and provide an opportunity to clarify the documentation requirements prior to implementation of a Final Rule. Allowing time for additional education and providing documentation clarity will afford physicians and providers the equivalent understanding and acknowledgment of the level of documentation needed to substantiate medical necessity for PMDs. “The industry has a real opportunity to work with CMS on modifications to the IFR and assist in the development of a Final Rule that preserves access to medically necessary PMDs,” says Seth Johnson, vice president, government affairs, Pride Mobility Products Corp, Exeter, Pa.
CMS must now issue detailed instructions on how providers are to operate now that the IFR has been rescinded. Until such guidance is issued, suppliers should continue to follow the Local Coverage Determination (LCD) and the requirements of the IFR. The guidance should be issued shortly.
Cosponsor Lull in Hobson-Tanner Bill
The Hobson-Tanner bill has made its way to 55 cosponsors, and while the industry goal of 200 cosponsors is still a way off, it is attainable nonetheless. “I can tell you that because of the work of Pride Mobility (it has sponsored two of its sales reps to travel throughout the Midwest and West Coast since November to get signatures) and the state associations, you will begin to see the number of sponsors continue to increase throughout February and March,” says Karyn Estrella, executive director, New England Medical Equipment Dealers Association.
The push to add cosponsors to the bill has not been a walk in the park though. With many pressing issues facing the industry, efforts to add cosponsors have not been in full force. “We have been working on so many issues it has been difficult to put all the focus on 3559,” Estrella says. “Part of the problem was Hurricanes Katrina and Rita. When Congress went back into session in September, the industry had to allow some time for them to deal with those issues. Then the industry was focused on the dispensing fee issue, submitting comments on the proposed quality standards, the IFR, etc.”
While the efforts have faced some obstacles along the way, the industry remains steadfast in its struggle to add cosponsors. “Through AAHomecare’s State Leaders Council, which I chair, we will continue to work on getting more sponsors,” says Estrella. “We are working in conjunction with Pride Mobility, VGM, and the MED Group. There will be more of a push for the remainder of the winter and spring.” Introduced on July 28, 2005, by Reps David L. Hobson (R-Ohio) and John S. Tanner (D-Tenn), the Medicare Durable Medical Equipment Access Act of 2005 would remedy many competitive bidding provisions.
Global Asthma/COPD Sales Forecast to Grow
According to a Research and Markets analysis, global asthma/COPD sales are forecast to grow to $23 billion by 2014, with inhaled corticosteroid/long-acting bronchodilator combinations set to be the leading class by value in 2014. The study says that there is a positive outlook over the next 5 years for the respiratory market, which will experience a sustained period of growth driven by the expansion of sales in existing classes, the launch of major new products, and the results from several landmark studies.
CMS Awards New DMEPOS Contracts
CMS has granted new contracts for four specialty contractors who will be responsible for handling the administration of Medicare claims from suppliers. The new Durable Medical Equipment Medicare Administrative Contractors (DME MACs), which were selected through a competitive bidding process, will replace the current Durable Medical Equipment Regional Carriers (DMERCs) and will have slightly realigned geographic jurisdictions from those serviced by the DMERCs. The DME MAC contracts, which have a combined potential value of $542 million, are the first of 23 that will be awarded by 2011 to fulfill requirements of the contracting reform provisions of the Medicare Modernization Act of 2003.
The DME MACs will immediately begin transition activities and will assume full responsibilities for the claims processing work currently performed by the DMERCs on July 1, 2006. A list of the new DME MAC jurisdictions appears below.
Region A, National Heritage Insurance Company (NHIC): Connecticut, Delaware, the District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont
Region B, AdminaStar Federal Inc: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin
Region C, Palmetto GBA LLC: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Okla-homa, Puerto Rico, South Carolina, Tennessee, Texas, US Virgin Islands, Virginia, and West Virginia
Region D, Noridian Administrative Services: Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington, and Wyoming
Medicaid Whistleblower Legislation Aids Fight Against Fraud
The Attorney General recently gained a powerful tool in the fight against Medicaid fraud with the recent signing into law of new Medicaid Whistleblower Protection legislation. The legislation was unveiled in March 2005 by Michigan Attorney General Mike Cox and the bill’s sponsor, Rep David Law (R-Commerce Township). “Medicaid fraud costs the people of Michigan millions each year and takes from people who need and deserve the help Medicaid provides,” says Cox. “This law will enhance my office’s ability to discover and prosecute Medicaid fraud.”
Almost 20% of Michigan’s annual budget is dedicated to Medicaid. National studies indicate that between 3% and 10% of a state’s Medicaid costs are fraudulent claims. For Michigan, this equates to anywhere between $225 million and $800 million. In addition, the successful prosecution of Medicaid fraud will result in penalties three times the amount of the restitution awarded to the state.
The statute amends the Medicaid False Claims Act to provide whistleblowers with legal protection, as well as a financial incentive to those willing to bring a civil suit against, and assist in, the investigation and prosecution of a violator of the Medicaid False Claims Act.
Mark McClellan
CMS Sends Survey to Measure Provider Satisfaction
CMS recently sent out a new survey designed to measure the satisfaction of providers in the fee-for-service (FFS) program. The survey asks providers to rate services of contractors that are responsible for processing claims, educating them about changes in Medicare policies, and responding to provider inquiries. The initiative, the Medicare Contractor Provider Satisfaction Survey (MCPSS), will be administered on an annual basis. It is designed to garner quantifiable data on provider satisfaction levels with key services performed by the 42 FFS contractors that process and pay more than $280 billion in Medicare claims each year. “The Medicare program depends on health care providers all over the country to serve our beneficiaries, and this new survey will help us work with the Medicare contractors to help us serve our providers as effectively as possible,” says CMS Administrator Mark B. McClellan, MD, PhD.
CMS Issues Proposal to Increase Oxygen Coverage
CMS is seeking public comment on a proposal that would expand home oxygen coverage criteria. The proposal would provide coverage to Medicare beneficiaries with PaO2 measurements from 56 to 65 mm Hg (partial pressure of oxygen, arterial), or whose oxygen saturation is at or above 89%. According to the CMS memo, the agency proposes to issue a National Coverage Determination to cover the home use of oxygen for those beneficiaries meeting the qualifications described above who are enrolled subjects in clinical trials identified by CMS and sponsored by the National Heart, Lung & Blood Institute. DP
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