One you should probably expect to come across often is HME, and understanding it may be essential to effective medical billing.

What Does HME Stand For?

Simply googling “What does HME stand for” without the proper context, however, may yield some less-than-relevant results: heavy military equipment, hazardous materials endorsement, and hybrid memory express, to name a few. So what does HME stand for in the context of medical billing?

The Medical Definition of HME

For our purposes, we need only define HME in the context of medical care and billing. In short, HME stands for home medical equipment. It’s typically seen as a more specific subset of durable medical equipment, or simply DME. 

HME is essentially DME supplies intended specifically for use outside of the hospital, generally in a patient’s own home.

The defining feature of HME (and the larger body of DME as well) is its durability. These items are not immediately disposable. Rather, most of them are intended for repeated or long-term use. When a patient is released from the hospital but still requires ongoing medical treatment or aid, different kinds of HME may be installed in the home to facilitate recovery or simply improve quality of life.

Common Examples of HME Items

There is a fairly extensive array of HMEs available on the market, each designed to address a specific medical need. Some examples you’re likely already familiar with are wheelchairs, home hospital beds, walkers, and canes. 

However, there are more technical varieties of home medical equipment as well. For example, a patient’s home treatment program may necessitate oxygen concentrators, diabetic supplies, or home infusion equipment. Despite the vast range of differences these items can take, virtually all kinds of HME play an essential role in healthcare treatments and recovery programs.

How Is HME Prescribed?

HME is typically prescribed by healthcare professionals, such as physicians, nurses, or physical therapists, after a careful assessment of the patient’s condition. Any HME prescription by a healthcare provider will be based on the patient’s specific needs.

The prescription process generally involves evaluating the patient’s medical history, current health status, and functional limitations. Based on that information, the healthcare provider will recommend appropriate HME items to aid in the patient’s recovery, mobility, or management of their medical condition. The official prescription ensures that the HME can be properly covered by insurance or reimbursement programs.

The Impact of HME on Your Medical Billing

As you may have guessed, HME can have a significant impact on your medical billing procedures, making a keen understanding of this equipment essential for any healthcare provider or billing team. Healthcare providers and HME suppliers have to navigate some highly complex billing procedures to ensure proper reimbursement for the equipment prescribed.

Maximizing reimbursement for HME supplies is dependent on accurate coding, careful documentation, and strict adherence to guidelines. To do otherwise would be to risk countless claim denials and having to start all over again. 

If this all sounds complicated, you’re not alone in your concerns. That’s why countless medical professionals like you trust third-party services like Medbill to take care of their medical billing needs.

What Does HME Stand For: Learn More from Medbill

The answer to the question “What does HME stand for?” is deceptively simple, but it comes with a lot of necessary context to get a full picture of this equipment’s importance in the medical field. Home medical equipment isn’t just important for the patients who depend on it for independence, recovery, and quality of life; it’s also fairly impactful on the billing procedures of providers and suppliers.

If you’re one of the countless healthcare providers and HME providers who struggle to keep up with the complex needs of effective medical billing, Medbill is here to help. Our team is specially trained to handle your billing procedures accurately and efficiently to get you the payouts you deserve for your services and supplies. 

Get in touch today to learn how Medbill can help you revolutionize your healthcare business. Want to learn more about medical billing for HME? Contact Medbill today.

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What to Expect with the New CRT Provisions 

When CMS published their Fiscal Year 2022 Inpatient Rehabilitation Facility Prospective Payment System Final Rule (CMS-1748-F), it outlined three key points regarding fee schedule adjustments. 

#1 Items with a Group 3 or Higher Connection for Complex Rehabilitative Power Wheelchairs 

CMS is placing the final touches on a fee schedule adjustment with information from the DMEPOS Competitive Bidding Program (CBP). The adjustment will include:

• Seat and back cushions 
• Seating systems
• Wheelchair accessories

#2 Items in Connection with Complex Rehabilitative Manual Wheelchairs

CMS will extend the fee schedule adjustment exclusion to:

• Seat and back cushions 
• Seating systems
• Wheelchair accessories

#3 Modifying the Definition of “Item” Under the DMEPOS CBP

Currently, CMS is modifying the regulatory definition of “item” under the DMEPOS CBP at 42 CFR 414.402. It’ll exclude the below items when furnished in connection with the wheelchairs from DMEPOS CBP. Which is required by section 106(a) of the Further Consolidated Appropriations Act, 2020.

• Complex rehabilitative manual wheelchairs 
• Certain other manual wheelchairs 
• Related accessories 

Support from Patient Advocacy Groups

Thank you to all the advocacy leaders who worked tirelessly to guarantee that the full scope of CRT wheelchairs and accessories are provided to patients and aren’t part of the bidding program.

• ITEM Coalition
• Mobility Community Advocacy Leaders 
• NCART Partners 
• United Spinal Association 
• Representatives and Senators who provided support 
  • Rep. John Larson (D-Conn.)
  • Rep. Lee Zeldin (R-N.Y.)
  • Sen. Bob Casey (D-Pa.)
  • Sen. Rob Portman (R-Ohio)

Thank you, AAHomecare, for providing the DME industry with this update in your July 30 email.

Stay in the Know with Industry Updates

Medbill is a team of leading DME billers who stay current on the ever-revolving DME and HME industry. Contact us to learn more about how we can help with your DME billing needs. 

The post CRT Accessories Now Exempt from Bidding-Derived Pricing appeared first on Medbill DME Billing Services.

Patient Treatment Disruption 

Although Philips hasn’t provided a time estimate regarding replacements and repairs, there is a concern that the recall will disrupt many patients diagnosed with obstructive sleep apnea (OSA) and their prescribed course of treatment.

Many policy requirements can disrupt patient treatment, including: 

• Time-specified adherence rules
• Sleep test requirements 
• Clinical evaluation 
• Device replacement rules 
• Patient repair or replacement costs 

CMS and Private Payers Support Needed 

Undersigned medical societies and patient advocacy organizations have urged private insurance payers and CMS to support OSA patients during this recall. 

Organizations include:

• American Academy of Sleep Medicine (AASM)
• American Academy of Neurology (AAN)
• American Thoracic Society (ATS)
• American, College of Chest Physicians (CHEST)
• Alliance of Sleep Apnea Partners (ASAP)
• American Sleep Apnea Association (ASAA)

How CMS and Private Payers Can Help

CMS and private payers can help support OSA patients and DME suppliers and providers by: 

• Temporarily suspending any time-specified adherence rules.
• Allowing patients to receive a new device or have their current one repaired.
• Allowing exceptions to coverage requirements for replacing PAP equipment after a certain number of years. 

Repairs and Replacements 

Help provide patient support by allowing DME suppliers to repair or replace recalled devices without requiring:

• Documentation of a new clinical evaluation
• Sleep test or trial period
• Remove patient costs for any repair or replacement expenses 

90-day Adherence Rule & Equipment Replacement Requirement 

All the Phillips Respironics recall devices are subject to the CMS Local Coverage Determination (LCD) Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718). The L33718 requirement states that a clinical re-evaluation and documentation is needed “no sooner than the 31st day but no later than the 91st day after starting therapy”. 

L33718 also includes specific requirements regarding equipment replacement. It states, “If a PAP device is replaced during the 5-year reasonable useful lifetime (RUL) because of loss, theft, or irreparable damage due to a specific incident, there is no requirement for a new clinical evaluation, sleep test, or trial period.” 

The aforementioned medical societies and patient advocacy organizations are asking CMS to temporarily suspend this 90-day adherence rule. While also allowing an exception to the RUL requirements for the Philips Respironics recalled products. 

FDA Recommendations 

The U.S. Food and Drug Administration (FDA) has released recommendations for health care providers and patients during this recall. Read the entire FDA Safety Communication article. Some recommendations include:

• Review the FDA recommendations with the patient and encourage them to talk with their health care provider. Actions may include:
  • Using another similar device (that’s not part of the recall)
  • Using alternative treatments for sleep apnea 
  • Beginning long term therapies for sleep apnea
• Follow the manufacturer’s instructions and recommended cleaning and replacement guidelines 
• Register the device on Philips Respironics’s recall website
• Report device problems through the FDA’s MedWatch Voluntary Reporting Form

Information about the Philips Respironics Recall 

The Philips Respironics recall notification impacts 18 Bi-Level PAP, CPAP, and mechanical ventilator devices that are part of the first-generation DreamStation product line. Access the complete list of the recalled devices here. 

The Philips voluntary recall is due to the potential health risks of the polyester-based polyurethane (PE-PUR) sound abatement foam, which may degrade over time and enter the patient’s airway, or the foam may off-gas certain chemicals.

Read Philips Respironics Recall – What DME Providers Can Expect for more information regarding this recall. 

Stay Up to Date with Medbill 

The Medbill team will provide you with valuable information and guidance on how to handle this recall. If you have any questions, contact the Medbill team. 

Learn more about how Medbill’s DME billing services can help you. 

The post Ongoing Patient Treatment & Support during the Philips Respironics Recall appeared first on Medbill DME Billing Services.

Expected NCD Changes

These modifications are from the comments from last year’s opening of the National Coverage Analysis (NCA) for Home Use of Oxygen Use to Treat Cluster Headaches. 

The changes include, but aren’t limited to:

• Coverage for acute conditions
• Removal of oxygen CMN
• Removal of the trial of alternative therapies

Expected Outcome from the NCD Changes

These changes should help to expand the use of home-based oxygen and other policy recommendations. Thank you, AAHomecare, for advocating with CMS on these changes! 

In CMS’ report about the changes to Section D1 of 1993 NCD 240.2 (Conditions for Which Oxygen May Be Covered), the new guidance “will reinforce that patients suffering from any medical condition, be it of respiratory or non-respiratory origin, may receive home oxygen and oxygen equipment for the duration of illness, be it short or long term, if this service is otherwise reasonable and necessary.”

To read the full report and all the details in the CMS’ “Proposed Decision Memo for Home Use of Oxygen and Home Oxygen Use to Treat Cluster Headaches (CAG-00296R2).”

CMS is Accepting Public Comments 

Currently, CMS is accepting public comments on these changes until August 1, 2021. Click here to submit your comments on the NCD changes.

Stay Current on All Industry Updates 

The Medbill team are industry-leading DME billers who constantly stay up to date on the DME and HME industry. Contact us to learn how we can help you stay current with your DME billing. 

The post Great Industry News – Proposed Changes to the Oxygen NCD appeared first on Medbill DME Billing Services.

The Noridian education team has just released an FAQ on impacts to Medicare beneficiary coverage and billing related to the recall for Philips respiratory devices.

• Frequently Asked Questions – Philips Respironics Respiratory Products Recall – JA DME – Noridian
• Frequently Asked Questions – Philips Respironics Respiratory Products Recall – JD DME – Noridian

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Our document review service provides an audit ready quality and compliance check on your billing documents. A pre-review process is available through our Document Review department if you need additional time and resources. 

Pre-Review Process Benefits 

Our pre-review process is an optional service that works with our document review. We perform the pre-review service before a product is dispensed. Typically, the Document Review department reviews all documentation post-dispensing but before billing the insurance company. 

Reviewing the order documentation before dispensing equipment helps to:

1. Reduce non-covered equipment costs.
2. Provide timely communication to referral sources (if additional information is needed). 
3. Free up time to focus on revenue growth or other business needs. 

Medbill’s Document Review Services

To learn more about our document review process, read our article on “How to Successfully Navigate the DME Billing World.”

3 Ways the Pre-Review Process Increases Time & Resources 

Our pre-review services will free up your time, your staff’s time, and your resources. This will allow you to work on other business needs (customer service, marketing efforts, business growth, etc.).  

Below are three pre-review tasks we take care of during your document review service.  

#1 Review Documentation Before Dispensing an Order

During the pre-review process, we assess the medical necessity documentation and dispensing order before fulfilling an order. This reduces the amount of non-covered equipment costs with an order.

#2 Assist You During the Intake Process  

We provide your intake staff with feedback on their documentation evaluation. We review the patient order documents and determine the patient’s approval chances for the prescribed equipment.

#3 Take Over Tasks Specific to You 

We can customize our services for your specific needs. For instance, if you want us to assess the oxygen setups in the pre-review process, we can take that task over for you. 

Finding the Best Solution for You 

At Medbill, we go above and beyond with our services to help you meet your needs. Our goal is to free up your time and your staff’s time so you can focus on revenue growth. Contact the Medbill team to learn how our services can help you. 

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During this time, the Medbill team has received questions asking for clarification for Medicare orders. The information below should help provide you clarity on the billing guidelines.

Billing Oxygen Claims During the PHE

Since the pause on LCD clinical indications, the Medbill team has received questions asking for clarification for Medicare orders. Below are the guidelines to keep in mind when billing oxygen claims. 

#1 CR Modifier and “COVID-19” Claim Note

Use the CR modifier and “COVID-19” item claim note any time you don’t meet all standard requirements due to the PHE. Use this note whether or not the patient has a COVID-19 diagnosis.

#2 Documentation Requirements 

While there are many flexibilities already in place when it comes to the COVID-19 diagnosis, you still need to make sure you meet the documentation requirements. 

Including:

• Medical records should reflect the need for oxygen
• Provide a completed Standard Written Order (SWO) 
• Valid Proof of Delivery

#3 Additional Reminders

• Once the COVID-19 PHE ends, the DME MACs will return to enforcement of the clinical indications for coverage. 
• If you need more information on billing claims during the COVID-19 PHE, read more here.

Other Clinical Indications for Coverage 

CMS is not enforcing clinical coverage criteria for claims with dates of service on or after March 1, 2020 (and for the duration of this COVID-19 PHE) in the following NCDs and LCDs.

• Continuous Positive Airway Pressure for Obstructive Sleep Apnea (NCD 240.4)
• Durable Medical Equipment Reference List (NCD 280.1) – Only clinical indications for ventilators are not enforced
• External Infusion Pumps (L33794)
• Glucose Monitors (L33822) – Only clinical indications for Therapeutic Continuous
  • Glucose Monitors (CGM) are not enforced
• High-Frequency Chest Wall Oscillation (L33785)
• Home Oxygen (NCD 240.2)
• Infusion Pumps (NCD 280.14)
• Intrapulmonary Percussive Ventilator (NCD 240.5)
• Mechanical In-exsufflation Devices (L33795)
• Nebulizers (L33370)
• Oral Appliances for the Treatment of Obstructive Sleep Apnea (L33611)
• Oxygen and Oxygen Equipment (L33797)
• Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea (L33718)
• Respiratory Assist Devices (L33800)
• Suction Pumps (L33612) – Only clinical indications for respiratory suction pumps
  • (E0600) are not enforced

Claims – CR Modifier, KX Modifier, Claim Narrative

As a reminder, make sure when you submit a claim with the CR modifier to include the KX modifier or the claim narrative.

For more information on modifiers and claim narrative, click here. 

Stay Current on All Industry News with Medbill

The Medbill team stays up to date on the constantly changing DME and HME billing industry and keeps our customers current on these changes.

Contact the Medbill team today to learn more about how we can help you with your needs.  

The post Clarity on Billing Oxygen Claims During the COVID-19 PHE appeared first on Medbill DME Billing Services.

This article will provide you with additional information on the SWO and why frequency is still required for supply items.

SWO Requirements

The SWO can be completed by someone other than the practitioner (unless otherwise noted). However, the treating practitioner still needs to review and sign the SWO.

An SWO must contain the:

• Beneficiary’s name or Medicare Beneficiary Identifier (MBI)
• Order date
• General description of the item, including:
  • Description – It can be either a general description, an HCPCS code, an HCPCS code narrative, or a brand name/model number.
  • Equipment – May include all other ordered options, accessories, or additional features separately billed or require an upgraded code (List each separately).
  • Supplies – The DMEPOS order/prescription may include all ordered supplies that are separately billed (List each separately).
• Dispensed quantity 
• Treating practitioner name or National Provider Identifier (NPI)
• Treating practitioner’s signature

Click here to read a full summary of the new SWO requirements.  

Written Orders Prior to Delivery (WOPD)

A completed SWO passed onto a DMEPOS supplier before item delivery is a Written Orders Prior to Delivery (WOPD). DMEPOS items might be subject to a WOPD and Face-to-Face Encounter if the DMEPOS item is on CMS’s Required List.

The Required List will include:

• Any statute required DMEPOS items (i.e., Power Mobility Devices)
• Additional DMEPOS items selected by CMS on their Required List

Review CMS and DME MAC’s websites for the Required List of the selected HCPCS codes. It will be published once the items are added to the Federal Register Notice (the Required List will be updated regularly).

Frequency is Still Required for an SWO

Frequency is still required for supply items on an SWO. Even though the new SWO guidelines removed frequency from the requirement list, Medicare will still look to the medical records to ensure there’s support for the frequency being billed.

Where should the frequency be included?

The frequency either needs to be clear and listed on the SWO or in the medical records. Unfortunately, it’s not a common practice for practitioners or physicians to include frequency in the medical records.

Why is frequency still needed if it’s not on the SWO requirement list?

Frequency is how Medicare and Third-Party Payors reimburse suppliers. Medicare and Third-Party Payors want to see if the quantity of monthly supplies is truly medically necessary. Since the quantity of items doesn’t always equal the frequency, they need to see it listed either on the SWO or medical records.

The Supplier Manual Chapter 3 Section 4 states, “For any DME item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use.”

SWO and Frequency

Overall, the new Medicare guidelines now require an SWO (instead of a DWO) before any DMEPOS items are billed. Although the SWO requirements don’t include frequency as a required item, it still needs to be included. The frequency can be on the SWO or in the medical record.

Stay Current on All DME Billing Changes with Medbill

As a full-service DME billing service provider, we will help you stay on top of your claims and cash flow. As part of our Document Review Services, we help you create a clear path to lower denials and a more streamlined revenue cycle.

Learn more by contacting a Medbill team member today!

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OIG History 

The OIG leads the United States’s fight against Medicare and Medicaid waste, fraud, and abuse along with more than 100 other Department of Health & Human Services (HHS) programs. The HHS OIG has the largest inspector general’s office in the Federal Government, with around 1,600 staff members.

Why Medicare and Medicaid?

The Medicare and Medicaid programs represent a large portion of the federal budget and directly impact the country’s vulnerable men and women. 

Office of Audit Services (OAS)

The OAS conducts independent audits into the Medicare and Medicaid programs. 

Their audits:

•   Assess the program and its operations
•   Examine the program’s performance
•   Search for waste, abuse, and mismanagement
•   Promote efficiency throughout the program

Past Audits

The OIG’s past audits have helped to uncover Medicare and Medicare mistakes that led to waste.

Some of their past audits include:

• CMS and its Contractors Did Not Use CERT Program Data to Identify and Focus on Error-Prone Providers
• CMS Did Not Ensure That Medicare Hospital Payments for Claims That Included Medical Device Credits Were Reduced in Accordance With Federal Regulations, Resulting in as Much as $35 Million in Overpayments
• Medicare-Allowed Charges for Noninvasive Ventilators Are Substantially Higher Than Payment Rates of Select Non-Medicare Payers

OIG Strategic Plan for 2020-2025

The current OIG plan outlines its current priorities in the next few years and will guide them on where they should spend their time and resources. You can read the entire strategic plan here.

Some of their priorities regarding the Medicare and Medicaid programs include:

•   Medicare Advantage 
•   Emergency preparedness and response for Medicare beneficiaries
•   Patient safety and accuracy of payment for in-home and community settings
•   Proper spending of Medicare funds
  •   Payment accuracy
  •   Efficiency of payment polices
  •   Eligibility determinations

You can read more details on page 18 in the report here. 

Have Confidence with Your DME Billing 

Medbill, a trusted and educated DME billing company, works effortlessly to ensure your claims are billed correctly and paid on time. Learn more about how the Medbill team can help your billing department here. 

Ready to move forward? Contact us today!

The post How the OIG Contractor Audits Relates to CMS appeared first on Medbill DME Billing Services.

$158 Million More in Medicare Payments

On Tuesday, April 13, the House passed the amended version of H.R. 1868. This extension will result in approximately $158 million more in Medicare payments to DME and HME suppliers over the rest of this year (based on current Medicare data). That means DME and HME suppliers will receive the additional $158 million on top of the previous $193 million already provided from the paused cuts from May 2020 through March 2021.

CMS Held Off Claims

On March 31, the Centers of Medicare & Medicaid Services (CMS) announced a temporary pause for all Medicare claims (with service dates on or after April 1, 2021) without affecting the provider’s cash flow. Read that announcement here.

$2 Billion in “Bottom Line” Policy Wins

Thank you, AAHomecare, for providing the industry with this update. You can read their March 24 AAH Insider email to learn more about the more than $2 billion in “bottom line” advocacy success here. 

Quote from AAHomecare’s President and CEO

“Keeping the 2% sequester cuts on hold for the remainder of the year will help offset the new costs and operational challenges associated with serving patients brought on by the pandemic,” said Tom Ryan, AAHomecare president, and CEO. “This bill is the latest example of the terrific bipartisan Congressional support for healthcare providers over the past year, and these measures have been especially welcome by the HME community.” 

“I’m especially proud of the thousands of HME suppliers who reached out to their legislators to seek support for extending the sequester moratorium,” continued Ryan. “The volume and passion of your outreach on this issue has been exceptional.”

Don’t Miss Any Industry Updates 

As a leading DME Billers, the Medbill team stays up to date on the constantly changing DME and HME industry. Contact us today to learn more about our services and how we can help you stay current with your DME billing. 

The post A Big Win for the Industry – Medicare Sequester Cuts Paused! appeared first on Medbill DME Billing Services.

Our 4 step Document Review Process:

• follows specific payer guidelines for medical necessity and billing procedures.
• ensures only clean claims are submitted.
• acts as a “human firewall” for clean claims.
• utilizes the same information that is required in the event of a claim audit.

We are different from other companies because our review is much more than a checklist; it is a thorough analysis that starts at claims intake. We are a support system for your intake team, and we work collaboratively to ensure claims are paid and audit ready.

Contact us today so we can start your audit ready process!

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Legislation in the works by Sen. John Thune, R-S.D., would delay the next round of cuts for nine to 12 months, depending on the CBO score.

“This proposal is fresh and new,” said Jay Witter, senior vice president of government relations for AAHomecare during the association’s legislative update at Medtrade Spring in Las Vegas last week. “There will be a bill here shortly. We need your help and we need it quickly.”

On Jan. 1, CMS implemented the first round of cuts* in regional and rural areas, basing reimbursement on a 50/50 blend of the current and adjusted rates. On July 1, reimbursement will be based only on the adjusted rates.

The plan is to get a bill introduced and passed through an expedited “hotline” process.

“The window of opportunity in this crazy election year is very small,” said Tom Ryan, president and CEO. “This is what’s in front of us today—we can’t go back.”

The pay-for for the bill: Move up the start date of an already planned Medicaid cut from calendar year 2019 (Jan. 1, 2019) to fiscal year 2019 (Oct. 1, 2018). The cut will match the federal portion of Medicaid allowables to adjusted Medicare reimbursement.

Other provisions in the bill: a ceiling for future rounds of competitive bidding set at the unadjusted fee schedule rates as of Jan. 1, 2015; and a requirement that CMS revisit adjusting pricing for non-bid areas that takes into account travel distance, clearing price and other associated costs for furnishing equipment that will be in effect Jan. 1, 2019.

“Our champs in the Senate are lining up allies,” said Witter. “(Rep. Tom Price, R-Ga.,) is raring to go in the House.”

Stakeholders are also working with Senate members to ask CMS to fix the bidding program without forcing the issue through legislation.

“Our contention is that CMS can do this on their own,” said Witter. “We have a number of heavy hitters on our side.”

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CMS says it wants to pay private insurers 0.95% less next year. When more intensive services are factored in, however, the agency says it expects overall payments to increase about 1.05%.

“The proposed rates will enhance the stability of the Medicare Advantage program and minimize disruption to seniors and care providers,” stated Andy Slavitt, CMS Principal Deputy Administrator, in a press release.

CMS is currently accepting comments on the proposal and plans to publish a final version on April 6.

The agency has reported record high enrollment in Medicare Advantage plans each year since 2010, a trend continuing in 2015 with a total increase of more than 40% since the Affordable Care Act was passed.

Additionally, CMS reports that premiums for these plans have fallen nearly 6% from 2010 to 2015.

In past years, proposed decreases in payments to Medicare Advantage plans have been reversed. In 2014, for example, a 1.9% decline turned into a 0.4% increase.

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The largest increase in visits (34%) was made by adults in their mid-20s to mid-40s, according to the new brief.

“Continuing to examine office-based physician visits by patients with diabetes is especially important given changes in standards of care that may influence such visits,” said Jill Ashman, a physician at the CDC’s National Center for Health Statistics, in the brief.

The total number of visits was higher among older adults—those 65 and older made 53.7 million visits in 2010, while those younger than 25 made 2.6 million visits, according to the brief.

Visits by patients with diabetes made up 11% of all office-based physician visits in 2010.

Researchers say regardless of age, patients with diabetes use “extensive health resources,” with frequent doctor visits and multiple prescriptions, the brief states.

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The agency says it has begun its pre-bidding supplier awareness program, and will announce the bidding schedule and education program this fall. Bidding is set to begin some time in the winter of 2015.

The original contracts for Round 2 are set to expire June 30, 2016.

CMS plans to include the following product categories in the recompete:

• Enteral nutrients, equipment and supplies

• General home equipment and related supplies and accessories (includes hospital beds and related accessories, Group 1 and 2 support surfaces, commode chairs, patient lifts and seat lifts)

• Nebulizers and related supplies

• Negative pressure wound therapy (NPWT) pumps and related supplies and accessories

• Respiratory equipment and related supplies and accessories (includes oxygen, oxygen equipment, and supplies; continuous positive airway pressure (CPAP) devices and respiratory assist devices (RADs) and related supplies and accessories)

• Standard mobility equipment and related accessories (includes walkers, standard power and manual wheelchairs, and scooters)

• Transcutaneous electrical nerve stimulation (TENS) devices and supplies

CMS has shuffled around some products in the recompete, including walkers, now in the standard mobility category, and has added TENS devices, which was included in the Round 1 recompete but not the original Round 2. Not included: infusion pumps and supplies, which were part of the Round 1 recompete.

The agency plans to run the recompete in the same geographic areas, but due to Office of Management and Budget updates there will be 90 metropolitan statistiscal areas (MSAs) instead of 91. Another change: It has redefined the CBAs so that no CBA includes more than one state.

CMS will also recompete the contracts for the national mail-order program for diabetes testing supplies for all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam and American Samoa.

For more info on the recompete visit: http://www.dmecompetitivebid.com/

To see a list of specific items in each category visit: http://dmecompetitivebid.com/

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Biggest loser: rural areas

In a July 2 proposed rule, the agency outlines plans to apply competitive bidding prices in non-bid areas by using regional prices limited by a national ceiling (110% of the average of regional prices) and the floor (90% of the average of regional prices).

“Until they calculate the ceiling and the floor, it’s tough to say much about this,” said Kim Brummett, senior director of government affairs for AAHomecare. “But it will be a huge hit in rural areas.”

With 45% cuts, on average, as part of Round 2, the regional prices will likely mean big cuts for providers in rural areas even at 110% of the average of regional prices, stakeholders say. To boot: Providers in rural areas are less likely to see volume increases from the program, due to the demographics of the areas they do business in.

In its comments to an advance notice of proposed rulemaking published in February, AAHomecare argued that pricing for HME in rural areas should receive an add-on, much as it does for home health.

“No rural add-on and average bid rates that were wrong—it just doesn’t add up,” Brummett said.

Stakeholders bristle at the idea of using competitive bidding pricing, in general, for anything going forward.

“We believe the methodology is flawed to begin with and the rates are unsustainable,” said Tom Ryan, president and CEO of AAHomecare.

The agency plans to apply expanded competitive bidding pricing Jan. 1, 2016.

Testing the waters with bundling

CMS also outlines plans to phase in bundled monthly payments for enteral nutrition, oxygen, standard manual and power wheelchairs, hospital beds, CPAP devices and respiratory assist devices furnished in no more than 12 metropolitan statistical areas (MSAs).

“At least it’s a demo,” Brummett said. “The big question: What is the rate going to be?”

The MSAs chosen for the demo would have a general population of at least 250,000 and a Medicare Part B enrollment population of at least 20,000 not already included in Round 1 or 2.

Stakeholders worry what bundled payments will do to patient and quality outcomes, for some products more than others.

“When you’re talking about CPAP, compliance is important, and at the end of the day, you have to make sure you have outcomes,” Ryan said.

The agency plans to implement bundled monthly payments, which would cover equipment, supplies, accessories and any necessary maintenance and repairs, Jan. 1, 2015.

CMS will accept comments on the proposed rule until Sept. 2. It expects the rule to appear in the July 11 Federal Register.

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During the United Spinal Association’s third annual Roll on Capitol Hill, activists made 200 congressional office visits and talked about better access to health care, disability rights, employment opportunities, protection of social security benefits and accessible transportation.

“With regard to transportation and access to jobs, if you don’t have the right equipment, you can’t get out of the house and the rest doesn’t matter,” said Joe Gaskins, who participated in the event for the first time as president and CEO of United Spinal. “It’s putting the cart before the horse in some instances. If we don’t have the right medical equipment for people with disabilities, then they’re really restricted.”

Representing 26 states, Washington, D.C., and Puerto Rico, 120 activists attended the event.

“We had a lot of folks from the West Coast coming all the way over here,” said Alex Bennewith, vice president of government relations at United Spinal.

Congressional staffers were eager to hear what activists had to say, Gaskins said.

“I thought we were very well received and we have been getting good responses from congressional offices since the event that they are signing up to support our bills, including the CRT legislation,” said Gaskins.

With so many groups backing a separate benefit for complex rehab, “It’s hard to not know about it,” said Justin Richardson, director of communications and customer relations for Numotion and a member of the board of directors of the North Carolina Spinal Cord Injury Association.

For those congressional offices that didn’t—Gaskins hopes the visits will be a turning point.

“For some, it was a first-time opportunity to actually meet people that needed this equipment, so it gave them an opportunity firsthand to hear anecdotally some of the things people go through just to get through a regular day,” he said.

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“We’re trying to make a stand that it’s over the top, but we don’t have any numbers to back that up,” said Kim Brummett, vice president of regulatory affairs for the association. “If we don’t have any numbers that we can share, at the end of the day, it’s all anecdotal stuff.”

With HME Audit Key, providers will use a secure electronic form to answer questions about audits, including how many they have at the redetermination, reconsideration and ALJ levels, and how many appeals they’ve won. The anonymous submissions will be compiled into a data set that AAHomecare can examine to see the impact of audits and share with lawmakers.

HME Audit Key is part of a multi-pronged effort that AAHomecare has undertaken since restarting its Audit Task Force last fall. The association has also been working closely with Rep. Renee Ellmers, R-N.C., on introducing a bill to reform the audit process.

AAHomecare’s goal is not to eliminate audits, but to reform them.

“We want smart audits,” Brummett said. “We want them to be thorough and good and make sense, and hold people accountable.”

While AAHomecare has been collecting anecdotes about audits via email, HME Audit Key is all about the numbers. And for valid statistics, it needs a large sample size.

“We need to get as many providers to participate as possible,” said Tom Ryan, president and CEO of AAHomecare. “Our goal is to get everyone to understand this is an industry-wide effort, not just an AAHomecare member effort.”

In June, AAHomecare kicked off a campaign to raise $250,00 over two years to develop HME Audit Key, and create and maintain a secure database to support it, Brummett said.

Brummett said AAHomecare expects HME Audit Key to be ready for a trial run, if not ready for use, by the end of 2014.

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“This bill will help fix the Medicare bidding program by making sure that bidders honor their bids and provide proof of licensure before bidding,” the association stated in a bulletin.

AAHomecare is still waiting for a bill number and text for the bill to be made public.

Industry stakeholders expected Reps. Pat Tiberi, R-Ohio, and John Larson, D-Conn., to lead a group of lawmakers in introducing the bill this week. The bill would require providers to obtain bid bonds as part of the competitive bidding program. If a provider receives and accepts a contract from CMS, the bond would turn into a performance bond. If a provider receives a contract offer but does not accept it and its bid is at or below the bid price, the government can collect on the bond.

The bill would also require providers to prove that they meet licensure requirements before they submit bids.

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If a provider receives and accepts a contract from CMS, the bid bond would turn into a performance bond. If a provider receives a contract offer but does not accept it and its bid is at or below the bid price, the government can collect on the bond, explains Cara Bachenheimer, senior vice president of government relations for Invacare.

“That’s the beauty of it,” she said. “We believe the bill will be at least budget neutral because of this possibility of collecting on the bonds.”

The bill would also require providers to prove that they meet licensure requirements before they submit bids. A similar provision was included in the Senate Finance Committee’s version of the “doc fix” bill earlier this year.

Because the process for obtaining a bid bond would be similar to a surety bond, it shouldn’t be much of a burden for providers. An added bonus: In addition to CMS, the surety bond company would perform a financial assessment, stakeholders say.

“It’s a two-fold checks and balance,” said Jay Witter, senior vice president of public policy at AAHomecare.

The bill signals a shift in strategy for the industry. While a bill that would replace the competitive bidding program with a market-pricing program (MPP) already includes a provision requiring binding binds, it also includes a number of other provisions, which may be weighing it down, stakeholders say.

“Out of the gargantuan MPP bill, everyone understands binding bids,” Bachenheimer said. “This is non-controversial.”

The industry’s goal is to get the bill passed, on its own or as part of a larger bill, before the next round of bidding is set to take place in 2015, stakeholders say.

“This is something that Tiberi has talked about with the chairs of the relevant committees,” Witter said. “He’s run all the traps on this.”

Stakeholders are also making ground on another bill, this one to reform the audit program. It was announced at AAHomecare’s Washington Legislative Conference in May that Rep. Renee Ellmers, R-N.C., planned to introduce such a bill. Since then, she has been fine-tuning language to make sure that, like with the bid bill, it has legs, stakeholders say.

“Every time you do something like this, you want to fix all the problems, but her goal is not to fix all 100 problems,” said Beth Bowen, executive director of the North Carolina Association for Medical Equipment Services, which will host Ellmers at its summer meeting on June 27. “She wants a bill with teeth but that will pass.”

The industry continues to build its case against both the audit and competitive bidding programs. Just last week at the Heartland Conference, The VGM Group released a study that shows Medicare saves money by investing in HME. For every $1 that Medicare spends on mobility equipment, for example, it saves $16.78 in treatment for avoided falls, according to the study, conducted by Brian Leitten of Leitten Consulting.

“You always hear the drum beat from CMS about all the savings,” said John Gallagher, vice president of government relations for VGM. “We need to be able to say, ‘No, you’re losing money.’ You’re gutting the very entity that’s saving you money.”

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