GAMES February 11, 2015
Washington Update
CARA BACHENHEIMER, INVACARE CORPORATION
1
On Capitol Hill

President’s Budget Proposal Feb 2, 2015
 Medicaid
rates based on bid rates $4.3B
 Face-to-face fix?


Doc fix/SGR expires March 31, 2015
Binding Bids Bills

H.R. 284 & S. 148 (last year’s HR 4920 & S. 2975)
Reps. Tiberi (R-OH) and Larson (D-CT)
 Sens. Portman (R-OH) and Cardin (D-MD)
 Would require bidders to secure a bid bond prior to
submitting bid
 Financial vetting!


Other Bid Program Fixes In the Works
Market Pricing Program Demo
 Transparency & due process issues

2
NCB Schedule

Round 1 Re-Compete
9
MSAs
 January

Round 2
 91
MSAs = 106 CBAs
 July

1, 2014 – December 31, 2016
1, 2013- June 30, 2016
Round 2 Re-Compete
 July
1, 2016 – December 31, 2018
 Contracts

will be 2.5 years, not 3 years
Non-Bid Areas – January 1, 2016
 Fee
schedule rates will be reduced
3
Round 2 Recompete Schedule
4

Dec 18, 2014 – Registration began

Jan 22, 2015 – 63-day bid window opened

Feb 17, 2015 – Registration closes

Feb 23, 2015 – Covered document review date for bidders to
submit financial documents

March 25, 2015 – Bid window closes

July 1, 2016 – Dec 31, 2019


Contract periods will be 2.5 years, not 3 years
Same Geographic Areas, but

90 MSAs due to OMB changes

No bid area will cross state lines→ 117 bid areas

NMO Diabetic supplies to cover all territories
Product Categories
5
Round 1 Recompete
Round 2
Round 2 Recompete
Respiratory (oxygen, CPAP,
RADS, nebulizers)
Oxygen
Respiratory (oxygen, CPAP,
RADs)
Standard Mobility (walkers,
standard power and
manual, scooters &
accessories)
Standard wheelchairs
(power & manual), scooters
& accessories
Standard Mobility (walkers,
standard power and
manual, scooters &
accessories)
General HME (beds, Groups Beds and accessories
1 and 2 support surfaces,
TENS, commode chairs,
patient lifts, seat lifts)
General HME (beds, Groups
1 and 2 support surfaces,
commode chairs, patient
lifts, seat lifts)
Enteral
Enteral
Enteral
NPWT
NPWT
NPWT
External Infusion Pumps
Support surfaces – Group 2
TENS
CPAP & RADs
Walkers
Nebulizers
CMS Rulemaking Process
1.
2.
Application of Bid Rate Information in
Non-Bid Areas, and
Changes to Bid Program
 February
26, 2014
 Advance
 July
Notice of Proposed Rule
11, 2014
 Proposed
 November
 Final
Rule
6, 2014
Rule
 January
1, 2015
 Effective
Date of New Rules
6
Non-Bid Areas – January 1, 2016
7
Rule establishes methodology CMS will use
to reduce rates in non-bid areas, based
upon current Round 1 and Round 2 bid
rates
 CMS divides country into 8 regions
 Establish Regional SPAs = average of
current Round 1 and Round 2 bid areas
SPAs in that region
 National ceiling and floor to constrain
RSPAs
 Ceiling will be 110% and floor will be 90%
of average of (state) weighted RSPAs

Non-Bid Areas – January 1, 2016
8
Non-Bid Areas – January 1, 2016
9

Phase-In of new RSPA rates

January 1, 2016: rates will be blend of 50%
of “old” rate and 50% new RSPA

Starting July 1, 2016: 100% RSPAs

“Rural” areas paid at national ceiling of
110%
Non-Bid Areas – January 1, 2016
10

“Rural” = a geographic area
represented by a zip code if at least 50%
of the total geographic area of the area
included in the zip code is estimated to
be outside any MSA. A rural area also
includes a geographic area represented
by a zip code that is a low population
density area excluded from a CBA

CMS has not yet identified these areas
by zip code, but expect very few
RSPAs January 1, 2016 & July 1, 2016
Code
Current
E1390
1-1-16
178.24
7-1 -16
2016
Ceiling
11
R1 NE
R2 ME
R3 GL
R4 PL
R5 SE
R6 SW
R7 RM
R8 FW
139.63
134.21
134.48
136.63
136.57
136.40
134.88
134.72
103.38
101.02
90.18
90.71
95.02
94.89
94.56
91.52
91.20
E1392
51.63
46.90
43.10
42.38
41.74
43.40
41.91
41.83
44.02
43.41
E0260
132.39
78.33
75.64
68.77
69.27
73.68
70.81
69.44
70.20
70.57
K0738
51.63
46.90
43.10
42.38
41.74
43.40
41.91
41.83
44.02
43.41
K0001
58.25
29.20
26.80
24.88
25.37
26.28
27.76
26.46
26.80
26.68
K0823
568.89
315.13
279.55
276.66
280.73
282.36
299.65
280.98
288.92
288.94
K0003
97.98
45.03
40.78
37.89
39.58
40.73
42.86
40.06
41.38
42.39
(Bed)
Non-Bid Areas – January 1, 2016



12
Payment for “low volume” and items in no
more than 10 CBAs paid at 110% of RSPAs
Items where only available SPA is from a
CBP no longer in effect, paid at 110% of
previous SPAs
Accessories included in one or more PCs,
paid at weighted average of the SPAs for
the item in each bid area
 Accessories
used with CRT will no longer be
paid at higher fee schedule!

“Unbalanced Bidding”

Lower SPAs of “lower” item to SPA of “higher”
item (e.g., Group 1 vs Group 2 PMDs)
Bundling Phase-In
13

Phase-in of new bundling payment method

In place of current capped rental and
purchase payment rules

First phase: up to 12 new bid areas


80 possible MSAs, population of at least 250,000

Next phase: via rulemaking!
Starting with power wheelchairs and CPAP

Proposed Manual WC, beds, oxygen, enteral,
RADs too
Bundling Phase-In

14
Payment will be on continuous monthly
rental basis

No ownership transfer

Bids and SPA will be for monthly rental of
equipment, maintenance and servicing,
replacement of supplies and accessories
New Bundling Payment Method
15

Phased-In – starts in up to 12 NEW bid areas

Many Questions! (e.g., When?)

How many items will be bundled together?
 Could
be one bundled code for all standard
base power chairs, accessories, batteries,
etc.
 Could
keep base codes separate, and
bundle in for each base everything else

CMS will provide “advance notice” of details
NCB New Rules

Phase-In of New Repair Rule
 In
16
up to 12 (new) CBAs, under current rental
rules, bidders will factor into bids costs of repair
and maintenance services after ownership
transfers, until medical need ends, 5 years, or
beneficiary moves outside CBA - during
contract period
 Limited
to items you originally furnished
 Not
responsible for repairing items someone
else provided
 Doesn’t
address most of the problem
Audits – Air Act

Audit Improvement and Reform Act (AIR)
17
 H.R.
5083 introduced by Representatives Renee
Ellmers (R-NC) and John Barrow (D-GA) on
7/11/14
 Designed to increase transparency, education
and outreach and reward DMEPOS providers with
low error rates on audited claims
 Will apply to all MACs, RACs and other
contractors performing audits on DMEPOS
providers

www.FixMedicareAudits.org
 Copy
of legislation, issue brief and how to support
the bill
Audits – Air Act
18

Restore clinical inference and judgment when evaluating audits.
Will significantly reduce error rates

Require reporting of error rates on audited claims after
adjustment for those audited claims that have been overturned
on appeal

Require audit contractors to establish an education and outreach
program to help providers better understand the regulations and
how to document medical necessity for Medicare patients.
Funding for these programs will come from 25% of recoupments

Allow HHS to ensure that all suppliers are audited at least once
every two years and those with low error rates can be excused
from some or all audits during that two year period. DMEPOS
suppliers with a 15% or below audited clams error rate will be
subject to only 1 claim audit a year
Audits – Air Act
19
 Require
Medicare Contractor transparency
and reporting
 Limit
documentation review periods to 3
years for all Medicare audits
 For
reoccurring claims, the Secretary shall
toll the timely claim filing limits so DMEPOS
suppliers are not prohibited from taking an
audited claim through the entire appeals
process on the basis that the timely claim
filing limits have expired
PMD Prior Authorization Demo

20
Current program began September 1, 2012
3
year program – Ends August 31, 2015
 Began
TX)

in 7 states (CA, FL, IL, MI, NC, NY,
47% of PMD claims
 Monthly
expenditure decrease of $20M to
$9M in non-demo states, vs $12M to $4M
in demo states
 Oct
1, 2014, 12 more states: AZ, GA, IN,
KY, LA, MD, MO, NJ, OH, PA, TN, WA
PMD Prior Authorization Demo

“Reduce improper payments for PMDs”


Process to allow suppliers to know if Medicare
coverage criteria are met for the PMD before
delivery


Reduce the “pay and chase” method
Review of beneficiary’s medical condition and
documentation to determine if existing coverage
guidelines are met
http://www.cms.gov/Research-Statistics-Dataand-Systems/Monitoring-Programs/MedicareFFS-Compliance-Programs/MedicalReview/PADemo.html
21
PMD Prior Authorization Demo
22

All power operated vehicles (K0800–K0802;
K0812)

All standard power wheelchairs (K0813–K0829)

All Group II complex rehab power wheelchairs
(K0835–K0843)

All Group III complex rehab power wheelchairs
without power options (K0848–K0855)

Group III complex rehab chairs with power options
(K0856–K0864) are excluded

All pediatric power wheelchairs (K0890–K0891)

Miscellaneous power wheelchairs (K0898)
PMD Prior Authorization Demo

23
PA is required for all power wheelchairs
 Non-compliance
results in 25% payment
reduction and automatic pre-payment review
 PA
is not required for claims submitted with GA,
GY or EY modifiers (not medically necessary or
non-covered)

Required documentation
 F2F
examination
 Seven-element
order
 Detailed
product description
 Relevant
and necessary clinical information
PMD Prior Authorization Demo

Medical Review reviews and issues decision

Affirmative decision


(14-digit unique tracking number – UTN)

Non-affirmative decision

Rejection

Decisions are sent to the supplier, patient and physician
Initial requests


24
Post mark notification within 10 business days from initial
request
Resubmitted requests

Post mark notification within 20 business days from
request

No limit on number of resubmissions
Face-to-Face Exam for DME






25
Final rule in November 16, 2012 Federal Register.
Requires a physician or other practitioner “face-toface” exam prior to ordering certain DME.
Originally effective for new orders July 1, 2013

CMS delayed enforcement until October 1, 2013

Delayed again until sometime in 2014 (09/09/13)

WOPD requirement enforced beginning on January 1,
2014
Doctor, PA, NP, or CNS – LEGISLATIVE CHANGE?
Doctor must document and communicate to the
DME supplier that the Doctor, PA, NP or CNS did a
F2F.
F2F must occur within 6 months prior to the order.
Face-to-Face Exam for DME
26

F2F must include a needs assessment, evaluation
and/or treat the beneficiary for the medical
condition that supports the need for the DME
ordered

F2F must be documented in the medical record

CMS “discourages” the use of templates

Physician must sign

Or co-sign the medical record when done by a NP,
PA, or CNS

A signed order does not satisfy this requirement

Other signature requirements (legibility) apply
Face-to-Face for DME
27
 For
items that do not require a written order
prior to delivery, suppliers are allowed to
dispense DME to the beneficiary based upon
a verbal order
BUT
the supplier must have the written
order before submitting claim
 For
items that do require written order prior to
delivery, supplier must have the written order,
with face-to-face documentation, prior to
delivery and when submitting claim
Face-to-Face for DME
28
 Supplier
must maintain the written order and
supporting documentation and make
available to CMS upon request for 7 years
 Beneficiaries
discharged from the hospital
do not require a separate F2F encounter, as
long as the physician or treating practitioner
who performed the F2F in the hospital issues
the DME order within 6 months after the date
of discharge
Face-to-Face for DME
 Minimum
elements for the order:
 Beneficiary's
 Item
name
of DME ordered
 Prescribing
 Signature
 The
29
practitioner NPI
of the prescribing practitioner
date of the order
 Removed
beneficiary diagnosis and usage
instructions
Face-to-Face for DME
E0185
E0188
E0189
E0194
E0197
E0198
E0199
E0250
E0251
E0255
E0256
E0260
E0261
E0265
E0266
E0290
E0291
E0292
E0293
E0294
E0295
E0296
E0297
E0300
E0301
E0302
E0303
E0304
E0424
E0431
E0433
E0434
E0439
E0441
E0442
E0443
E0444
E0450
E0457
E0459
E0460
E0461
E0462
E0463
E0464
E0470
E0471
E0472
E0480
E0482
E0483
E0484
E0570
E0575
E0580
E0585
E0601
E0607
E0627
E0628
E0629
E0636
E0650
E0651
E0652
E0655
E0656
E0657
E0660
E0665
E0666
E0667
E0668
E0669
E0671
E0672
E0673
E0675
E0692
E0693
E0694
E0720
E0730
E0731
E0740
E0744
E0745
E0747
E0748
E0749
E0760
E0762
E0764
E0765
E0782
E0783
E0784
E0786
E0840
E0849
E0850
E0855
E0856
E0958
E0959
E0960
E0961
E0966
E0967
E0968
30
E0969
E0971
E0973
E0974
E0978
E0980
E0981
E0982
E0983
E0984
E0985
E0986
E0990
E0992
E0994
E0995
E1002
E1003
E1004
E1005
E1006
E1007
E1008
E1010
E1014
E1015
E1020
E1028
E1029
E1030
E1031
E1035
E1036
E1037
E1038
E1039
E1161
E1227
E1228
E1232
E1233
E1234
E1235
E1236
E1237
E1238
E1296
E1297
E1298
E1310
E2502
E2506
E2508
E2510
E2227
K0001
K0002
K0003
K0004
K0005
K0006
K0007
K0009
K0606
K0730
Resources & Information
31
dmecompetitivebid.com
Invacare’s Washington Updates &
Policy & Funding Sections on the Web
www.invacare.com
(click on Invacare Homecare)
[email protected]
32
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