In mid-December, CMS made announcements on several hot-button issues that home medical equipment providers had been waiting for all year.
On Dec. 15, instead of the final coverage criteria that was expected, the agency announced it was opening a National Coverage Determination as part of its three-pronged wheelchair coverage, coding and pricing review. The purpose of the NCD process, which allows CMS six months to post a draft coverage decision, is to get more input from interested parties (that means you and your patients) on recommendations from the Interagency Wheelchair Work Group. Formed by CMS earlier in 2004, the group had been working on new coverage policy guidance since June.
While the NCD may mean a short-term continuation of Medicare's strict claims handling for powered mobility equipment, in effect since discovery of massive fraud and abuse of the program benefit in 2003, the Work Group's proposals are considered generally favorable. As stated by CMS, its wheelchair initiative is intended “to make sure patients get the care and equipment they need and providers are properly paid while curbing abuse.”
On Dec. 16, CMS announced that it would also hold off on releasing 2005 fees for home oxygen, which had originally been expected in November. In this case, the agency explained, the delay will allow time for more data from the Office of Inspector General to be analyzed comparing FEHBP pricing to Medicare pricing for oxygen. As set out by the Medicare Modernization Act, the new rates must be based on the percentage difference of such a comparison.
This decision, too, may cause some painful short-term effects. For starters, CMS intends to hold oxygen claims until at least Jan. 15 when the new data from OIG is to arrive. But a more detailed analysis should ultimately lead to more accurate oxygen payments — hopefully less severe than the 10 to 20 percent cuts OIG had recommended — and that's a positive step.
Lastly, on Dec. 17 Medicare released its Part B drug pricing schedule for the first quarter of 2005, finalizing the reimbursement cuts for respiratory medications that also were mandated under MMA. Although the cuts are deep, in November CMS responded to strong provider protest with the addition of service fees to offset the costs of providing the drugs.
All three of these announcements herald the dramatic changes this industry will experience over the next few years as a result of MMA, changes that have been called the beginning of “a new Medicare era.” And it seems they may also signal a new relationship between the industry and CMS.
Were these year-end decisions from the agency a little late? Yes. Are they exactly what you might want? No. Do the delays in wheelchair coverage criteria and oxygen reimbursement make it difficult to plan for your business and to serve customers in the best manner? Definitely. But taken in whole, these announcements and the events leading to them point out that, for the first time in a long time, CMS is listening. And for a long time, that is exactly what this industry has asked.
From all of us at HomeCare, best wishes for a happy and prosperous New Year.
