There is a popular song out that repeats the phrase, “Here
we go again.” For mobility providers, that could be a mantra.
Except this time, the challenges facing the industry are
unprecedented.
Without a doubt, competitive bidding is the most ominous
concern, particularly since the round one payment rates, announced
March 20, are drastically lower than expected. But coding issues,
accreditation, proposed supplier standards and the threat of
additional reimbursement cuts also have left some providers stumped
as to how to move forward — or even how to stay in
business.
Although the outcome of these issues has yet to be fully
determined, one thing is clear: Providers must tackle them all.
“The basic bottom line is how providers of mobility
products can set a model in our industry that can operate
profitably and at the same time service the needs of the clients,
because these two are at odds right now,” states Tom Whelan,
vice president of product management for seating products, Sunrise
Medical, Longmont, Colo.
“Every day, providers are faced with choosing between
giving the client what is the optimum solution that makes the best
use of assisted technology or giving them what makes it profitable
enough to stay in business.”
Whelan says that “bad coding” has set up a system
that does not reflect the variations of assistive technology.
“As a rehab supplier, your job is to make an optimum
relationship between the client's needs and the technical
solutions. You have to use the code set to describe that and submit
for billing, but the code set strictly is not robust enough to
handle it,” he says.
David Jones, director of The MED Group's National Rehab Network,
Lubbock, Texas, says competitive bidding and related consequences
are affecting providers, patients and manufacturers alike.
The issues he ticks off include patient, physician and clinician
education; gaining support for H.R. 2231 (which would carve complex
rehab out of competitive bidding); price compaction; provider
acquisitions; the power mobility device fee schedule; and
accreditation.
“This is obviously the tip of the iceberg as it relates to
the challenges our industry faces. However, I am optimistic that
the opportunities presented today as severe challenges will be
looked back on as a time when industry professionals collaborated
and made progressive and positive changes,” he says.
Jerry Keiderling, president of VGM Group's U.S. Rehab, Waterloo,
Iowa, notes that CMS' proposed supplier standards, published in the
Federal Register Jan. 25, are another new concern.
“There a few standards that for the most part are going to
lock some people out of doing rehab,” he says.
For example, as of April 1, CMS required that rehab equipment
come from a provider employing an Assistive Technology Supplier.
But a revision of existing standard No. 1 would require that
providers offering licensed services employ such personnel as W-2
employees, not 1099 in- dependent contractors.
“There are rehab providers that saw and heard from medical
directors and CMS that it was permissible to contract an [assistive
technology supplier]. Now, apparently under the new standard, you
can't.”
If this standard is finalized, Keiderling says, those providers
that “have their contracts in place [with an ATS] will not be
compliant.”
The myriad issues facing the industry create valid worries, says
Tom Rolick, vice president of business development for Permobil,
Lebanon, Tenn. “Our industry needs to move on. We need the
new rules and regulations to be clearly defined and implemented so
we can get back to the business of taking care of people who use
our products.”
COMPETITIVE BIDDING
The exact effect of competitive bidding is still unknown —
at press time, CMS had not released the names of round one bid
winners — but there had already been ramifications.
“While we will know the full impact later in 2008 …
national competitive bidding has greatly affected the rehab
provider community and how it continues to evolve,” says
Jones. “Many of the smaller rehab providers are no longer in
business, and while the reasons for pursuing other opportunities
vary, one thing is clear: The service delivery model is certain to
change dramatically with fewer independent providers involved.
“A clear understanding of how this will ultimately affect
the beneficiary has yet to be determined, and while there are
certainly many more ways competitive bidding is impacting the rehab
provider community, this is paramount,” he says.
Tim Pederson, ATS, CEO of WestMed Rehab in Rapid City, S.D.,
adds the inclusion of complex rehab in competitive bidding is a
huge source of anxiety.
“There is great consternation in the industry about moving
forward,” Pederson says. Even though CMS has included the
category in both rounds one and two, he says, “there is
really no sense in trying to bid complex rehab. That's like trying
to bid custom orthotics and prosthetics. You just can't do
it.”
In the process of formulating a bid, he explains, “if you
look at your lower-end services, your consumer power services for
instance, you can look at your population and apply some
statistical analysis of strokes, COPD, congestive heart failure and
osteoarthritis, and you can come up with a reasonable assumption of
what your marketplace will look like.
“For people who need complex rehab, that analysis goes out
the window because it's by chance.”
Pederson, who serves as chair of the American Association for
Homecare's Rehab and Assistive Technology Council, says the
industry's focus has been to educate legislators and policymakers
about complex rehab. But he cautions there is much more work to be
done. “I don't think that we are where we need to be yet, but
the fact that we have a carve-out bill in Congress right now is a
great step,” he says.
Permobil's Rolick is also optimistic. “One way or another,
we believe complex rehab will not be governed by the rules of
competitive bidding,” he says.
Yet, without knowing how the scenario will turn out, providers
everywhere need to be prepared, notes Keiderling. Regardless of
where providers operate, competitive bidding will affect them.
“It's going to affect everybody one way or the other, so
providers better pay attention to it and fight [against] it,”
he advises. “Even though it's not going to affect you today
in your area as [a round one or round two] MSA, you still know that
it's wrong, and you still have reasons why it shouldn't go
forward.”
Pederson agrees, noting the payment structure that results from
the bidding program will have a reach beyond the 80 MSAs that have
been selected for inclusion.
“I don't think anybody is going to be immune to the
effects because certainly, one of these days, [CMS is] going to
assemble that information and decide there needs to be a new
national fee schedule based upon the pricing that was achieved in
the competitive bidding areas, and a national pricing policy will
be established,” he says.
Documentation also continues to be a frustration for mobility
providers, and the industry is working to determine how to reduce
the high number of claim denials.
Power mobility device documentation in particular has become an
increasing challenge due in large part to a change in expectation,
says MED Group's Jones.
“CMS now requires a face-to-face evaluation with the
prescribing physician. The physician must document, per CMS
guidelines, specific chart note indicators as to medical necessity
for the patient requiring the PMD,” he explains.
“Herein lies the problem.
“While the face-to-face evaluation is not only a good
idea, it is necessary, but CMS has implemented these documentation
requirements without adequate education to the physician community
nor any negative impact on the physician if they don't meet the
requirements.
“In order to reduce the denial rate, the focus must be
placed on education, consistency and transparency.”
PREPARING FOR THE FUTURE
Experts agree that mobility providers must make changes to
remain viable.
Pederson advises providers to understand their costs fully and
determine their focus.
“We have to know our costs and how to reduce those
costs,” he says. “We have to choose the businesses that
we are most interested in being involved in and do them the best
that we possibly can. Providers can't be everything to everybody
anymore.”
Whelan says providers should be clear they have the most
efficient model in place and that they are providing services that
are profitable.
“Make sure you have stripped all of the cost out of the
system that you can and eliminate those services that are not
profitable,” he advises. “I understand everybody's
desire to do the right thing, to be good people and to consider the
needs of the people that use technology, but as long as we do not
involve them in the process and help them understand the
limitations, they are not going to participate in the
solution.”
According to Gary Gilberti, president of Baltimore-based
Chesapeake Rehab Equipment, “Our referral sources have to
understand that even though we are medical providers, we are also
businesses,” he says. “We just can't provide certain
products and we can't provide certain services and still remain
viable.”
U.S. Rehab's Keiderling says the approach to staying in business
is two-fold. For providers focused on Medicare business, he advises
learning as much about competitive bidding as possible. “You
must become educated on it so that you can work yourself through
that process,” he says.
On the other hand, HME companies that are looking to move away
from their dependency on Medicare reimbursement must focus on
marketing.
“If having Medicare or any of those product lines per se
is not an important part of your business, then kick up the
marketing on your retail operations, including both cash sales and
private insurance,” he recommends. “Keep those clients
and that type of business and seek more of it.”
Will it get worse before it gets better? That's likely, mobility
stakeholders believe, but most are hopeful.
“We are at that crux where the whole system — every
part of the system — is under stress. And it will be until we
fix all of it and create the right service delivery model and the
right manufacturing model,” says Whelan. “But by
educating and influencing legislators and the public through
marketing and public relations efforts, we can change the direction
this is going.”
Manual Wheelchair Coding Still in the Works
The SADMERC continues to work toward creating new manual
wheelchair codes to keep up with new technology. In October, Dr.
Doran Edwards, the SADMERC's medical director, announced
consideration of two options:
Establishing 10 “builder” codes that would allow a
variety of options so a manual wheelchair could be customized for a
patient's weight and health requirements; or
Creating 40 codes in 10 weight categories to cover a spectrum of
needs.
With the builder code, a provider would start with a basic
frame, seat back and wheels. Everything else would need to be
added. However, Edwards said, that could “make it possible
for you to make a chair more individualized.”
The weight-type coding would include more features, but there
could be a major drawback. “By doing that, we have
handicapped people who need one thing more and we've overpaid for
those who need less,” Edwards said.
It's quite a challenge to decide which type of code serves both
the needs of the patients and the industry, Edwards said.
“We're trying to create a coding platform that still allows
for the sophisticated products. So do we follow the model of the
[power mobility devices] and slice the pie as thinly as you can
slice it?” he asked, referring to the revised PMD codes that
swelled to a total of 78.
That might be too confusing, he said, “so maybe the
builder chair would be easier to deal with.”
Edwards said various entities have weighed in on the issue,
including manufacturers, clinicians, consultants and professional
organizations such as the Rehabilitation Engineering and Assistive
Technology Society of North America.
The medical director also said the SADMERC is looking into
coding for pediatric chairs. As many as a dozen codes could be
added in that category, he said.
To date, no decisions have been released, and it appears it
could be 2009 before the new codes are implemented.
“The industry has been very supportive and has provided
significant, broad-based input with regard to the technical
differences in the various manual wheelchair types,” a CMS
spokesperson told HomeCareXTRA earlier this year.
“The SADMERC is gathering the comments for inclusion in any
future deliberations.”
Whatever the SADMERC finally decides, things will not be the
same. Coding changes will lead to reimbursement changes. Codes for
various options and accessories would also be revised.
But one thing will not change, Edwards said. “We still
want to provide the full technology to the patient.”
