As has been the case in recent years, the awareness of
sleep-disordered breathing and the health problems it causes
continues to rise. The identification of symptoms and risks are
highlighted continually in both the mainstream media and through
personal and clinical blogs. Likewise, primary care physicians are
increasingly becoming more attuned to the needs of their at-risk
patients.
Finding
So it would appear safe to say the market is growing. But with
growth comes change.
"It is pretty much a unanimous agreement that the sleep market
is changing. There are a lot of forces at play that all of the
parties — from vendors to HME providers to physicians —
are wide awake about, and [they are] thinking seriously about what
it means to them and the roles they play in the diagnostic and
treatment pathway," says Maura Weis, Philips Respironics' director
of sleep marketing for North America. "Sometimes these challenges
create new and better ways of providing positive care.
"There is growth, for sure," Weis says, "but it is a matter of
how to obtain the growth in a profitable way while maintaining the
appropriate level of care. What this calls for is for the different
entities to look at things with a different mind and, ideally, look
at each other as to how to work together to maintain the growth and
make it profitable while maintaining the high level of care that
patients deserve."
Citing the nation's obesity epidemic and an increased level of
acceptance by patients to get tested, Bob Hoffman, director of VGM
Group's Nationwide Respiratory division, agrees that the
opportunity for growth still exists. "Most individuals know
somebody who is on a CPAP and have heard firsthand the benefits it
can offer," he says.
But he does note that the country's economic slowdown has hurt.
"With higher deductibles now commonplace, getting the sleep test is
oftentimes something that can easily be put off from the patient's
perspective," he says.
Weis expands on his point. "Another issue is patient coverage
plans and the changes in some of the deductible models. This is
influencing the patient's perspective on what they want to do for
themselves related to recognizing the sleep issue and moving into a
treatment plan," she says.
The effects of the recently announced rates under Round 1 of the
DMEPOS competitive bidding program, with the average cut for CPAP,
RADs and related supplies at 34 percent, also will certainly affect
the sleep market and its providers.
"In terms of the competitive bidding rates that we just learned
about — wow. What a shocker to us all. People are even
questioning the accuracy of it all and saying that there has to be
some bad math here," says Weis. "The results are what they are, and
they are pretty alarming. Obviously, we are still waiting to see
what the next steps are and what contracts will be secured."
She also points to the likely trickle-down effect from other
payers once the bid program is implemented (January 2011).
Kristin Mastin, director of marketing for DeVilbiss Healthcare,
had a similar reaction to the Round 1 rates.
"With average CPAP fees dwindling by another 34 percent under
competitive bidding, it's clear that our industry remains under
attack," she says.
Compliance = Success
Following diagnosis and a treatment prescription, clinical
success for the patient and economic success for providers are
completely dependent on compliance.
"Compliance is key," stresses provider Todd Cressler of
Pennsylvania-based CressCare Medical. Calling it one of his
company's key metrics, he says, "We promote and encourage our staff
to come up with programs and ideas that positively affect
compliance."
Even with a dedicated focus, however, compliance can still be a
hurdle. For Cressler, that means about 12 percent of set-ups result
in pick-ups due to lack of compliance. Of those, Cressler says, a
quarter are attributable to insurance medical policy, while the
remainder are patients who, despite all best efforts, simply are
not CPAP-compliant.
"Keeping the patient compliant and documenting that compliance
continues to be the biggest challenge," agrees Hoffman. "Some
initial compliance issues will never go away, such as congestion,
claustrophobia and pressure sores. The good news is that with the
improved CPAP systems and a variety of interfaces available, these
obstacles can be overcome with the proper initial education and
follow-up."
For some, however, compliance documentation has become the
bigger issue, especially since CMS issued new coverage
mandates.
"Compliance has always been what this industry has worked for
and, now, with the requirements coming out, starting with CMS and,
certainly, moving into the private payer models as well, there is
more of a need to focus on it because it will now determine if and
when you get paid," says Weis.
Hoffman notes that documentation takes "technician time, added
provider expense and patient and physician cooperation to ensure
all the guidelines for continued reimbursement are met."
Mastin also acknowledges the difficulty. "It's clear providers
are facing some challenges with obtaining this information as
evidenced from the recent Jurisdiction C audit that indicated that
23 percent of claims did not include objective proof of adherence
to therapy in the patient's file, and 14 percent of claims did not
meet the CMS requirements for adherence," she explains.
Although improvements in PAP devices have made the therapy more
comfortable, which positively impacts initial compliance, Weis
points to the ongoing challenge in keeping patients compliant.
"A bigger impact is how providers are able to work with their
patients to keep them compliant," she says. "When [providers] can
get access to data quickly, such as through a modem, they are in a
much better role to take action and work with that patient to get
them compliant."
Supply Replacement Programs: Not Optional
"Whether a provider sets up five or 500 new patients a month, a
functional and efficient supply replacement program is a must,"
says Hoffman, noting that such programs can help with both patient
compliance and profitability.
"Routinely replaced equipment will help ensure proper fit and
compliance. The revenue generated from the reoccurring mask sales
is essential to keeping providers not only profitable but, in some
instances, keeping them in business."
Weis recommends a holistic approach that includes focusing on
set-up and re-supply.
"Keep in touch with patients who are compliant and stay engaged
with them in an efficient way so you can continue to provide them
with supplies. The return on that type of model is very easy to
measure," she says.
Both Hoffman and Weis acknowledge that supply fulfillment
programs can be challenging in themselves.
"The good news is that there are resources that can fulfill
those different parts. Providers have the option to decide what
they are going to do in-house and what they are going to outsource.
The return can be strong either way," says Weis.
Because of the active nature of the typical CPAP user, the
success rate of contacting them during normal business hours for
supply replenishment is poor, so outsourcing the function can be a
necessity, Hoffman believes.
Mastin advises providers to proceed cautiously and explore all
options that are available, as the outsourcing solution is an
extension of their company.
"Service levels are critically important to retain customers,"
she says.
Enhance Referrals, Move Forward
A comprehensive and organized compliance program is imperative
both for patient success and for business growth, according to
Hoffman. "It demonstrates to your referral sources that you are the
provider of choice, and it opens up an ongoing cash flow
opportunity for your business," he says.
Cressler notes it is important to understand referral sources
and help them understand your business.
"The most successful HME providers listen to what their
referrals want and give it to them," adds Mastin. "Physicians
really want to work with a provider that will take good care of
their patients."
Strong, clinical care is essential.
"Given all the dynamics of the market, let's all stay focused on
great care. That is what is going to drive referrals and drive
business," says Weis. She also encourages providers not to be
shortsighted as they navigate the changes ahead.
"We are going through some changes and we all want to get
through this together. Let's be open-minded to new models and new
technologies and work with each other to make them both effective
for patient care as well as cost-efficient," she says.
Adds Cressler: Know what you do and do it well.
"Stop doing some things just to do them. Get the right people on
the bus and get them in the right positions," he advises. "Keep
changing. If you are not changing, you are moving backward."
'Lessons Learned' from E0601 Claims
A recent review of claims for CPAPs in Jurisdiction C
"showed that suppliers are not following published Medicare
guidelines and policies in submitting claims for necessary and
reasonable HCPCS code E0601 services," according to
Cigna.
The review included 100 randomly selected claims paid between
Oct. 1 and Dec. 31, 2009, and submitted by 96 different providers.
An analysis showed these "lessons learned," the DME MAC said:
- Seven claims had no written order in the file.
- On 17 claims, the order did not list all separately billed
items. - The order on 69 claims did not have refill/replacement
instructions. - Length of need was not on the order for 12 claims.
- No medical records were submitted for six claims.
- The file for 19 claims did not include a face-to-face clinical
evaluation conducted by the treating physician prior to the sleep
test. - No sleep test was provided for 10 claims.
- The file for 26 claims did not include a clinical re-evaluation
conducted by the treating physician between the 31st and 91st day
after initiating therapy. - On 23 claims, the file did not include proof of adherence to
therapy. - The adherence report on 14 claims did not verify use of the
device four hours per night on 70 percent of nights in a 30-day
period.
Experts Interviewed
- Todd Cressler, owner, CressCare Medical,
Harrisurg, Pa. - Bob Hoffman, director, Nationwide Respiratory,
a division of VGM Group, Waterloo, Iowa - Kristin Mastin, director of marketing,
DeVilbiss Healthcare, Somerset, Pa. - Maura Weis, director, sleep marketing, North
America, Philips Respironics, Murrysville, Pa.
