Bachenheimer Outlines DME Provisions in House Draft

ATLANTA—With Congress in the midst of debate on massive
House and Senate packages to reform the nation’s health care
system, lately it’s been hard to keep up with the legislative
proposals flying across Capitol Hill.
 
While the Senate HELP (Health, Education Labor and Pensions)
Committee unveiled its plan for government-sponsored insurance and
an employer mandate last week, that legislation must be combined
with any Medicare provisions fashioned by the Senate Finance
Committee, which is still honing its bill.
 
Meanwhile, in late June, the chairmen of three House committees
working on health reform released a “discussion draft”
for the system overhaul that, among other measures affecting
Medicare providers, would eliminate the first-month purchase option
for power wheelchairs (see “Democrats’ Reform Plan Hits
PWC Purchase Option”).
 
The Democratic committee leaders—from Ways and Means, Energy
and Commerce and Education and Labor—say their proposal in
its totality would control costs, improve choices for consumers and
expand access to affordable health care for all
Americans. 
 
For help in wading through the text of the 852-page document,
Invacare Corp.’s Cara Bachenheimer, senior vice president of
government relations, offers this summary of DME provisions in
the House draft.
 
—With respect to DME, the package contains a provision that
would eliminate the purchase option for power-driven wheelchairs.
The effective date would be Jan. 1, 2011; that is, if enacted into
law as drafted, the provision would apply to power wheelchairs
furnished on or after Jan. 1, 2011.
 
—There are no provisions in the draft to cut or modify
payment to the Medicare home oxygen benefit. (One caveat,
Bachenheimer noted, “is that some House staff have indicated
additional provider payment cuts may be included after the
Congressional Budget Office provides its cost estimate on the
entire package. Further, it is expected that the Senate Finance
Committee package will include payment cuts to the home oxygen
benefit.”)

 —The draft bill contains a number of anti-fraud and
abuse provisions that could impact the provision of DME. It would
require physicians to provide documentation on referrals to
programs with a high risk of waste, fraud and abuse including DME
and home health agencies. The package would also give HHS the
authority to disenroll physicians and suppliers who do not maintain
and, on request, provide documentation related to written orders
and requests for payment for DME and home health services. In
addition, only Medicare participating physicians could order DME or
home health services paid for by Medicare.
 
—The draft bill would require providers to adopt compliance
programs as a condition for participating in Medicare and Medicaid;
would require a face-to-face exam before physicians could certify
eligibility for Medicare home health services; and would require
Medicare and Medicaid integrity contractors that carry out audits
and payment review to provide annual reports and conduct regular
evaluations of effectiveness.
 
—In addition, the House bill would increase HHS’
authority in program areas determined to pose a significant risk of
fraudulent activity. This would include screening (such as
background checks, unannounced site visits, screening against
excluded individual and provider lists, etc.); an enhanced
oversight period (30 days to one year—oversight includes site
visits, prepayment review, enhanced review of claims, etc.); and an
enrollment moratorium on new applicants if HHS determines that
access would not be adversely impacted.
 
—The bill would create penalties for offenses including
knowingly making a false statement or misrepresentation on an
enrollment application; knowingly submitting false claims data;
delaying Office of Inspector General audits, evaluations and
investigations; and obstructing program audits.
 
—The bill would narrow the window for submitting Medicare
claims for payment from three years to one year and would create a
national pre-enrollment screening program to determine whether
potential providers or suppliers have been excluded from other
federal or state programs or have a revoked license in any state.
The bill would also create a comprehensive “Medicare and
Medicaid Provider/Supplier Data Bank” to enable oversight of
suspect utilization and prescribing patterns and complex business
arrangements that may conceal fraudulent activity.
 
—Additional language in the draft would cut Medicare payments
in the home health, skilled nursing, long-term care hospital,
inpatient rehabilitation, psychiatric hospital, hospice, dialysis
and outpatient hospital sectors.
 
But remember, Bachenheimer said, that things could change. Since
their return from the July 4 recess, the three House committees
have begun revision of their plan and continue to work toward a
floor vote by August. A new draft of the tri-committee bill could
come at any time. Likewise, Bachenheimer said she expects a summary
of the Senate Finance Committee bill soon, and warns it also will
likely include elimination of the first-month purchase option for
PWCs. 
 
And, she reminded, “As with all bills, the House and Senate
must ultimately pass the identical package before it can be signed
into law by the President.”