Maine Providers Win One, Others Continue Medicaid Battles

AUGUSTA, Maine — As home medical equipment providers
across the nation battle with Medicaid officials to hang on to
their reimbursements, Maine providers scored a bit of a triumph
Wednesday.

Providers managed to sidestep Gov. John Baldacci’s proposal for
a 10 percent across-the-board Medicaid cut when the Maine Health
and Human Services committee refused to go along with the idea. The
cut would have been on top of a $700,000 reimbursement drop for the
state’s HME providers that went into effect Oct. 5.

“Now they were looking at $1.3 million more,” said Karyn
Estrella, executive director of the New England Medical Equipment
Dealers association. NEMED heard about the proposed cut just last
week and quickly alerted its members, she said.

“Our members did a great job. They had their staffs calling and
emailing,” Estrella said. Beleaguered providers told legislators
they couldn’t take any more cuts and would have to cancel their
contracts with Medicaid.

Estrella said that in Wednesday testimony, HHS committee members
said they had been hearing from providers and were concerned about
beneficiaries’ lack of access to HME. They did not recommend the
cut to the powerful state appropriations committee.

“We got a little win today,” Estrella said.

Still, assaults continue on other fronts in NEMED territory. In
Massachusetts, Estrella said, providers are fighting a proposed
$2.3 million cut for HME that was to take effect Jan. 1.

“We were able to get a delay, but as it stands now, they are
still mandated to make that cut,” said Estrella, who added that she
and others from NEMED would meet Monday with members of the state
legislature to talk about the issue.

Estrella said the state plans to close four health care
institutions over the next four years, which would put people back
in their homes, into group homes or some other setting. The
legislature does not understand that the home medical equipment
sector needs to be intact to serve those people, she said.

“They are just not connecting the dots. You can’t expand that
type of care while you are simultaneously cutting the industry that
can help you make that happen,” Estrella said.

In Rhode Island, the state is attempting to reduce the Medicaid
provider pool to one provider for each of three DMEPOS categories.
NEMED’s letters to state officials objecting to the plan went
unanswered, Estrella said. The request for bids was issued in
August, and the bid window closed Dec. 3. While the state Medicaid
agency has said it received bids, “we don’t know if they were
qualifying bids. We’re in a holding pattern right now,” Estrella
said.

All in all, said Estrella, the states’ Medicaid issues have been
plentiful to the point of being overwhelming. “Since June, we have
been on this incredible ride with reimbursement issues in four
states,” she said, adding to the list New Hampshire, which now has
a single manufacturer providing incontinence supplies to its
Medicaid patients.

“Our members are battle-weary at this point. There have been so
many years without any letup, and they are trying to run their
companies at the same time. It’s really hard.”

HME providers in other states are also finding themselves on the
front lines of reimbursement combat with Medicaid.

• Florida — When it comes to state issues
  with HME, Florida providers have gotten hammered recently as major
  insurers consolidated their networks, dropping hundreds of HME
  providers, and state officials were jumping on the consolidation
  bandwagon in hopes of hacking millions off their Medicaid
  budget.

  Even as Florida providers are fighting the state’s plan to
  consolidate incontinent and diabetic supplies, thus eliminating
  hundreds more providers from servicing those patients, they have
  been hit with yet another salvo. Florida’s Agency for Health Care
  Administration, which administers the state’s Medicaid program, has
  alerted providers that they must refund any overpayments within 35
  days of receiving a final overpayment notice or they will be
  terminated from the program.

  Such terminations cannot be appealed. AHCA also is withholding
  all Medicaid reimbursement beginning 30 days following notice of
  overpayment, according to the Florida Alliance for Home Care
  Services. An exception is made for providers who have made full
  repayment or come to an agreement with the agency.

  There is some good news coming out of Florida, according to
  FAHCS. A Florida father has won a lawsuit seeking incontinent
  supplies through Medicaid for his severely disabled daughter, who
  had been stuck on a waiting list with 17,000 others. The win
  signals changes for the current Medicaid program in Florida. AHCA
  must now pay for all incontinent supplies, including those for the
  17,000 on the waiting list. FAHCS officials say the ruling could
  expand to other categories of Medicaid.

• Georgia — Providers in Georgia are
  waiting on tenterhooks as the state’s Department of Community
  Health is slated to begin reprocessing and recoupment for all
  DMEPOS claims for July and August 2009 because of new Medicaid
  codes and fees — set at 80 percent of 2007 Medicare rates.
  The new fee schedule became effective July 1 last year but was not
  implemented until September, so claims during the two-month period
  were paid at previous rates “and now they’re going to recoup the
  money,” explained Ed Cockman, RPh, co-owner of Family Health Care
  in Valdosta, Ga. As an example, Cockman said, for an E1390 oxygen
  claim the difference in reimbursement Georgia Medicaid wants back
  amounts to about $45.

  The reprocessing, which members of the Georgia Association of
  Medical Equipment Services believe could number thousands of claims
  — takes place today through Feb. 12. Providers whose claims
  are denied after the reprocessing must correct and resubmit their
  claims within 90 days of the denial. Claims resubmitted after the
  90-day limit are subject to further denial and are not eligible for
  reprocessing.

  “Doctors are dropping out of Georgia Medicaid like crazy,” said
  Cockman, “and if there are any further problems, you will see [HME]
  providers getting out of the program, too.”

• Missouri — Providers in Missouri are
  trying to blunt the force of an expected Medicaid cut that could
  slice as much as $5 million from the state’s reimbursement for HME
  this year. The state has asked the HME sector for its input on what
  to cut, and members of the Midwest Association for Medical
  Equipment Services said they are trying to save reimbursement on
  such narrow-margin items as complex rehab by exploring options that
  include going to a single-source provider for adult and pediatric
  nutritonals. They cost the state between $3 million and $4 million
  annually.

• Nebraska — MAMES is pushing to get a bill
  passed in Nebraska that would prevent HME providers from being
  unable to supply or sell a medical device without a pharmacy
  license. The Food and Drug Administration recently approved a
  designation on most medical devices of “Rx Only,” which in Nebraska
  would require a seller to have a pharmacy license since it would
  bring the device within the state’s definition of a “prescription
  device” or a “legend device.”

  In addition, MAMES has created a Nebraska task force to grapple
  with new Medicaid requirements. Those include: providing actual
  cost invoices with incentive discounts on all codes without
  established allowables and a reimbursement rate of 130 percent of
  cost invoice; prior authorization for all nursing home wheelchair
  repairs without regard for a minimum dollar amount; and an
  inordinate turnaround time for prior authorizations for repairs and
  new equipment.

• New York — Gov. David Paterson is
  proposing to reduce state Medicaid reimbursement by $459 million in
  FY 2010-2011 (which begins April 1), a cut that would slice into
  HME, as well as hospitals, nursing homes and other home care
  reimbursement. Paterson said the state expects its Medicaid
  caseload to balloon by 400,000 this year, boosting its Medicaid
  costs to $53.2 billion from $50.6 billion.

  There is a chance the cut will not be necessary — under
  President Obama’s proposed federal budget, New York would gain an
  additional $3 billion to help pay for Medicaid.

• North Carolina — Some HME providers are
  still scrambling to replace their patients’ old diabetic supplies
  with those from manufacturer Prodigy Diabetes Care after the state
  designated the Charlotte, N.C.-based company as the state’s only
  provider of diabetic supplies to Medicaid patients.

  The state awarded the contract to Prodigy in October with an
  effective date of Nov. 15, giving providers only a narrow window in
  which to prepare. The state did not change the Medicaid
  reimbursement rates for diabetic supplies, but providers are
  concerned that the Prodigy supplies will be more costly, thus
  affecting their profit margins.

• Oklahoma — Providers in Oklahoma narrowly
  avoided major Medicaid cuts that would have eliminated
  reimbursement for adult HME entirely and slashed the rest of HME
  reimbursements by 10 percent. Instead, providers are seeing reduced
  reimbursement for oxygen and nebulizers with compressors. The state
  Medicaid program now pays $158 for stationary oxygen concentrators
  and $120 for nebulizers with compressors. It has ceased paying for
  nebulizers for adults.