The Big Fix

Jim Greatorex thinks something is broken in the mobility marketplace, and it is past time for it to be fixed.

“In a three-week span, we received four calls from Medicare recipients who had received equipment that had been dropped off by a national company and was sitting in their basements because it was unusable,” says the president of Black Bear Medical, Portland, Maine, who is also vice president of the New England Medical Equipment Dealers Association. “Whatever would put a stop to this needs to happen … You can’t tell me that [companies that do this] have the client’s best interest at heart.”

Like so many other home medical equipment providers, Greatorex, a 23-year veteran of the industry, is hopeful that both recent and impending actions by the Centers for Medicare and Medicaid Services will put an end to such abuses and remove the shadow of fraud that hangs heavy over the industry.

In early February, CMS proposed new coverage criteria for wheelchairs and scooters, expanded the number of billing codes from five to 49 and is preparing a rule requiring beneficiaries to have a face-to-face exam with a physician in order to receive equipment. The agency is also considering revision of the accompanying Certificate of Medical Necessity (CMN) and, as required by the Medicare Modernization Act, adding supplier quality standards that are expected to be finalized by the fall.

It is the first time Greatorex and others say they have had hope of positive change in the industry. “In the last two years, our industry had been better represented in Washington, and [government officials] understand us better than they ever have,” Greatorex says. “I am hopeful that a new policy, instead of being 100 percent detrimental, will be somewhat helpful.”

Dan Meuser, president of Pride USA in Exeter, Pa., also is optimistic. “I like our industry’s position,” says Meuser, noting that HME’s relationship with legislators and policymakers has changed in the last year. “Actions are not taken behind closed doors, things are being done in an open manner with industry input, and, therefore, anything that is going to affect [the HME] business [HME providers and manufacturers] are going to know in advance.”

He points to the formation of the Interagency Wheelchair Work Group, a group comprised of physicians, clinicians, physical therapists and others from CMS and other government agencies, as a sign of positive change. “It came up with the new wheelchair guidance that the industry is entirely behind; this is a group brought on by CMS. I don’t know when the last time was that something like that occurred.”

Cara Bachenheimer, vice president of government relations for Elyria, Ohio-based Invacare, is also encouraged. “We’re moving in the right direction overall,” she says. “When all these issues are sorted out, I think we will have a much better set of criteria that clinicians and consumers and suppliers can understand when a Medicare beneficiary qualifies for a power wheelchair.”

But for all the cautious optimism that appears to prevail, there are still some real concerns about the shape of the industry — and its future.

“I think providers are concerned about the future, not only the [new coding], but all the regulatory action that’s revolving around this benefit,” says Eric Sokol, director of the Power Mobility Coalition, a group of mobility manufacturers and providers. “We’re talking about not only the coding but coverage criteria and the revised CMN.”

And that’s not all, Sokol adds. “Billing operations will have to be retooled, software will have to be retooled, salespeople will have to be more careful about linking the proper equipment to the user, and there will probably be some increased administrative burdens on suppliers.”

Bachenheimer is concerned not only about what will be implemented, but how. “There are a lot of different pieces to this puzzle. First, we have new codes, and with new codes we will have new medical policy, national coverage policy as well as the [Durable Medical Equipment Regional Carrier] policy, and we will have new payments. And on top of that, we have the face-to-face examination requirement that CMS is putting out, we will have a new CMN and we will have better documentation guidelines from CMS. So there are a lot of pieces in the works. One of my concerns is that they are not going to be implemented in a logical fashion.”

For example, CMS may issue the new CMN before the national coverage criteria is finalized, which will likely add to the confusion among industry players, she says.

“Logically, the new codes are announced first, then the second thing is to determine what products fall into what code,” Bachenheimer says. “The third step is to develop appropriate pricing on the products that fall into that code, and at the same time, the DMERCs’ medical policy needs to be done. But that needs to be developed once the national coverage criteria is developed because the DMERCs amplify national coverage criteria. And then once you have finished all that, you develop a CMN.”

Will the good ultimately outweigh the bad? Industry players can only hope so.

THE CODING CONUNDRUM

Perhaps the greatest focus is on the revised power wheelchair coding. For years, HME providers and manufacturers have called on CMS to add new power wheelchair codes. Lumping power wheelchairs together under the K0011 code with a reimbursement ceiling that is too generous for a basic power chair and much too low for a specialty rehab chair creates billing nightmares for providers, equipment difficulties for end-users and opportunities for fraud for unethical suppliers, they say.

Over the years, numerous groups have offered suggestions for revised coding to CMS, to no avail. But in 2003, faced with millions of dollars in fraudulent claims for power wheelchairs, CMS began exploring measures for eradicating fraud in the industry — and that led the agency to decide, finally, to expand the number of codes.

CMS’ new power chair and scooter codes, grouped and sub-grouped by specific characteristics of various power chairs and scooters, are to take effect Jan. 1, 2006, while existing codes — K0010, K0011, K0012, K0014 — will be discontinued with no grace period or crosswalks. The new codes, which include pediatric and other mobility equipment, will be used not only by Medicare but by Medicaid and private insurers as well.

“We were hoping for six or eight new codes, but I guess we’re [getting about] 50,” says Greatorex wryly. “It certainly is better than one. But I don’t understand why we have to have 50. There aren’t 50 applications.”

“The multitude of codes really doesn’t bother us too much,” says Meuser. “We look at the groups the codes fall within. Groups make a lot of sense … They will better reflect the product model selection in the marketplace.”

CMS also appears to be moving toward coverage criteria that consider functionality of the end-user rather than diagnosis, which most in the industry applaud. In December, the agency opened a National Coverage Determination to review the criteria for wheelchair coverage.

“Our goal is to focus on a set of clinical and functional characteristics that are evidence-based and will better predict who would benefit from a power wheelchair or scooter,” said Sean Tunis, M.D., CMS’ chief medical officer, at the time.

Those were encouraging words to providers and manufacturers, and overall, stakeholders have praised the resulting NCD draft, saying it is a vast improvement over current coverage criteria. Even though it keeps intact Medicare’s rule limiting coverage to DME primarily used in the home — a sticking point that some say they are disappointed CMS failed to address — the recently issued draft eliminates the requirement that beneficiaries must be bed- or chair-confined to qualify for a wheelchair.

“That [functionality] is the appropriate way to ensure that legitimate beneficiaries get the equipment they need,” says Bryan Dylewski, CEO and founder of Mobility Products Unlimited of Holly Hill, Fla.

At press time, CMS was planning to issue the final NCD in March, along with guidance on documentation and other specifics.

Dylewski says he is concerned about the documentation requirements. Will CMS require providers to submit physician progress notes, which frequently don’t even include such facts as a patient’s inability to walk?

“If you have different codes, do the higher-end rehab codes require different evaluations than the lighter codes?” Dylewski asks. “I think there needs to be guidance [on] the documentation issue.”

RATIONAL REIMBURSEMENT?

And what effect will the new coding have on reimbursement?

“I’m glad that they are going to have more codes, but what are they going to pay?” asks Jeffrey Hall, owner of Reliable Medical Supply in Brooklyn Park, Minn.

No one knows yet, but some like Sokol fear the answer is lower Medicare allowables. “The codes are going to be used to more closely align cost with product,” he predicts. “I think they are going to lower costs and this will be the … path toward lowering the reimbursement when competitive bidding happens [in 2007].

“Suppliers,” he adds, “will take a little bit of a cut in reimbursement in exchange for more efficient payment and reliability. We’re certainly hopeful that this will free up payments.”

Syd Gubin, president and owner of The Seating Center, a Palm Springs, Calif.-based division of Home Health Supply, believes the realignment will result in more appropriate reimbursement for rehab providers. “Ultimately, it will establish a separate identity for custom mobility, and hopefully, we’ll get some recognition for what it actually is and what it entails,” he says. “Right now, you have people putting out $1,500 wheelchairs and they are getting $5,000 for them. And you’ve got people putting out $7,000 power chairs and they’re still getting $5,000 … It’s just as unfair to be under-compensated as over-compensated.

“You need to be fairly and reasonably compensated for the equipment and service you provide.”

Meuser acknowledges that the allowables are of concern to Pride and the Restore Access to Mobility Partnership (RAMP), whose members include Pride, Invacare, Sunrise Medical, Mobility Products Unlimited, the American Association for Homecare and The MED Group.

“We are going to do our best to have logic prevail. We are going to present all the factual evidence, the costing that the [Statistical Analysis Durable Medical Equipment Regional Carrier] asks us for … to show them where the appropriate allowables should be,” he says. “We have no evidence that CMS is looking at this as a way to cut costs. They are controlling costs — and will continue to control costs — in other ways: the [Medicare Modernization Act] cuts, accreditation, which will limit the number of providers that exist, and fraud investigations.”

Even if reimbursement doesn’t drop much, Hall says there could be a hidden cost to providers. “I have seen the codes and the descriptions. I don’t necessarily agree with the basic equipment package,” he says. “When you start including things that would have been an upcharge, my question is, how drastically are they going to increase these allowables? To take a $300 or $400 hit on the base charge of a chair is going to be hard to make up.”

CMS’ NEW CMN

Questions also swirl around the revised CMN. Providers are generally skeptical that a new CMN will ease their paperwork burden or be clear enough to avoid misinterpretation.

“I know CMS wants to make it easier and more cost-effective, but I think only time will tell,” says Leslie Rigg, CRTS and co-owner of ATS Wheelchair and Medical in Boise, Idaho. “Any change means more paperwork, and even though CMS wants it to be cut-and-dried, there are always questions about new policies, procedures and codes.”

“I don’t think that they will ever be able to ask enough questions that [will] adequately describe … the pathology of someone’s disease,” says Gubin. Even now, he says, his company “has to send our claims on paper because the fields are so limited. We have a lot of unlisted stuff so we have to send a lot of supporting documentation.”

Hall also has misgivings about the new CMN. “Given that it’s the first one coming out of the shoot, it’s going to be open to interpretation and how the physician interprets it,” he says. And that could jeopardize a provider’s reimbursement.

Also, physicians already have little time to answer the current document’s six or seven questions. Hall wonders how they will handle the CMN when it has more.

But Meuser says the new CMN could shift some of the burden for information from provider to physician. “[It] will put some of the onus on the physicians to cover some of the additional documentation requests that have been asked for before,” he says. “This new coverage guidance is so very important … The outcome is that the DMERCs are going to look for documentation that determines the patient’s ability to work out the functions of daily living with safety as opposed to chair- or bed-confined.”

Whatever the specifics of Medicare’s new mobility policy, they signal a sea change at CMS and in the industry itself, stakeholders say. Providers have to be prepared for that change.

“It has to be business as usual now because we don’t know what’s coming,” says Rigg. “But you have to be thinking about making time for in-service training, making time to update your system, making time to get coding and pricing together,” along with educating the staff about the new system.

Hall says that now is the time for providers to look at how they can cut costs, as well as to assess whether they have the right people in the right positions.

Once the new regulations are in place, there’s little doubt that the field of providers will shrink, say Hall and others.

“There are going to be some [for whom] it is too difficult,” Hall says. “These smaller companies … may say, ‘We aren’t going to do Medicare. We’ll do supplies and so on, but no Medicare.’”

Greatorex agrees. “If you are not diversified, you may be in a position where you have to sell or you may not make it.”

Indeed, industry players suggest that how you react to CMS’ actions could make the difference between thriving in business and closing up shop.

“You know that book, Who Moved My Cheese? Our whole staff has read it,” says Hall, referring to the popular book on change by Spencer Johnson (G.P. Putnam’s Sons).

“Well, hold on tight, people, because the cheese is moving now.”