Keeping Fingers Crossed

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:

1. 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
2. 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.”