Debate Continues

As of press time, Congress continued debate and deliberation on a massive package to reform the nation’s health care system. While there are skeptics about whether President Obama can succeed on one of his biggest campaign promises, Democratic leadership in the House and Senate were moving forward on an ambitious schedule.

The House, which released a “discussion draft” bill in early June, expected to have markups completed and a vote on the floor by August. The Senate had not yet released its plan but will follow a similar process.

• DME Provisions in Draft House Package: The draft House health reform bill contains numerous provisions impacting Medicare payment for various providers. 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-driven wheelchairs furnished on or after Jan. 1, 2011. There are no provisions in this draft House bill to cut or modify payment to the Medicare home oxygen benefit. One caveat, however, 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.
• Anti-Fraud and Abuse Provisions: The draft House 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 on 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.

As with all bills, however, the House and Senate must ultimately pass the identical package before any legislation on health care reform can be signed into law by the president.

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A specialist in health care legislation, regulations and government relations, Cara C. Bachenheimer is vice president, government relations, for Invacare Corp., Elyria, Ohio. Bachenheimer previously worked at the law firm of Epstein, Becker & Green in Washington, D.C., and at the American Association for Homecare and the Health Industry Distributors Association. You can reach her at 440/329-6226 or [email protected].