Advocacy for reimbursements that reflect market realities remains a top priority for home medical equipment (HME) suppliers and for the American Association for Homecare (AAHomecare), but our industry must be proactive in identifying other challenges and seizing opportunities to improve our business and operational environment.
The AAHomecare team is excited by the prospect of building on our recent reimbursement win on Capitol Hill and to address new challenges on the horizon; I’ll expand on a couple of the newest issues as well.
Extending a Win on Reimbursement
The persistent efforts of HME advocates and our lobbying team paid off with the inclusion of provisions in December’s omnibus bill extending 75%/25% blended Medicare rates in non-rural areas beyond the conclusion of the COVID-19 public health emergency (PHE) to the end of 2023.
When the Biden Administration signaled its intention to end the COVID-19 PHE effective mid-May, the importance of the omnibus legislation became clearer: It will result in around $30 million more for HME suppliers in those additional seven and a half months, based on Congressional Budget Office estimates. Those non-rural rates will also have an influence on other payers who peg reimbursements to these rates, including Medicaid rates in 21 states and TRICARE.
With the December 2023 end date for those enhanced non-rural rates established, the focus now turns towards a longer-term extension, as well as to continue to push for long-sought adjustments for suppliers in former competitive bid areas (CBAs). Convincing congressional leaders to provide additional funding for HME against the headwinds of efforts to rein in federal spending will be another big challenge for leaders and advocates in our industry— but our previous achievements in moving the needle forward on reimbursements show our industry’s grassroots advocates can effectively put our issues in the spotlight on Capitol Hill.
Keeping Our Eyes on Competitive Bidding Program
Even as we focus on shoring up current rates, HME stakeholders need to prepare for what’s next for the competitive bidding (CB) program. We are engaging with the Centers for Medicare & Medicaid Services (CMS) to get clarity on the future of the program. If CMS indicates it plans to move forward, we will work with Congress to ensure that important policies currently in place— including clearing price methodology and using the unadjusted fee schedule as a bid ceiling—are part of the next round.
If the CB program does move forward, we’ll need to partner with Congress to require CMS to accept higher rates if that is the result of the bidding process. Suppliers can’t be expected to make good-faith efforts to develop bids that allow them to be profitable while providing effective care if CMS has carte blanche to invalidate the results.
The health care field has seen tremendous technological advancements in recent decades, and the HME sector is no exception. Mobility products, respiratory devices, medical supplies and other home medical equipment and service protocols continue to improve, to the benefit of the patients, caregivers and clinicians our industry supports.
One area where HME has been slow to innovate, however, is the order process for equipment. Reliance on phone calls or faxes to order homecare products is gradually decreasing, but we need to accelerate that transition through more widespread adoption of e-prescribing. Taking “touches” out of the ordering process benefits patients, prescribers and providers. In addition to facilitating quicker patient discharges, and reducing errors, e-prescribing also has important benefits on the back end of the order by helping reduce denials and improper payments.
AAHomecare is planning to engage CMS and Congress to push for policies that will help spur further adoption of e-prescribing. I’m excited to see how this technology continues to evolve and gain acceptance by both prescribers and HME suppliers.
A Road Map for MAPs
Twenty years since its inception, the Medicare Advantage program now has nearly 29 million participants and will soon cover more than half of all Medicare beneficiaries. AAHomecare is stepping up our policy efforts to ensure that Medicare Advantage Plans (MAPs) provide the same access to home-based care as Part B.
To that end, AAHomecare has developed extensive policy recommendations on MAPs focusing on improved oversight and transparency, ensuring network access and patient choice, offering clear and consistent guidance on prior authorization requirements and including HME suppliers in their value-based care programs.
Specific examples among our dozen-plus recommendations include:
- Ensuring MAPs have published coverage and documentation requirements that are no more restrictive than Medicare fee-for-service (FFS) clinical or medical, operational, billing, advanced beneficiary notice and payment policies
- Requiring MAPs establish clear network adequacy criteria by durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) product category and by geographic area to ensure there is real patient choice
- MAPs should only have prior authorization requirements for DMEPOS items where the Medicare FFS program requires them
- Implementing additional transparency measures to enforce data reporting requirements for MAPs
MAPs have been under increasing scrutiny from policymakers and health care advocates alike. Over the past year, reports from the Department of Health and Human Services Office of Inspector General and the Kaiser Family Foundation have put a spotlight on unwarranted prior authorization denials.
Legislation to improve transparency for these plans and streamline prior authorizations passed in the House in 2022 but failed to advance in the Senate. The need to strengthen oversight and access to care under MAPs is becoming more apparent in Washington and across the health care spectrum, and the HME stakeholders must be a part of related policy discussions and action.
Continuing to Strengthen Our Capacity for Advocacy
In addition to the areas spotlighted above, AAHomecare has an ambitious policy agenda that includes reimbursement advocacy across the full spectrum of non-Medicare major payers, including state Medicaid programs and managed care organizations, TRICARE and major private payer groups.
Other priorities include:
- Maintaining coverage for oxygen and continuous glucose monitor (CGM) patients granted under relaxed PHE requirements beyond the end of
- the PHE
- Working with industry stakeholders on legislation to establish oxygen criteria via critical data elements and preventing expansion of the bidding program into CGM, ostomy and urological products
- Leading on mobility issues such as titanium or carbon fiber upgrades and right to repair
- Working to reduce audit and review burdens on HME suppliers
Our ability to win—and to continue winning—on these policy issues is directly linked to the leadership of AAHomecare members on our councils and work groups, as well as their passionate advocacy work at the federal and state level. These efforts have raised the credibility of this industry with legislators and regulators and raised awareness on the value of high-quality, home-based care. Member dues and additional corporate partner funds also help fuel this work.
Growing our base of engaged advocates is critical to building on our successes and continuing to improve the legislative, regulatory and business environment for HME. If you’re not a part of AAHomecare, please consider making this the year you join us in the advancement of our industry through policy initiatives that will help you continue to provide exceptional care and bolster your bottom line. Learn more about us and find membership info at aahomecare.org.