Diabetic, NPWT Hurdles

As the HME sector fights to eliminate the Medicare bid program and prevent further reimbursement cuts, other challenges require vigilance. Diabetes and negative pressure wound therapy providers face some important challenges right now.

Like other providers within HME, diabetic suppliers are under increased scrutiny for audits. Prepayment audits can be imposed by the DME Medicare Administrative Contractors (MACs), the Zone Program Integrity Contractors (ZPICs) and the Program Safeguard Contractors (PSCs). Post payment audits can be conducted by as many as eight different entities such as the DME MACs and the Comprehensive Error Rate Testing (CERT) Contractor as well as the ZPICs and the PSCs.

In early 2009, Jurisdiction C initiated a prepayment medical review of claims for glucose monitor test strips and lancets, focused on non-insulin-treated beneficiaries who receive quantities of supplies that exceed the utilization guidelines defined in the Local Coverage Determination. In mid-2009, National Government Services Jurisdiction B Medical Review completed a widespread prepayment medical review of NPWT pumps, which found a claims-error rate of 60 percent.

These reviews and audits pose additional burdens on providers in obtaining required documentation. Despite HME providers’ best efforts to be proactive and obtain the physician medical records, many times the records do not provide the level of documentation required by the auditing entity, resulting in a denial.

Mail-order HME providers are dependent on physicians regarding beneficiary insulin status. In audits involving medical records, many times auditors find that the beneficiary is on insulin, resulting in a claim denial for inappropriate modifiers. And sometimes beneficiaries order supplies from more than one HME provider, which complicates the reimbursement process.

In advocating for better policies, let’s keep the patient’s perspective in view: The goal of effective home medical care is to promote healing, enhance outcomes and reduce the potential for costly hospitalization. For instance, care of a wound cannot be viewed separately from care of the patient’s overall health. Co-morbid conditions may not only contribute to development of wounds but may also inhibit healing.

Diabetes is a good example. Neuropathy and impaired blood flow resulting from diabetes are significant contributors to the development of diabetic foot ulcers. Failure to treat the ulcer effectively could result in amputation of some or all of the foot, possibly leading to amputation of the leg. NPWT devices are used to treat these ulcers effectively, reducing the risk of amputation. However, since diabetes is the underlying contributing factor and could impede wound healing, the patient’s diabetes must be managed as well with appropriate diabetes testing and supplies.

Diabetes is only one of the common co-morbidities associated with wound care patients. Nutritional compromise, immobility, immune system suppression, systemic infection, and chemotherapy all affect healing and must be addressed as part of the care plan for any patient receiving treatment with NPWT products.

Randy Carson, chair of AAHomecare’s Medical Supplies Council, says the HME sector must work with CMS and its affiliate agencies “to identify minimum recommendations for evidence development for the [NPWT] category.” He notes that “AAHomecare is in dialog with the DME MAC medical directors regarding mail-order providers’ concerns on the issue of physician education with respect to maintaining adequate documentation of diabetes management in the patient record.”

The bottom line is that it’s important to stay familiar with the Medicare coverage guidelines as well as physician letters, local coverage determinations and policy articles on the DME MAC Web sites regarding diabetes, NPWT and other categories in your practice.

Read more AAHomecare Update columns.

Tyler J. Wilson is president and CEO of the American Association for Homecare, headquartered in Arlington, Va. You can reach him at [email protected]. For more information on critical home care issues, visit the association’s Web site at www.aahomecare.org.