Grand Poo Bah for a Day

On most days, each one of us could easily fix some of the biggest problems associated with third party payers and how they establish coding, coverage and payment for the products and services we provide. It’s simply a matter of logic, understanding our business and crafting Medicare rules that are completely in sync with those principles.

This month, I am going to play the role of “Medicare Grand Poo Bah” and tell you what I would do to fix the biggest challenges we face in dealing with the program. Here’s my priority list.

1. Fix the power mobility device benefit. When creating, improving or modifying any portion of the durable medical equipment benefit, the logical policy development is first to address coding of the products; second, to establish coverage criteria; third, to set the documentation rules; and fourth, to establish allowables for the new codes. Left to do today in my new role:
   • Establish new HCPCS codes and testing requirements for PMDs to ensure they are consistent with American manufacturers’ products and the testing requirements currently in place by ANSI-RESNA standards. The codes need to include clinical application information to enable development of specific code coverage criteria based on the consumer’s specific medical and other needs.
   • Provide meaningful documentation guidance for physicians, therapists and suppliers. The Interim Final Rule should be re-issued as a final regulation, incorporating the many public comments CMS received last year.
   • Draft the Local Coverage Determination to ensure beneficiaries have access to the PMD that meets their medical needs. We need not limit the appropriate PMD to one that is only functional in the home; we need to cover features for safety and independence when operating the PMD outdoors.
   • Establish equitable fee schedules for the new PMD HCPCS codes. Because the historic trend in power wheelchair prices is not represented by the price increases of the CPI-U, the use of gap-filling should take into account the actual pricing for power chairs since 1987.
   • Eliminate the “in the home” interpretation that denies beneficiaries access to devices that best meet their mobility needs in their homes — and their communities.
   • Fix the home oxygen therapy benefit.
     • Eliminate the 36-month cap on rental payments for home oxygen so beneficiaries have ongoing access to the necessary support services.
     • Eliminate the ownership transfer at 36 months so that seniors are not burdened with owning complex medical equipment, and are not responsible for understanding when and how to obtain maintenance and service, emergency, respiratory therapy and other 24/7 support services.
     • Identify specific services that are necessary to be provided with the equipment, including:
     • Ensuring that patients can adequately manage their oxygen in the event of natural or man-made emergencies that affect power or damage their homes, including 24/7 on-call and emergency support of all home oxygen patients.
     • Verifying the purity of oxygen delivered to patients, verifying the oxygen flow and verifying the alarm system functions.
     • Regular checking and replacement of the internal and external filter in accordance with the manufacturer’s specifications.
     • Ensuring a supply of disposable oxygen accessories, such as humidifiers, supply tubing, filters, nasal cannulas, trach masks, corrugated tubing, in-line adaptors and other miscellaneous devices.
     • Home delivery, set up, patient/caregiver instructions of safety and use, pick-up and replacement of malfunctioning equipment, depleted tanks and reserve systems.
     • Eliminate the “competitive acquisition” program that CMS is developing to begin in 2007 Obviously, this will take an Act of Congress, but this should be feasible in my current role — the sky’s the limit!

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 by phone at 440/329-6226 or by e-mail at [email protected].