PPACA’s Provisions

This is the second of a 4-part series on the provisions of the Patient Protection and Affordable Care Act (PPACA) and how the health reform law affects DME providers. Series: Part 1 | Part 2 | Part 3

At presstime for this issue, Republicans were lining up for a run at repeal of the Patient Protection and Affordable Care Act (PPACA), which was signed into law on March 23, 2010. Here’s a refresher on some provisions in the health reform law with serious effects for DME suppliers.

• Power Wheelchairs: The purchase option is available only to complex rehabilitation power wheelchairs and not to other power wheelchairs. Additionally, the rental payment amounts change to 15 percent for the first three months and 6 percent for the remaining rental months.
• Provider Screening and Enrollment: Providers and suppliers enrolling or re-enrolling in Medicare, Medicaid or CHIP will be subject to screening measures established by the HHS Secretary. All providers and suppliers will be subject to licensure checks and, if the Secretary determines, additional screening measures such as criminal background checks, fingerprinting and unscheduled and unannounced site visits. Applicants will also be required to disclose any current or previous affiliations with any provider or supplier that has uncollected debt, been subject to payment suspension under a federal health care program, excluded from a federal health care program or has had billing privileges denied or revoked. The Secretary may deny enrollment if such affiliations pose an undue risk of fraud, waste or abuse. In determining the size of a surety bond, the Secretary must take into account the volume of billing for a DME supplier. As well, the Secretary may impose a temporary moratorium on the enrollment of new providers and suppliers if it is determined such action is necessary to prevent or combat fraud, waste or abuse. The Secretary may adjust payments to a provider or supplier that has the same tax ID number as a provider or supplier that owes past-due obligations under Medicare, Medicaid or CHIP, regardless of such provider’s or supplier’s Medicare billing number or NPI.
• Enhanced Program Integrity: Any provider or supplier that receives an overpayment must report the overpayment and provide written notice of the reason for the overpayment. An overpayment must be reported and returned no later than 60 days after it is identified or the date of any corresponding cost report (if applicable). Failure to do so may result in civil money penalties. Additionally, a claim that includes items or services resulting from a violation of the Medicare/Medicaid anti-kickback statute constitutes a false or fraudulent claim under the Civil False Claims Act.
• Orders and Documentation: On or after July 1, 2010, DME or home health services must be ordered by a Medicare-enrolled physician or eligible professional. As a condition of Medicare payment, the patient notes must document that a physician, physician assistant, nurse practitioner, or clinical nurse specialist has had a face-to-face encounter with the patient during the six months prior to the written order for the DME, although the Secretary may determine another reasonable timeframe. (The July 1 deadline has since been delayed.) The Secretary may revoke enrollment of a supplier for various reasons, including failure to maintain and provide access to documentation relating to written orders or requests for payment for DME. Such revocation may be for no longer than one year per act.
• DMEPOS Competitive Bidding Program: The competitive bidding program will be expanded in Round 2 to 100 metropolitan statistical areas (i.e., Round 2 will include the nine MSAs from Round 1 plus 91 additional MSAs). The Secretary will be required to apply competitively bid prices to adjust payments for non-competitive bid areas nationwide by 2016.
• Prepayment Review, Oversight of Initial Claims: The Health Care and Education Reconciliation Act of 2010 was signed into law on March 30, 2010, and modified PPACA.

Under this law, the limits on when a Medicare Administrative Contractor can conduct a prepayment review have been removed. Also under the Reconciliation Act, if the Secretary determines that there is a significant risk of fraudulent activity among DME suppliers, then the Secretary will withhold Medicare payment of any claims submitted by a supplier that is initially enrolling in Medicare.

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Jeffrey S. Baird, Esq. is chairman of the Health Care Group at Brown & Fortunato, P.C., a law firm based in Amarillo, Texas. He represents pharmacies, infusion companies, home medical equipment companies and other health care providers throughout the United States. Baird is board-certified in health law by the Texas Board of Legal Specialization. He can be reached at 806/345-6320 or [email protected].