Brant: Enteral Nutrition Saga Continues

MIAMI—AMEPA President Rob Brant told members in an email
Friday he expects some worrisome questions during CMS’ Sept.
2 teleconference on the Round 1 rebid.
 
The second in a series of eight Special Open Door Forums on the
reprised DMEPOS bid program, the presentation will cover product
categories and bidding rules. Officials will also give an overview
of “special rules” for physicians, skilled nursing
facilities and hospitals, a CMS notice said.
 
Brant will be listening, especially when it comes to the portion of
the call on enteral nutrition and nursing homes or SNFs.
 
CMS’ Request for Bid instructions note that SNFs aren’t
exempt from the bidding program, Brant said. They can, however,
choose to become a “specialty supplier” and be awarded
a contract to furnish competitively bid items only to their own
residents—and thus would be exempt from servicing the entire
competitive bidding
area.
 
That, Brant said, could be an issue. Here’s how he
illustrated the point:
 
Two companies try to provide the
government with the lowest price to provide widgets, or in this
case, enteral feed supplies and services for the DMEPOS competitive
bidding program.
 
Company A has to rent a physical plant, purchase delivery vehicles,
maintain delivery technicians, and has to guarantee to cover a
multi-county area over 6,000 square miles in size with a variety of
brands of feed, educate, train, troubleshoot, service, repair and
replace feeding pumps and other delivery products, on-call 24 hours
a day for three years.
 
Company B is a nursing home/skilled nursing facility and provides
the same products and services in a 20-bed, 6,000-square foot
facility. Company B does not have to rent a physical plant or
purchase delivery vehicles and most importantly, does not have to
guarantee service coverage over a 6,000-square mile, multi-county
area, so they only need one delivery technician.
 
It would be simple enough to guess which company could place the
lowest bid price, but what complicates the issue is that Company B,
in their 6,000-square foot facility, may set the reimbursement
rates for all winning bidders trying to cover a 6,000-square mile,
multi-county area. That may be exactly what Medicare set up when
they released the Request for Bid (RFB) instructions as they
pertain to ‘Specialty Suppliers.’”

Heavy service requirements and reimbursement issues complicate
the enteral products bidding category further, Brant said.
 
“There are over a hundred different brands that a physician
may order for a patient. Depending on how the patient reacts to a
formula, the physician may change the brand of feed from one day to
the next,” he said.
 
Most enteral products are paid using only two different billing
codes, so a product that is typically ordered for renal failure
patients might cost four times as much as others, but the
reimbursement rates are the same, he explained. “These
calculated losses cause non-participating providers to refuse
accepting Medicare assignment for those enteral patients, an
option that bid winners will not have,” he said.

Brant pointed out the enteral nutrition category had been dropped
from the second round of the Polk County, Fla., bidding
demonstration in 2001.  
 
In 2007, providers again raised red flags about patient care and
access following CMS’ decision not to include enteral
nutrition under the grandfather clause of its final rule on
competitive bidding, along with the absence of a transition period
for enteral nutrition recipients. (See
Enteral Nutrition Sector Raises Concerns about Patient Care under
NCB, July 16, 2007.)
  
“This new chapter in the enteral feed saga will likely lead
to questions” during CMS’ upcoming call, Brant
said.
 
He’s already asking a couple of his own: “How do
‘special suppliers’ affect the bid price, and should
their bids be removed when calculating bid winning rates for a
CBA?”
 
To listen in to the CMS call, scheduled from 2 to 3 p.m. ET
Wednesday, Sept. 2, dial 800/837-1935 and reference conference ID
23044340.
 
For a list of the remaining Special Open Door calls on the Round 1
rebid, see the CBIC Web site at www.dmecompetitivebid.com.