Catching Up with ADMEA

The Alabama Durable Medical Equipment Association (ADMEA) held its annual convention July 25 and 26 at the Embassy Suites Hotel in Hoover, Alabama. Suppliers from across the state attended the convention for education and policy updates. The program was fast-paced and packed with information.

Mark Higley, vice president of regulatory affairs for VGM Group, opened the convention with a discussion of the rule on everyone’s mind—the End Stage Renal Disease (ESRD) Proposed Rule, which effectively stalls competitive bidding for two years. Kim Brummett, vice president of regulatory affairs for AAHomecare joined Higley midway through the presentation to aid the discussion. Comments on the rule are due to CMS by September 10, 2018.

The current bid contracts (and prices) are going away. Any “willing provider” will be able to provide service. This sounds great for patients, but providers aren’t so sure.

Are the rural ZIP codes rural enough? Small cities (micropolitan) in non-CBA areas are not considered rural and don’t have the rural 50/50 rates. According to Brummett, providers often offer services in both rural and non-CBA areas, based on their location, but they are not reimbursed as they should be because they are based in a micropolitan ZIP code. VGM and AAHomecare would like to see a better definition of rural versus micropolitan from CMS. Providers want to see better rates.

Lead-item pricing for the new bid program is based off the 2015 allowed dollars. The idea is to make the bidding process simpler for providers by only having to bid on one item in a code category. However, because of price inversion (an accessory is reimbursed higher than the device), VGM and AAHomecare recommend lead-item pricing for both devices and accessory categories.

Other items to note are the changing payment classes for oxygen, the opportunity for providers in common ownership arrangements to bid if the arrangements are terminated, and proposed splits to nine large CBAs.

Brummett presented on AAHomecare’s goals and accomplishments. Accomplishments included fixes to the PICOS claims system allowing claims extensions for 13 months for physicians who are retired or deceased; a rescinded requirement from CMS for revised certificates of medical necessity for oxygen that led to false answers from physicians to Question 5 on the CMN; an addition of modifiers to the oxygen LCD that allows claims to deny appropriately when a beneficiary does not qualify for coverage.

In 2018, AAHomecare is working to respond to all proposed rules, including the new ESRD rule. In response to the DME interim final rule, released in May, AAHomcare submitted comments that CMS should use 50/50 blended rates in all non-CBA areas, use the clearing price (maximum winning bid) for non-CBA areas, monitor 1-800-Medicare for beneficiary issues in non-CBAs, be mindful of the impact of Medicare policies on all payers, and keep CRT accessories exempt from CB pricing.

Brummett also outlined concerns for the DME industry from President Trump’s 2019 budget, some of which have been addressed by the ERSD proposed rule.

The budget proposes a few changes for the industry, including:

• Expanding prior authorization.
• Expanding competitive bidding to the entire country, including rural areas.
• Adding additional requirements for DME items that require refills or serial claims, such as CPAP supplies. This would create the role of a Medicare benefits manager. AAHomecare believes this would be costly to the Medicare program, and delay access to care for Medicare patients.
• Eliminating the face-to-face requirement for care.
• Increasing the minimum amount required to appeal a case before an administrative law judge. DMEPOS appeals are 57 percent of the backlog.
• Establishing a post-adjudication user fee for third- and fourth-level appeals.
• Requiring a good-faith attestation on all appeals. This is to discourage the filing of appeals.

In Alabama-related news, Brummett shared that suppliers in the state are down 17 percent while locations are down 21 percent from 2010.

The Alabama Medicaid agency presented on the face-to-face rule change in the state, effective August 1, 2018. Under Alabama Medicaid, qualified practitioners include registered nurse practitioners, clinical nurse specialists, physician assistants, acute and post-acute physicians in home health services. Alabama DME dealers can find the alert here.

AAHomecare’s vice president of payer relations, Laura Williard, presented on building relationships with payers. “It’s more than getting a contract signed,” she said.

Williard advised targeting managed care plans, preferred provider organizations, Medicare Advantage plans, accountable care organizations, workers’ compensation groups and value-based care models. She also advised thinking outside the box of traditional payers. Building relationships with payers is tough but can be done. Hard data—and unique data—are great to bring to the table in a negotiation. Leave the data with the payer for review. When you sign the contract, make sure it is specific and clear.

When it comes to finding C-suite executives, social media is your friend, Williard advised attendees, as are state association meetings such as ADMEA.

ADMEA held additional presentations covering incremental sales, Medicare updates, and how to succeed in the reimbursement climate. Providers also had the opportunity to take the Board of Certification/Accreditation (BOC) Certified DME Specialist Exam or workshops in Medicare billing and high impact leadership during the convention.

Attending your state’s convention is a great opportunity to network and learn about what is happening in the industry. The education is not just about the national issues, but also what is affecting your region and market. Providers in Alabama are feeling the squeeze of competitive bidding as much as others. The time spent with industry experts is well worth the time out of the office.