Information Tidal Wave: CMS Reveals Instructions for Round One Providers

BALTIMORE–In back-to-back teleconferences last week, CMS
unleashed a veritable tidal wave of information for providers
preparing for the implementation of competitive bidding–well,
almost.

The May 13 teleconferences began with a national provider
training call that was designed to “address some of the
situations [providers] may encounter” before the
implementation of round one on July 1. Using a PowerPoint outline,
CMS and CBIC officials discussed contracts, payment rules, payment
policies, mail-order diabetic supplies, use of the ABN,
grandfathering and more.

But asked when round one contract winners will be announced and
what the timeline for round two will be, the answers were that
information would come “in the near future.”

Additionally, despite six pages of information on various
policies for grandfathering, complications including the oxygen
rental cap caused confusion among listeners, as did instructions on
mail-order diabetic supplies.

“If a contract supplier did not win, can that uncontracted
supplier hand deliver the [diabetic] supplies to the patient? Would
that be a mail order or not a mail order type of
arrangement?” one caller asked.

Joel Kaiser, deputy director of DMEPOS policy, answered this
way:

“The reason we separated mail orders from non-mail orders
is that we were basing it on concerns and comments that competitive
bidding was going to impact beneficiaries’ abilities to go to
local storefronts and pharmacies … to receive their diabetic
care,” Kaiser said. “We are applying competitive
bidding to mail order only.”

Pointing out a definition in a new chapter of its claims
processing manual that deals with competitive bidding, Kaiser said
in “Chapter 36 in the Internet home manual [that] ‘mail order’
refers to items ordered remotely, that is by phone, email, Internet
or mail and delivered to the beneficiaries’ residence by
common carriers … and does not include items obtained by
beneficiaries from local supplier storefronts.”

But when the caller responded that the definition was “a
little foggy,” Kaiser conceded.

“We probably could and should further define what we mean
by local storefront so that there is no question about it,”
Kaiser said. “You may be right. There may be a little
ambiguity there, so we’ll be looking into it to see if maybe
we can further define what we mean by ‘local
storefront.’”

Questions also arose concerning competitive bidding’s
effects on beneficiary services.

One caller, a physical therapist who services beneficiaries in
two separate round one CBAs, said she and other therapists have
“concerns” about beneficiary care in the realm of
complex rehab.

“The concerns amongst a lot of the therapists are that
some of the companies that appear to be the ones who are going to
be getting the bid for our areas are companies who have never
provided complex rehab in the past and don’t have the basis
to do it,” she said. “They don’t understand the
complexity of it. And I know that that’s not fraud, but is
there someone we can contact to say when companies are being given
the bid who clearly, from a clinical perspective, can’t
provide the services that the clients need?”

CMS’ Sandra Bastinelli responded, advising the caller to
contact either the OIG Fraud Hotline, the accrediting organizations
for the companies in question or CMS, at which time she said the
concerns would be investigated.

During an Open Door Forum immediately following the training
call, Kaiser outlined basic information on grandfathering and
clarified the differences between MSAs and CBAs–information
critical to those providers who may be involved in round two.

Kaiser advised providers to access the Medicare Claims
Processing Manual’s new Chapter 36 for more information on
grandfathering, which includes policies on grandfathered providers
and items, transfer of title of capped rental items and oxygen
equipment. “Suppliers need to make these grandfathering
decisions in the very near future, and they need to start informing
beneficiaries about what their plans are regarding
grandfathering,” he said.

“If you elect to become a grandfather supplier for an
item, you must be a grandfather for all beneficiaries in a
competitive bid area. It is not a decision made by the supplier on
a beneficiary-by-beneficiary basis. It is a decision made by a
supplier on an item-by-item basis.” Kaiser said. “You
can pick and choose among the items that are subject to competitive
bidding but you cannot pick and choose whether to be a grandfather
supplier on a beneficiary-to-beneficiary basis.”

Non-contract suppliers are responsible for notifying Medicare
patients of their plans to furnish grandfathered items–or
not–that beneficiaries have been receiving from the supplier, CMS
said.

On the subject of MSAs and CBAs, Kaiser offered this
clarification:

“An MSA is an area that is defined [by] a series of
counties. You can clearly identify whether an area is part of an
MSA or not part of an MSA by looking to see what counties are part
of the MSA, so there’s really no question about whether an
area is part of an MSA or not.

“You don’t need to know what zip code you are
in,” Kaiser continued. “If there’s a county and
it’s part of an MSA, it’s part of an MSA. There’s
no ifs, ands or buts.

“As far as CBAs are concerned, they may differ from the
actual boundaries of the MSAs, and the reason is because the law
gives us the authority to exempt or carve out low
population-density areas of an MSA. So we’re not talking
about huge, massive parts of an MSA … what we’re really
talking about is areas on the fringe …

“It’s not where the supplier is located, it’s
whether you furnish items to beneficiaries in an MSA,” Kaiser
said. “If you are furnishing items to beneficiaries in a
given MSA on a routine basis, you’re probably furnishing
those items to people who live in the more populated areas …
There’s not much chance that those will not be part of the
CBA.”

To see which counties are included in the round two MSAs, Kaiser
said to visit the Census Bureau Web site.

Bastinelli also took the opportunity to say that CMS is still
reviewing comments on proposed revisions to its accreditation
quality standards, for which the comment period ended March 18.

“We hope to have the final of those quality standards
posted soon,” she said.

Kaiser offered a similar statement with regard to announcing the
winners in round one.

“Contracting for round one will be announced in the near
future,” he said. “We are very close to finishing up
the contracting process for round one and will be announcing them
in the near future.”

CMS has announced its next educational call on competitive bidding
for May 27. For information and to register for the call, visit

www2.eventsvc.com/palmettogba052908.