Commentary: Enough Is Enough

By Roberta Domos, RRT

No, I’m not a DME supplier (or health care provider as I like to
refer to my fellow DME colleagues, since you really do provide the
health care services that keep chronically ill patients from eating
up hospital dollars). No, I’m just a DME consultant who has tried
to help providers navigate through these troublesome waters for
what seems like eons.

Twelve years ago I left the day-to-day management of a robust,
multi-branch, fully accredited DME company to strike out as an
independent consultant. And for twelve years I have seen CMS beat
down the Home Medical Equipment industry without a single nod to
how much money they save the Medicare program in hospital dollars.
Maybe I missed it, but I have not seen one, single, solitary
acknowledgment, let alone an OIG opinion recognizing that fact. And
for twelve long years I have recognized that what hurts the DME
industry hurts me, and the family I am trying to provide for, just
like DME providers are trying to provide for theirs.

It used to be that DME providers could feel good about what they
did — make a living providing a needed service that overall,
saved the government money in the long run. What a great feeling at
the end of a day of hard work! They still provide that valuable
service, but unfortunately, minus the ability to make a decent
living.

Nowadays it’s considered a collective sin of the DME industry as
a whole if the National Supplier Clearinghouse can’t keep crooks
from getting a Medicare number. Our consulting company does more
DME start-ups than any consulting group in the industry, and we
manage to dissuade the crooks. It’s true that crooks don’t usually
inquire of, or hire a consultant, but truly, it’s not that hard to
spot them. Why punish the entire industry because some outsource
agency on a government contract is apparently less than successful
at its mission?

CMS are you listening? I’m rock-solid sure Domos HME Consulting
Group, a myriad of other consultants, and the American Association
for Homecare can help you keep crooks from getting Medicare
numbers. Really, just give us a call — our rates are
reasonable, and we have a vested interest in the mission.

Next up on my list of beefs? MAC pre-payment probe reviews. The
MACs have helpfully informed us that 90 plus percent of claims for
whatever product they may be reviewing should be denied. Why?
Because apparently physicians are on a mission to foist unneeded
medical equipment on unsuspecting senior citizens. Do these
physicians get any remuneration for this dastardly deed? No, of
course not. But apparently they are willing to abuse senior
citizens with unnecessary oxygen concentrators and wheelchairs
anyway.

Recently, in my email inbox, I received some helpful advice from
one of the MACs. I quote: “In order to avoid denials on standard
wheelchairs providers should ensure that physician notes include
the following:

• What is the patient’s ability to ambulate? If they are able to
  ambulate, with what type of assistive device is required? If not
  able to ambulate, why not?

• How far is the client able to ambulate?

• How long will ambulation be a problem? Is this a short term
  non-weight bearing issue?

• Is the assistive device currently being used by the client safe?
  If not, why not?

• Is the patient able to transfer in and out of bed and/or in and
  out of the chair?

• Is there any equipment required for transfers from bed to chair
  and/or chair to toilet?

• Is the patient able to perform pressure relief/weight shift? If
  the patient is unable to perform a functional weight shift
  documentation should clearly indicate why.

• What is the patient’s sitting and standing balance?

• Is there an objective functional assessment that includes
  impairment of strength, range of motion, sensation, or coordination
  of arms and legs?

• Is there presence of abnormal tone or deformities of arms, legs,
  or trunk, including any spasticity present?

• What are the patient’s neck, trunk, and pelvic posture and
  flexibility?

• Are there interventions that have been tried in the past by the
  patient and the results?

• Is there history of past use of a walker, manual wheelchair,
  POV, or power wheelchair and the results?

• If the patient has frequent falls, indicate why they are having
  falls and if the falls are occurring with or without use of an
  assistive device such as a walker.”

Are they kidding? Doesn’t each and every DME MAC have a
physician Medical Director as its chief policy consultant? Do they
not approve this kind of policy guidance? Have any of them EVER
documented this level of detail when prescribing a manual
wheelchair for a 75-year-old arthritic patient who can barely make
it to the kitchen to prepare a meal? If so, I have never seen it in
25 years of reviewing medical records.

And it doesn’t stop at manual wheelchairs. Several months ago
the Medicare medical policy for patients requiring a bi-level PAP
device was expanded to include requirements for a host of
additional physician documentation to justify the use of a bi-level
device over that of a continuous PAP device. Then, shortly after
that we were informed that oxygen saturation tests incompatible
with life were not enough justification for the provision of
oxygen. Contrary to common sense we need documentation that the
patient had been evaluated by the physician at within 30 days prior
to the prescription. Apparently it does not occur to CMS that
arterial blood gas or oximetry testing is not permitted without a
prescription from a physician, who presumably ordered that testing
based on other physical findings during an evaluation, whether that
physical evaluation was specifically documented to CMS’s
satisfaction or not. Perhaps CMS needs to brush up on FDA
regulations regarding tests that document the need for supplemental
oxygen.

Here are the bold facts: Physicians simply do not document chart
notes designed to justify their medical decisions to bureaucrats.
They don’t feel the need to do that, and they never will. Frankly,
they resent it, and as a clinician I don’t blame them. As a former
clinical instructor for respiratory care I can guarantee that
Insurance Charting 101 is not included in the curriculum.

Under these regulations NO patient will ever qualify for a
standard wheelchair, no matter how badly they may actually need
one. In essence, every manual wheelchair ever paid for by the
Medicare program was paid “in error.” And the phrase “in error”
should, in no way, be confused with the concept of genuine medical
necessity.

As further evidence, patients with an oxygen saturation below
that which is compatible with life should be left to die sans
complete chart notes regarding why the physician ordered the oxygen
testing in the first place. We should pay no mind to the actual
results of the test ordered by the physician. Unfortunately, based
on a reading of their reports to congress over the years, I am sure
the OIG would heartily agree. And no, I do not believe that is in
any way an exaggeration.

When was Medicare given the mandate to treat our senior citizens
so poorly? I don’t recall them being given any mandate other than
one to cut spending. And this, apparently, is their road to
accomplishing that. The only reason they get away with it is
because softhearted DME providers, trying to make a living doing
something they can feel proud of at the end of the day, shield
patients and physicians from these draconian rules. The end result
is that DME providers are the only ones pointing out how ridiculous
these rules are.

It’s time to say I’m mad as hell and I’m not going to take it
anymore. Every DME provider in this country needs to print out the
“qualifying” criteria, documentation requirements, and the
“helpful” guidance provided by the MACs; provide it to referral
sources and patients, and say, “Sorry doctor, I cannot provide your
75-year-old arthritic patient with a basic, standard wheelchair
unless you are willing to write a full chapter on the patient’s
medical history, past and present, prior to the time I provide the
wheelchair.”

“Sorry, Doc, but even though your patient has a room air oxygen
saturation of 80% I cannot provide them with oxygen because you did
not chart your concerns about their chronic cardiorespiratory
problems before discharging them from the hospital. I regret that
you were so wrapped up in their recent stroke that you were unable
to focus, to the satisfaction of government bureaucrats, on their
other, life-sustaining health care needs at that time.”

“Sorry Mr. Smith, you’re a Medicare patient, and they will not
pay for the medical supplies your physician told us you need
because your doctor failed to complete some forms to convert their
Medicare information to an electronic database (PECOS of course).
Would you mind, terribly, going to another physician to treat your
diabetes who is registered in Medicare’s computerized system even
though they know nothing about you or your medical history?”

Will DME providers dare say such things in order to heed these
draconian rules, and get the patients and physicians in line to
protest with us? Likely not, because there are always other less
informed DME providers down the street who will acquiesce, and take
the referral anyway. That’s why providers bid at rates lower than
their cost of goods in order to “win” the recent Medicare
competitive bid.

But it has to begin somewhere. If you are going down, at least
do it with a fight. Join your state association and the American
Association for Homecare, and then make a pact with your fellow DME
providers — no more shielding Medicare patients and Medicare
referring physicians from this nonsense. Let it begin with you.

Roberta Domos, RRT, is owner and president of Domos HME
Consulting Group in Redmond, Wash. You can reach her through
www.hmeconsulting.com or at 425/882-2035.