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:
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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?
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How far is the client able to ambulate?
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How long will ambulation be a problem? Is this a short term non-weight bearing issue?
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Is the assistive device currently being used by the client safe? If not, why not?
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Is the patient able to transfer in and out of bed and/or in and out of the chair?
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Is there any equipment required for transfers from bed to chair and/or chair to toilet?
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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.
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What is the patient's sitting and standing balance?
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Is there an objective functional assessment that includes impairment of strength, range of motion, sensation, or coordination of arms and legs?
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Is there presence of abnormal tone or deformities of arms, legs, or trunk, including any spasticity present?
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What are the patient's neck, trunk, and pelvic posture and flexibility?
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Are there interventions that have been tried in the past by the patient and the results?
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Is there history of past use of a walker, manual wheelchair, POV, or power wheelchair and the results?
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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.