ATLANTA — A year after the 36-month cap for oxygen rental began on Jan. 1, 2009, providers are licking their wounds but most are still standing. Thanks to close attention to costs and billing processes, HME stakeholders estimate the majority of providers have come through the drastic change for the first year, but patient care has been affected.
"Many of the providers had reductions in revenues and reduced employee levels, which compromised service and accessibility to the patients we service," said John Rhodes, RRT, president of Mountain Home Care Equipment, Ellijay, Ga. "This also has made a big impact on transitioning patients to different regions of the country. We must be vigilant about what happens legislatively in the near future, and take an interest in the process if we are to continue to make home care the most affordable medical care possible."
While providers have had to make major adjustments, so have benefciaries. According to Lisa Getson, most patients still think they can move anywhere, choose any provider and switch oxygen modalities any time they want.
"The 36th month's statement from Medicare provides no information at all to the patient other than a superscripted note," pointed out Getson, executive vice president, government relations and corporate compliance, for Lake Forest, Calif.-based Apria Healthcare. "We have taken extra steps to educate our patients and referral sources about the restrictions on patients' right to choose a provider and/or move — restrictions that are caused by the arbitrary and medically inappropriate 36-month cap."
Kelly Riley, CRT, RCP, director of the National Respiratory Network for The MED Group, Lubbock, Texas, laments that a year later the industry is still struggling to get consistent and/or correct communication from CMS. Instead, phone calls made by both providers and patients alike continually result in misinformation, she said.
"Confusion still reigns for managing traveling, temporary and permanent relocated patients," said Riley. "This is an area [the American Association for Homecare's] regulatory council is working with CMS to resolve."
However, Riley continued, "That is little solace for the provider who has a patient at the 34-month mark who has to move outside of their market. Providers continue to get 'false' CO176 denials because there is not an adequate system in place to count months actually paid versus time from initial [date of service]. Twelve months of history now has proven that capping the oxygen benefit is not good for HME providers, physicians managing patient care and, least of all, patient and families."
Despite the hardships, many providers have shown a remarkable resiliency. Tim Good, CRT, RPFT, characterizes his oxygen business as "OK" for the past 12 months, but that does not mean it was easy by any stretch.
"The oxygen cap hit us hard," said Good, president of GoodCare by CPCI, Logan, Ohio. "Approximately 30 percent of our oxygen patients capped out, but about 30 percent of the capped patients had been on service for more than five years, and we were able to update their equipment and resume billing.
"We have been doing more Medicaid and managed care Medicaid, which has driven down our average reimbursement for oxygen. We have also needed to decrease institutional oxygen pricing (hospice) to stay competitive. Finally, we are also being required to provide significantly more high-tech oxygen equipment, such as portable concentrators, [Invacare] HomeFill units, etc., to compete, which impacts reimbursement."
To stay in business in 2009, Good was forced to lay off two employees, take on more debt and operate with declining revenues for each oxygen patient. Still, he survived, and his business is growing.
"On the horizon, I am much more concerned about competitive bidding and totally uncontrolled RAC and CERT audits," added Good. "We need to be working very hard to reign in these developments, since they are obviously designed by CMS to decrease the number of providers in the HME industry. 'After-the-fact' audits, where the rules can be changed at the whim of the auditors, are obviously unfair, and indicative of the agenda of CMS. Unfortunately, the national providers are sitting on the sidelines waiting for the independent providers to be forced out of business, with the assumption that they will then be able to swoop in and obtain the business left by the exiting/bankrupt independents."