Questions Abound as Round One Approaches

BALTIMORE–A second CMS provider training call last week showed
just how many questions about competitive bidding remain.

Among a barrage of detail-oriented queries, a range of topics
included subcontracting, patient residency, what will happen in
cases where contract winners are not licensed (if required) in
states where they won bids and what exactly is being done to
educate beneficiaries about the impending changes.

With just a few weeks left before round one is scheduled to take
effect July 1, CMS allowed one-and-a-half hours for the May 27
session, designed to field questions about exactly how the bidding
program will work. The time came and went with a ceaseless flow of
calls–and not everyone got their questions addressed.

Following is a sample of questions from those who made it
through the call-in queue.

–Jurisdiction: What to do when a patient’s
residence conflicts with his or her billing
address

An Ohio caller asked about a patient who was being solicited by
a winning bidder in Florida–but the patient resided in a nursing
home in Detroit. The caller explained that the confusion in this
situation derived from the fact that the patient’s Power of
Attorney is located in Florida.

In answer, CMS’ Joel Kaiser, deputy director of DMEPOS policy,
said, “If the beneficiary’s permanent address is in a
competitive bidding area but they are receiving services in an area
outside of the competitive bidding area, then we would consider
that beneficiary in ‘travel status.’”

Kaiser’s answer actually raises more questions, according to
industry consultant Sylvia Toscano of Professional Medical
Administrators in Boca Raton, Fla.

“If a patient resides in Wisconsin, let’s say, but their
sibling or son or daughter handles their Medicare affairs and that
relative resides in a CBA, the permanent address with Medicare is
listed as the relative’s address,” Toscano, who listened in
on the conference call, explained. “The item of DME such as
oxygen would need to be provided by a contract supplier but there
are no contract suppliers in Wisconsin because they are not in
round one. How does the patient receive their equipment? How would
a local supplier be paid under the Medicare program in this
instance?”

–Licensure: What happens when bid winners are not
properly licensed to serve a bidding area?

Rob Brant, a Miami provider and president of Accredited Medical
Equipment Providers of America (AMEPA), asked Kaiser what would
happen with those companies–at least eight of them in the Miami
CBA alone, according to Brant–that won bids but do not have an
oxygen license in the state of Florida.

“The contract suppliers were accredited to furnish the
items they have been awarded a contract for,” answered
Kaiser. “If you have information about a specific contract
supplier where you think they were accredited for something
inappropriately then you should send an email to us and we will
research it.”

Kaiser’s answer, which addressed accreditation, confused
Brant.

“[Kaiser] kept saying ‘We put the responsibility on the
accrediting body.’ But he is not even answering the question as to
whether they checked the licensure,” Brant said. (For more,
see “Oxygen Licensure Is Issue for Some Bid Winners” in this
issue.)

–Subcontracting: Can we or can’t
we?

Toscano asked Kaiser the following question: “The article
off of the [National Supplier Clearinghouse] Web site states that
CMS interprets [section] 1834 of the Social Security Act to mean ‘A
supplier receiving payment from Medicare must be the entity
furnishing and billing for the items or services, specifically a
supplier cannot contract with other entities to provide essential
services.’ Are we allowed to subcontract for competitive bidding if
we did not have an agreement in place at the time that this was
filed?”

Kaiser’s response: “Yes, you may subcontract. The
contracted supplier is the one who will be submitting the claims
for reimbursement. The contracted supplier is the one who is
responsible for meeting the terms of the contract and ensuring that
the items and services that are paid for under the DME benefit are
provided. It is the contractor who is doing the billing. They may
subcontract with other entities to provide various services for
DME.”

Toscano then pointed out that Palmetto GBA’s Web site states
that “suppliers may not contract with other entities to
provide essential services as the supplier is the entity receiving
payment for Medicare, and therefore must be the one providing the
items or services.”

Kaiser said he would have to consult with CMS’ Office of
Financial Management to get clarification on the issue.

“Can you explain ‘essential services’?” Toscano
persisted.

”I think we need to wait and get that answer from our
supplier enrollment, supplier standards experts, who are not here
today,” Kaiser said.

–Grandfathering: What should providers be
doing?

Kaiser noted that CMS’ new Chapter 36 of the Internet-only
claims processing manual includes a section on grandfathering.
“This relates to individuals who are receiving oxygen and
oxygen equipment, or rented DME, from a supplier currently,”
he told listeners. “We provide guidelines for the supplier
regarding their decision to remain as a grandfathered supplier,
giving the beneficiary that option, or what they should be doing if
they elect not to be a grandfathered supplier. And that goes along
with the whole transition issue.

“We’re expecting current suppliers, who obviously have to
notify the beneficiary if they are not going to grandfather, when
they are going to pick up the equipment. There are obviously rules
on when they can pick up the equipment, so they will have to be
making arrangements with the supplier about that. They will have to
be communicating with beneficiaries to make those arrangements and
supply that information as to whether they are going to continue to
provide services to the beneficiary.

“And if they are not, then the guidelines provide for them
to refer the patient to a contracted supplier and to go through the
channels to locate a new contract supplier,” Kaiser said.

–Beneficiary Outreach: What has been done and what
is allowed?

Several callers expressed confusion over the proper procedures
for beneficiary outreach. One caller asked whether current Medicare
rules governing the methods of direct contact between a provider
and a beneficiary still apply under competitive bidding.

“My related question is that now that these contracts are
announced, are the winning bidders free to advertise and
communicate with the marketplace subject to those preapproval
rules?” he asked, noting that some of his customers had been
contacted by contract winners and told they would have to change
providers because his company had not won a contract.

A CMS official responded, “We are not establishing special
marketing guidelines for contract suppliers under this program. All
of the current DMEPOS supplier guidelines that apply as far as
marketing continue to apply. For example, the current prohibitions
on cold-calling Medicare beneficiaries when there is no prior
history of service and also prohibition against misusing the word
Medicare and Medicare symbols continue to apply.”

Another caller asked what CMS has been doing to ensure
beneficiaries are ready for round one.

“What type of communication is going out to the
beneficiaries directly? The thousands of patients that are on
service right now today–how are we communicating with them? Who is
going to help them in transitioning if a supplier is not going to
grandfather? Who is taking the lead on helping that patient that’s
laying in their bed, unable to get the mail or anything?” the
caller asked.

The response: “We don’t have representatives here from the
communications staff … but [we’re] using every avenue we can.
We have organizations of the state health insurance programs who
are helping to reach beneficiaries. There is going to be a mailing
to beneficiaries in bid areas. [We have an] extensive network of
advocates for beneficiaries who are going to be helping us with
education.”

The caller pressed, “Who is helping the patients who don’t
go out of their homes? Who don’t go to meetings? I just don’t
understand how CMS is going to reach those patients to tell them
what is going on.”

The response: “We don’t have the beneficiary outreach
people here so it’s hard to give you, really, specifics. We’ll try
to have someone here next time.”

During the conference call, agency representatives referenced
two tip sheets–one on grandfathering and another for referral
agents–that would be posted to the CMS Web site. They also said
providers should notify beneficiaries of their decision on
grandfathering by June 1.

“According to the teleconference,” said Toscano, “a
non-contracted supplier that elects not to become a grandfathered
supplier must provide notification to the beneficiary. So they are
asking in the next 30 days [that providers] notify every single
rental patient that has a piece of rental equipment. If the patient
chooses to switch, the supplier must pick up the equipment.

“We’re supposed to notify each beneficiary, get the
letters back and arrange for pickup if necessary and tell them to
visit the Web site or make the phone call all within the next 30
days. I think that’s an undue burden on a lot of suppliers,
especially if they have thousands of rental patients,”
Toscano continued, adding she believes that “no beneficiary
education has been done [by CMS] to date.

“They promised intensive outreach and education. None to
our knowledge has been provided,” she said.

For more on the agency’s new tip sheets, see “CMS Issues Tip
Sheets for Grandfathering, Referral Agents” in this issue.

To hear a complete replay of the CMS teleconference, which will
be available through June 4, call 800/642-1687 and enter access
code 47261135.