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Legislation & Regulation

Coverage of federal and state legislation and regulation affecting HME providers, home health agencies and patients.

  • Debate on DMERC Power Wheelchair Clarification Heats Up

    Washington Debate surrounding the DMERC clarification on Medicare coverage for power wheelchairs heated up last month as industry stakeholders expressed their frustrations about the policy during a CMS Home Health, Hospice and DME Open Door Forum on Feb. 18. The controversial clarification followed CMS’ September 10-point plan, called “Operation Wheeler Dealer,” aimed at curbing fraud and abuse of the Medicare power wheelchair benefit. One of the plan’s points required the four durable medical equipment regional carriers to adopt a consistent approach to medical review of motorized equipment. According to the ensuing clarification, which was posted on the DMERCs’ Web sites in December, power wheelchairs are covered for “patients who are non-ambulatory,” that is, those who “can only bear weight to transfer from a bed to…
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  • Grassroots Lobbying It’s Our Business

    With the many Medicare changes (and when do we not have to deal with various legislative, regulatory and other policy changes?), every provider in our industry must first take the time to understand how important it is to get to know his or her legislators, and second, to spend time educating these legislators about our businesses, the products and services we provide and the consumers we serve. For those of you who have resisted over the years, now is the time to act. No one can do a better job than you. The following step-by-step primer focuses on how to lobby federal legislators, but the same rules apply to state representatives and senators. A specialist in health care legislation, regulations and government relations, Cara C….
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  • Getting Accredited and Doing It Now

    While the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) dictates that the Secretary of Health and Human Services develop quality standards for the durable medical equipment industry, the language of the law leaves interpretation wide open. Given the large number of DME providers and related organizations that must comply, it is expected that all accrediting organizations currently serving this industry will be needed to meet the requirement. It will be up to the provider to choose an accrediting organization and to develop a strategy for becoming accredited within a relatively short period of time. Fundamentally, accreditation is designed to establish a culture within a company that promotes sound business policies, best service and care practices, commitment to ethical conduct and methodologies that validate continual…
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  • Just More to Overcome, Not a Call to Exit

    OK. Among the many things home medical equipment providers were grateful for on Thanksgiving, Congress probably did not make the list. But come Monday morning, after a couple of “why me’s?,” and perhaps a dose of Prozac with a Starbucks chaser, HME owners across the country got around to what they do best — adapting and thriving. Here are a few reasons why the new Medicare Prescription Drug, Improvement, and Modernization Act (MMA) won’t send providers screaming into the night. As Bad as the Bill Is — and It’s Bad — It’s Not That Bad Other than the dramatic change in nebulizer reimbursement from discounts off Average Wholesale Price to a new model of Average Sale Price plus a paltry 6 percent (which clearly took…
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  • Are You Prepared for a Motorized Mobility Audit?

    If the DMERCs were to audit your K0011s (motorized wheelchair with programmable controls) and/or your E1230s (power operated vehicles/scooters), would you survive the audit? As part of the government’s 10-point plan to curb fraud and abuse in this market, the local medical review policy (LMRP) was reviewed carefully, giving consistency on how the DMERCs will audit and reimburse for these items. Not only will there be pre-payment reviews, there will be numerous post-payment reviews to verify that the provider should have been paid based on the documentation obtained. For K0011s and E1230s, Medicare will apply the national policy on old as well as current dates of service. The policy states that a “patient must be bed- or chair-confined without the use of a wheelchair, and…
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  • Doing Things Your Way

    The ROPE (Rule Overload Prevention and Elimination) system reduces “rule overload” while improving profitability and operational efficiency. Complying with the system requires climbing a ROPE ladder with five rungs. The first rung consists of three strands woven together: (1) Articulate how you want your systems to run and note, dispassionately, how they in fact do run; (2) identify whether the way you want to do things needs to be modified to satisfy legal rules; (3) and, finally, write down the operating policy. A Draft Policy But does this first rung really work? To find out, try running a preliminary test by creating a draft equipment purchasing policy. Start with questions. How do you purchase equipment? Do you have a standing order for minimum inventory? Do…
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  • Bush Calls for Improved Health Care Access

    Washington During his State of the Union address Jan. 20, President Bush called on Congress to help control health care costs and, at the same time, “extend the benefits of modern medicine” throughout the country. He also praised the Medicare Prescription Drug, Improvement, and Modernization Act that he signed into law in December. Among other priorities, the president’s speech proposed: In a statement issued following the address, the American Association for Homecare, Alexandria, Va., supported the president’s “vision for the future of America’s health care” but expressed concern about how Medicare’s overhaul will affect beneficiary access to care. “This is especially true as it relates to durable medical equipment, and the changes imposed on the home health and rehab sectors,” AAHomecare said. For breaking news,…
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  • Industry Stakeholders Fight DMERC Power Wheelchair Clarification

    Washington In response to the policy clarification on power wheelchairs issued in December by the four DMERCs, industry stakeholders continue their opposition and have requested an open dialog with the Baltimore-based Centers for Medicare and Medicaid Services on the issue. According to the DMERCs’ new clarification, power wheelchairs will be covered only for “patients who are non-ambulatory.” (See “The Scooter Store Lays Off 200,” page 8.) Industry advocates have also said that the clarification’s medical review guidelines may be applied retroactively. “The application of these new policies to beneficiaries who have already received power wheelchairs that met the previously accepted coverage criterion will cause irreparable harm to both beneficiaries and suppliers,” said American Association for Homecare President and CEO Kay Cox. In a December letter…
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  • Court Blocks California Medicaid Reimbursement Reductions

    Sacramento, Calif. Citing potential beneficiary access problems, a federal judge granted a preliminary injunction in December blocking provider cuts to Medi-Cal, the California Medicaid program, that were slated to go into effect Jan. 1. The cuts were part of a compromise budget proposal passed last summer by the state legislature and signed by then-governor Gray Davis. For California HME providers, the ruling affects those who sell disposable medical supplies such as incontinence supplies, said Bob Achermann, executive director of the California Association of Medical Product Suppliers (CAMPS). A 5 percent reduction of DME was “discretionary for the [California Department of Health],” he said. The department has not said it would enact the reductions yet, and they probably will not do so, he explained, “because of…
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  • Crossover Billing Begins For N.Y. Dual Eligibles

    Albany, N.Y. In December, the New York State Department of Health implemented a new procedure for billing Medicaid for Medicare co-insurance and deductible amounts for dual eligibles, or those eligible for both Medicaid and Medicare. The procedure follows state statutory changes enacted July 1, which reduced reimbursement to 20 percent of the 20 percent co-insurance cost, essentially representing a 16 percent cut, according to the New York Medical Equipment Providers association. For example, if a DME product costs $100, Medicare will pay $80, and the state’s Medicaid program will only reimburse $4 of the remaining $20 co-insurance, leaving $16 for the provider to absorb. Excluding pharmacy drug claims, according to NYMEP, the procedure is effective retroactively for dual-eligible claims submitted with dates of service on…
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  • Redefining Rehab: From State House to Capitol Hill

    In 2003, Tennessee became the first state to mandate certification for HME dealers when fitting individuals in wheelchairs for long-term use. Now known as “consumer protection” legislation, the law is a good beginning, according to Darren Jernigan, director of government affairs for Lebanon, Tenn.-based Permobil, which was instrumental in drafting the legislation and hopes to encourage other states to follow Tennessee’s lead. While provisions in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 make accreditation mandatory for providers reimbursed by Medicare, state laws would require certification for individuals and would apply to all providers, whether they do business with the government or not. “Requiring that a consumer who needs a wheelchair for long-term use be seen by a person with credentials in seating…
    Read More →: Redefining Rehab: From State House to Capitol Hill

  • Editor’s Inbox

    HME Providers “Set Up”To Take Fraud Fall There is nothing competitive about competitive bidding. It is just a tool for CMS to eliminate providers, fix prices and control fraud and abuse. Over the years, I have noticed that there seems to be an increase in the number of fraud cases uncovered by the FBI and OIG when there is some legislative change in the works. It is like they need to prove to everyone that what they are about to do is needed: “See! Look at the fraud! Now, take the punishment!” Interesting, isn’t it? The real rub of all of this is that the system is set up to allow an investigation of any one of us to result in an indictment. The paperwork…
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