2015 could see many initiatives continue to gain traction
by Seth Johnson

Late last year, our industry was very close to securing legislative relief from competitive bidding. Although the proposed legislation was unsuccessful, support has never been stronger to address Medicare policy issues and pass the complex rehab separate benefit legislation. So what is the timeframe for advancement?

Competitive Bidding

Legislation was reintroduced in both the House and Senate in January to essentially make future bids binding through a requirement that necessitates acquisition a bid bond in order to participate in the program. Medicare is also required to verify that all state licensure requirements have been met prior to including a bidder's submission in the bid pool. Our congressional champions are pushing for action on this measure at the earliest opportunity in order to include this reform in the Round 2 recompete bidding process.

Complex Rehab Technology Separate Benefit

Legislation to create a separate benefit category for complex rehab technology (CRT) within the Medicare program is set to be reintroduced early this year in both the House and Senate. This legislation would provide appropriate segregation of CRT products and services to better address the unique needs of these patients. Congressional and consumer group support has been overwhelming. We ended 2014 with bipartisan support, securing 168 cosponsors in the House and 22 cosponsors in the Senate. We also had over 50 national consumer and clinician organizations supporting the bill.

Prior Authorization

Last year saw CMS expand the current power mobility device (PMD) prior authorization demonstration from the original seven states to a total of 19 States, and issue a proposed rule to apply prior authorization to other items of DME. The results from the PMD demonstration have been positive for CMS, beneficiaries, physicians and providers alike. Having the documentation reviewed on the front end and receiving an affirmative decision from Medicare prior to delivery of the device provides a high level of audit protection. Expanding PMD prior authorization nationally and including all base codes, options and accessories is a top priority.

Audit Reform

Audit reform also remains a top priority. At press time, Rep. Renee Ellmers, R-NC, planned to reintroduce her bipartisan audit reform legislation in January. The legislation would:

  • Create an improper payment outreach and education program, requiring each MAC to provide training and technical assistance to referral sources and suppliers
  • Reduce error rates through target audits by Medicare audit contractors with respect to high-error DME suppliers identified
  • Ensure benefit integrity improvement by requiring the secretary of the Department of Health and Human Services to ensure that all medical equipment suppliers are audited at least once in a 24-month period to determine the supplier's payment error rate. The secretary is provided the authority to excuse suppliers with a low payment error rate from further audits for some or all of a 24-month period. Suppliers that fail to respond to more than 5 percent of the audit requests directed at them in a year are subject to a site visit and sanctions
  • Require application of timely filing limits to claims subject to payment audits by allowing a timely filing override by the DME MACs for any claims related to an initial claim that is subject to a prepayment or RAC post payment audit
  • As stated earlier, there are multiple ways to get these industry priorities passed this year. The one thing that we, as an industry, must continue to focus on is making sure our legislators are well educated and understand the impact these issues will have on your company if not advanced this year. The industry is long overdue for some significant wins on Capitol Hill. I am confident that together we can advance our priorities and make 2015 a positive year for the industry.