Introduction
Competitive Bidding/MPP
• Work for the passage of legislation that would create a
MPP Demonstration Project (Rep. Tom Price)
• Work with key members of Congress on legislative
proposal to address reimbursement cuts in non-CB
areas starting on January 1, 2016.
Audit Reform / Legislation
• Work for the reintroduction of the AIR Act (Reps. Ellmers
and Duckworth)
• Participated in review of Senate Finance Committee
Audit Legislation Chairman’s Mark Language
• Participated in GAO Study on Prepay/Postpay Audits
and the appeals process
Prior Authorization
• Work with House and Senate on legislative language to
make the PMD Demo permanent and nationwide.
21st Century Cures Act contains demonstration
extension and expansion
Goal: include all power mobility devices and
accessories and options; and begin expanding the PMD
prior authorization nationally. This legislation exempts
suppliers for audits if they receive prior approval.
• H.R. 2437 Introduced by Blackburn
– Exempts from audits
– Requires prompt review process
CRT/Separate Benefit Legislation
• H.R. 1516 introduced on March 19, 2015, Reps
Sensenbrenner (R-WI) and Crowley (D-NY)
Bricks and Mortar State Legislative Effort
• Work with the Executive Committee and state
associations to assist state associations that are seeking
bricks and mortar licensure requirement.
CB/Binding Bid Update
– Requires the bidders to obtain a bid bond, which is
set up similarly to a surety bond.
– Requires CMS and their contractors to verify all
licensure PRIOR to accepting a bid.
– Requires suppliers to accept contracts if the price is
at or above their bid
– If supplier does not accept contract, bond $$ is paid
to CMS
– Bond company will pursue supplier for bond payment
• Called the HME Audit Key, this new audit tracking system will quantify the
impacts of audits and present compelling data that policymakers cannot
ignore.
• This is a massive, long term commitment that will benefit the entire
industry and AAHomecare is committed to making sure it is given the
resources it needs to succeed.
STATE OF THE AUDIT KEY
• First phase of testing complete – focus on functionality
• Second phase of testing in process now – 25 companies
participating with real data
• Challenges with phase II, access to data and completion
– Going back to 2014
– Suppliers actually tracking data in this format
– Challenges within current software applications
• Potential to develop audit and appeal application
• Develop quarterly reports
FACTS OF THE AUDIT KEY
• Web based application with validation, anonymity and
security
• Compiles audit activity and data going back to January
2014
• Requires suppliers be able to track audit activity
cumulatively
• Includes operational questions to be able to report based
on size of an organization
DATA ELEMENTS OF THE AUDIT KEY
• # of unique patients
• # of unique Medicare fee for service patients
• Net revenue (aggregate audit impact on small
businesses)
• # of claims submitted to Medicare fee for service
• # of patients setup by product category (establish
universe)
• # of audits received from MAC and RAC contractors pre
and post pay
• # of appeals to redetermination, reconsideration and ALJ
• Status of appeal activity at redetermination,
reconsideration and ALJ
How to Register
Data Collection
Phase II Testers – Thank you!
A Plus Medical
Advanced Homecare
Apria Healthcare
BLACKBURN’S
Fairmeadows Home Health Center, Inc.
Fairmont Home Medical
Har-Kel, INC.
HomeMed, LLC.
Hoveround Corporation
Inogen, Inc.
Laurel Medical Solutions
Liberty Medical Specialties
Medical Service Company
Reliable Medical Supply
Roberts Home Medical
Seeley Medical
Shield Healthcare Centers, Inc.
AAHomecare Regulatory Goals 2015
•
Focus on issues associated with Medicare’s (ACA) WOPD requirements
identifying issues, prioritizing and actively pursuing changes that would
benefit AAH members and the beneficiaries they serve.
– Signature date on electronic orders
– WOPD Definition – 5 elements
– Date Stamp
– Face to Face Requirement Only on Initial Order
– Face to Face HCPCs Recommendation
•
Improve/influence CERT oversight, understanding framework of CERT
contractor and authority. Develop relationship with CMS oversight contacts.
– Control what we can Control
– Written Order Prior to Delivery
– Detailed Written Order
– Proof of Delivery
AAHomecare Regulatory Goals 2015
• Focus on issues with Medicare’s documentation requirements
related to accessories and supplies identifying issues,
prioritizing and actively pursuing changes.
Repair documentation
Change of supplier documentation for supplies
• Evaluate, review and respond to all issues advanced notices
of proposed rules, proposed rules within the timeframe
specified.
Expansion CB pricing non-CB areas/bundling
EHR IT Certification
Anticipate additional proposed rule on
CB pricing expansion
AAHomecare Regulatory Goals 2015
• Participate in HCPCS coding initiatives with HCPCS
Coding Alliance, working with the PDAC and Dr. Hughes,
researching coding history, etc.
HCPC annual coding meeting May 2015
Met with Dr. Hughes
• Identify key CMS contacts on Medicaid oversight issues
and work to meet with them on identified Medicaid
issues.
• Medically Unlikely Edit (MUE) requests from CMS to be
evaluated and responded to in a timely manner by the
Medical Supplies Council.
AAHomecare Regulatory Focus 2015
• Sale replacement PMD components on group 2 chairs capped
• Timely filing limit exemption where initial claim in audit status
• RAC oversight with new dedicated contractor
• Proof of delivery requirements when payer change
• Clarification on filing oxygen claim for denial when patient does not
qualify
• Repair documentation requirements
AAHomecare Regulatory Focus 2015
• CMN/DIF requirements removed
• OMHA appeals backlog recommendations and follow-up
• OIG competitive bidding report on access to care for beneficiaries
• GAO study on pre-pay/post-pay audits and appeals backlog
• EHR limitations and Medicare DMEPOS requirements
• ICD10 implementation
AUDIT REFORM CONTINUED EFFORTS
• Remove ability for MACs to issue ‘clarifications’
• Enhance review of DME suppliers who do not respond to
audit requests
• Limit the number of audits a DME supplier can receive
• Reinstate “clinical inference” and “clinical judgment”
• Require that electronic health records include DMEPOS
medical necessity documentation
• Mandate use of a template in power mobility device
(PMD) prior authorization demonstration.
Final Rule on CB Pricing Expansion
• Established 8 BEA regions in the country
• Allowables based on the un-weighted average of SPAs from CBAs that
are In each region
• National ceiling and floor limits would be based on 110 percent and 90
percent, of the average of the RSPAs weighted by the number of
contiguous states per region
• Any RSPA above the national ceiling would be brought down to the
ceiling and any RSPA below the national floor would be
brought up to the floor
• Rural area” means a geographic area represented by a zip code of at
least 50 % of the total geographic of the area estimated to be outside a
metropolitan area (MSA) and not included in a CBA AND includes a
geographic area represented by a postal zip code that is a low
population density area excluded from CBA
Final Rule on CB Pricing Expansion
• Phase in reduction of allowables:
1/1/16 50% of the difference between current allowable and RSPA
7/1/16 100% reduction to the new RSPA
• Example an area where the adjusted fee is the RSPA rate - $100 and the
current state fee schedule amount is $200, the rate will be $150 for 1/1/16
– 6/30/16 and then $100 for 7/1/16 forward
• Adjustments to the fee schedule amounts for areas outside the contiguous
United States would be based on the higher of the average of SPAs for
CBAs in areas outside the contiguous United States (Honolulu) or the
national ceiling limit
• Payment adjustments for HCPCS included in no more than ten
competitive bidding programs an items no longer included in CB to 110
percent of the unweighted average of the SPAs to be implemented
throughout the entire country
Final Rule on CB Pricing Expansion
• Established only 1 RSPA for items (hcpcs) included in more than
1 product category – wheelchair accessories
• Payment amounts will be the weighted average of the single
payment amounts for the code computed for each CBA based
claims payment data
• Defines unbalanced bidding when there are more than one item
in a category with additional features or functions (enteral pump
with alarm and without alarm)
• Limit the allowable to the lower level SPA for enteral pumps and
group 1 and 2 power wheelchairs
• CRT accessories to be paid at SPA, no longer exempt
Pricing Examples RURAL AREAS
RURAL %
RURAL %
HCPCS CODE CURRENT RURAL 1/1/16 REDUCTION 1/1/16 RURAL 7/1/16 REDUCTION 7/1/16
A6550
$25.86
$25.86
0%
$25.86
0%
A7000
$10.25
$9.40
8%
$8.54
17%
A7030
$177.80
$145.31
18%
$112.82
37%
A7034
$110.87
$90.28
19%
$69.68
37%
B4034
$6.17
$4.86
21%
$3.55
42%
B4035
$11.77
$9.16
22%
$6.55
44%
B4036
$8.08
$6.50
20%
$4.92
39%
B4150
$0.69
$0.57
18%
$0.44
36%
B4154
$1.23
$1.02
17%
$0.80
35%
B9002
$119.90
$95.75
20%
$71.60
40%
E0143
$20.35
$13.13
36%
$5.90
71%
E0255
$110.73
$96.45
13%
$82.16
26%
E0260
$132.39
$105.36
20%
$78.33
41%
E0277
$663.03
$465.25
30%
$267.47
60%
E0431
$29.97
$25.73
14%
$21.49
28%
E0470
$241.85
$185.72
23%
$129.59
46%
E0601
$105.29
$78.59
25%
$51.89
51%
E1390
$178.24
$140.81
21%
$103.38
42%
E1392
$51.63
$49.27
5%
$46.90
9%
E2365
$105.72
$92.66
12%
$79.60
25%
E2402
$1,617.82
$1,256.89
22%
$895.96
45%
K0001
$58.25
$43.73
25%
$29.20
50%
K0003
$97.98
$71.51
27%
$45.03
54%
K0738
$51.63
$49.27
5%
$46.90
9%
K0822
$565.17
$462.17
18%
$359.16
36%
K0823
$568.89
$442.01
22%
$315.13
45%
K0825
$626.80
$525.27
16%
$423.74
32%
Pricing Examples Georgia (Southeast Region)
HCPCS CODE
HCPCS DESCRIPTION
CURRENT SOUTHEAST
SOUTHEAST 1/1/16
SOUTHEAST % REDUCTION AVERAGE % REDUCTION
1/1/16
1/1/16
24%
E1390
OXYGEN CONCENTRATOR
$
180.92
$
137.91
E1392
OXYGEN CONCENTRATOR, PORTABLE
$
51.63
$
46.77
E0431
OXYGEN PORTABLE SYSTEM, GAS
$
30.42
$
24.84
K0738
OXYGEN, PORTABLE GAS, USED TO FILL
$
51.63
$
46.77
E0601
CPAP
$
100.96
$
74.18
E0470
RAD, BILEVEL
$
240.01
$
178.83
A7030
PAP, FULL FACE MASK
$
180.47
$
141.39
A7034
PAP, MASK NASAL INTERFACE
$
112.53
$
E2402
NPWT PUMP
$
1,642.09
A6550
NPWT WOUND CARE SET
$
26.25
A7000
NPWT CANNISTER DISPOSABLE
$
8.90
$
8.47
5%
E0255
HOSPITAL BED, HI LO
$
102.86
$
87.87
15%
E0260
HOSPITAL BED, SEMI ELECTRIC
$
134.38
$
102.60
24%
E0277
LOW AIR LOSS MATTRESS
$
670.91
$
459.49
32%
E0143
WALKER, WHEELS
$
107.19
$
80.22
K0001
MANUAL WHEELCHAIR STANDARD
$
54.88
$
41.32
K0003
MANUAL WHEELCHAIR LIGHT WEIGHT
$
94.37
$
B4150
ENTERAL FORMULA, CATEGORY 1
$
0.70
$
B4154
ENTERAL FORMULA, CATEGORY 4
$
1.25
B4034
ENTERAL SUPPLY KIT, SYRINGE
$
B4035
ENTERAL SUPPLY KIT, PUMP
$
B4036
ENTERAL SUPPLY KIT, GRAVITY
$
8.20
B9002
ENTERAL PUMP WITH ALARM
$
121.70
E2365
BATTERY, POWER WHEELCHAIR
$
124.49
K0822
POWER WHEELCHAIR, GROUP 2 SLING SEAT
$
573.65
K0823
POWER WHEELCHAIR, GROUP 2 CAPTAINS CHAIR
$
K0825
POWER WHEELCHAIR, GROUP 2 CAPTAINS CHAIR HEAVY DUTY
$
SOUTHEAST 7/1/16
SOUTHEAST % REDUCTION AVERAGE % REDUCTION
7/1/16
7/1/16
24% $
94.89
48%
48%
9%
9% $
41.91
19%
17%
18%
18% $
19.25
37%
36%
9%
9% $
41.91
19%
17%
27%
27% $
47.39
53%
54%
25%
25% $
117.65
51%
49%
22%
22% $
102.30
43%
43%
87.81
22%
22% $
63.09
44%
44%
$
1,237.77
25%
25% $
833.45
49%
51%
$
25.26
4%
4% $
24.27
8%
8%
6% $
8.04
10%
10%
15% $
72.88
29%
31%
24% $
70.81
47%
47%
32% $
248.07
63%
63%
25%
26% $
53.25
50%
52%
25%
27% $
27.76
49%
54%
68.62
27%
29% $
42.86
55%
57%
0.56
21%
22% $
0.41
41%
43%
$
1.00
20%
21% $
0.74
41%
42%
6.26
$
4.79
24%
24% $
3.31
47%
49%
11.95
$
9.10
24%
25% $
6.24
48%
51%
$
6.40
22%
23% $
4.60
44%
46%
$
94.68
22%
23% $
67.65
44%
47%
$
98.53
21%
20% $
72.56
42%
38%
$
451.34
21%
22% $
329.03
43%
43%
577.42
$
438.53
24%
25% $
299.65
48%
51%
636.20
$
515.23
19%
20% $
394.27
38%
40%
Final Rule on Bundling
• CMS has discretion to establish rules on whether covered items are
paid for on a purchase or rental basis as long as total payments to
contract suppliers are expected to be less than the total amounts that
would otherwise be paid
• Bundling will occur in no more than 12 new CBAs
• Only for CPAP devices and standard power wheelchairs
• Suppliers retain the title to the equipment and be responsible for repair
and maintenance
• No exact timeframe for when the special payment rules will be
implemented. CBPs would be phased in as early as 2017
• As part of the process of allowing the rental agreements to continue, the
grandfathered supplier would be paid based on existing rules
• Non-contract suppliers have the option to continue
rental agreements
Final Rule on Bundling
• Comparator CBAs will be located in the same state as the CBA
where bundling CBAs are established
• Selected based on factors that could include geographic
location, general population, beneficiary population, patient mix,
and utilization of items
• Analysis strongly suggests that the benefits associated with
paying on a continuous monthly rental basis outweigh the
potential of increased copayments for the beneficiary
• Subsequent rulemaking would be necessary to adopt special
payment rules for other items or in more than 12 CBAs
• The process for documenting medical necessity for items would
be addressed outside the rulemaking process
VENTILATOR CODING CHANGES
EFFECTIVE JANUARY 1, 2016
Codes to be added effective January 1, 2016 (numbers not yet
assigned):
Exxx1 Home ventilator, any type, used with invasive interface
(e.g., tracheostomy tube)
Exxx2 Home ventilator, any type, used with non-invasive interface
(e.g,. mask, chest shell)
Codes to be discontinued effective December 31, 2015:
E0450 E0460 E0461 E0463 E0464
The Medicare fee schedule amounts for code E0450 will be used to
establish the fee schedule amounts for both new code Exxx1 and
Exxx2, thereby restoring payment to the levels mandated by the
statute for ventilators in general.
VENTILATOR CODING CHANGES
EFFECTIVE JANUARY 1, 2016
CMS intends to closely monitor use of new codes Exxx1 and Exxx2
to ensure that items used for the treatment of OSA are not being
billed under these codes.
Comments submitted:
Pricing concerns
Authority to make the pricing change
Pricing based on obsolete equipment
Lack of appropriate notice and comment
requirements
Special note:
CMS removed the inclusion of E0464 in round 1 2017
CMS Proposes HCPCS Changes for Miscellaneous
DME
CMS is proposing to revise the coding used to describe
miscellaneous durable medical equipment (DME) E1399.
Likewise, HCPCS code K0108 describes a “wheelchair component
or accessory, not otherwise specified” and is currently being used
to bill for inexpensive DME, other covered DME, and replacement
parts of wheelchairs. To promote more accurate payment of
Medicare DME claims
HCPC
# UNITS
ALLOWED $
PAID $
E1399
74,809
$4,720,843.18
$3,665,892.50
K0108
153,571
$21,510,709.52
$16,725,059.51
CMS is proposing replace HCPCS codes E1399 and
K0108 with the following HCPCS codes
KXXX1 DME, Miscellaneous, Purchase Price Does Not Exceed $150 -- CMS
calculates that the 2015 fee schedule amount would be $97.94
KXXX2 DME, Miscellaneous, the Purchase Price Exceeds $150 -- CMS
determines that the 2015 capped rental fee schedule amounts would be
$80.60 for rental months 1 thru 3 and $60.45 for months 4 thru 13
KXXX3 Wheelchair Component or Accessory, Miscellaneous, the Purchase
Price Does not Exceed $150 - CMS calculates that the 2015 fee schedule
would be $72.56
KXXX4 Wheelchair Component or Accessory, Miscellaneous, the Purchase
Price Exceeds $150 – CMS calculates that the 2015 fee schedule amounts for
items in this code would be $53.41 for months 1 thru 3 and $40.06 for months
4 thru 13
KXXX5 Repair Part For Use With Beneficiary Owned DME, Other Than
Wheelchair - Not Otherwise Specified – Payment individual consideration
KXXX6 Repair Part For Use With Beneficiary Owned Wheelchair,
Not Otherwise Specified – Payment individual consideration
AAH Comments Submitted July 9, 2015
• The Agency reserves the right to make internal coding changes as
necessary without notice.
• AAH Comments:
• Did not give the public sufficient notice of the Agency’s plan to
adopt new codes and assign new payment amounts.
• Proposes to create a new HCPCS coding logic that radically
departs from the one the Agency has used over the last 25 years.
• Uses a payment methodology that does not follow the structure
Congress established for the DME fee schedules under the Social
Security Act (SSA).
• Trying to effect payment adjustments by way of coding
determinations.
• Will result in gross under or overpayment.
Additional AAH Comments Submitted July 9, 2015
• CMS created miscellaneous codes for items that are unique or used
infrequently and that generally do not warrant their own codes. These
items are fundamentally different from other DME items and from each
other so they cannot be grouped together under one code and code
descriptor.
• CMS’ rules for assigning HCPCS codes state clearly that the Agency
considers products based on their similarity in function or
therapeutic effectiveness among other criteria.
• CMS’ decision to depart from the coding methodology that the Agency
itself created and instead designate HCPCS code descriptors based on
the price of DME products rather than their clinical function or features
of the technology, is arbitrary and undermines the fee schedule statute.
• AAHomecare recommends that CMS withdraw the proposal to
create new codes for miscellaneous DME based on the item’s price
and retain the current miscellaneous codes and pricing
methodology based on the contractor’s individual
• consideration.
How You Can Help
• Email or call the DC office of your Representative and
Senators asking for support for a specific issue.
• Action.AAHomecare.org has everything you need to
email or call your elected officials.
• Share your personal story and emphasize the specific
role of homecare in your community.
• Don’t give up. Keep up the volume.
You Can Do Even More on Social Media
• Just by sharing AAHomecare
or Save My Medical Supplies
information on your
Facebook page, you are
helping build awareness
about our issues in your
community. This is priceless
PR and just one post can
have a dramatic effect.
• A recent Save My Medical
Supplies Facebook post was
shared 39 times- it reached
more than 7,000 people.
• Imagine if 20 more HME
companies had shared that
on their Facebook pages?
Going Further: Engaging and Mobilizing Your
Patients
• Providers cannot be the only voice in the homecare debate.
• We need our patients to speak up! They have the numbers that can
prompt action.
• AAHomecare has an entire campaign devoted to mobilizing
patients- Save My Medical Supplies.
Contact Information:
Kim Brummett
Vice President, Regulatory Affairs
Kimb@aahomecare.org
(202) 372-0750
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