H.R. 5555 Gets Amended and Passes Energy and Commerce Committee

Published by Government Relations on December 06, 2023


On Wednesday, Dec. 6, The House Energy and Commerce Committee approved an amended version of H.R. 5555. The amended version of this bill extends the 75/25 blended rate in non-rural, non-CBAs through 2024 but does not include the 90/10 blended rate adjustment for suppliers in former CBAs. This is a great step forward in getting the 75/25 blended rate included as part of an appropriations bill early in 2024.

“Thanks to all of the engagement from our members, H.R. 5555 continues to move in a positive direction,” said Ike Isaacson, SVP of Government and Regulatory Relations. “We continue to be Champions of Change, together, to ensure that people get the services that they need. Your considerable efforts are paying off, and we need to keep the momentum going.”

If you would like to learn more about this bill or see who is already sponsoring it, please click here. While the key committees continue to work through bill priorities, we need your congressperson to stand up for you and for your clients to ensure that our bills are passed and that services can continue. If you have already reached out to your legislator, please consider doing so again.




GRASSROOTS EFFORTS NEEDED TO EXTEND NON-RURAL RELIEF

Grassroots efforts are underway to help secure co-sponsors for S. 1294 – Competitive Bidding Relief Act of 2023 to extend the 75/25 non-bid non-rural relief through 2024; below are key targets for co-sponsorship based on their past support of the issue.

In 2017, the Senate sent a letter to HHS regarding the need for non-bid relief, and many of those Senators are still in office today.  Please be sure to reach out to your Senators reiterating the continued importance of extending relief since we know CMS is proposing to go back to 100% of the adjusted rate starting January 1, 2024 when the relief is set to expire!

You can also share the AAHomecare issue brief when you reach out.

As a reminder, the SWMESA office is here to help! Send an email to info@swmesa.com. It is critical that your senator hears from you! 

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CMS INCLUDES DME PROVISIONS IN HHA PROPOSED RULE

On Friday, June 30, CMS released the 2024 Home Health Prospective Payment System (HH PPS) Rate Update proposed rule that includes items impacting DME.

It is a lot to unpack in the 164 page pdf over the 4th of July holiday!

Here is a quick overview of the CMS proposals what that is based off their Fact Sheet:

  • Proposal for Disposable Negative Pressure Wound Therapy: Included in Consolidated Appropriations Act (CAA), 2023, published Dec 29, 2022, CMS is proposing to codify statutory requirements for negative pressure wound therapy (NPWT) using a disposable device for patients under a home health plan of care. The CAA, 2023 requires that beginning January 1, 2024, there is a separate payment for the device only. Payment for the services to apply the device is to be included under the home health prospective payment system. There are also changes to now report the disposable device on the type of home health claim most familiar to Home Health Agencies.
  • Medicare fee schedule: As you know the CARES Act, https://www.govinfo.gov/content/pkg/PLAW-116publ136/pdf/PLAW-116publ136.pdf, required that Medicare payment rates for DME in areas other than rural and noncontiguous areas (aka non-rural rates) during the PHE be equal to 75 percent of the adjusted payment amounts (based on the DME competitive bidding program information), and 25 percent of the unadjusted fee schedule amounts. The CAA, 2023, requires payment based on these rates through the end of the COVID–19 PHE or December 31, 2023, whichever is later. CMS is proposing to make changes to the regulations to codify these payment rates through the end of the COVID–19 PHE or unless otherwise specified by law (aka December 31, 2023). CMS is proposing to revise § 414.210(g)(9)(vi) to state that for items and services furnished in all areas with dates of service on or after January 1, 2024, the fee schedule amount for the area is equal to the adjusted payment amount established under paragraph (g) of this section (which is the Application of Competitive Bidding Information and Limitation of Inherent Reasonableness Authority).
  • Lymphedema Compression Treatment Items: The CAA, 2023 establishes a Medicare Part B benefit for standard and custom-fitted gradient compression garments and other compression treatment items, for the treatment of lymphedema that are prescribed by an authorized practitioner.  This rule would address the scope of the new benefit by defining what constitutes a standard- or custom-fitted gradient compression garment and identifying other compression items used for the treatment of lymphedema that would fall under the new benefit category, beginning January 1, 2024. The rule proposes that Medicare would cover gradient compression garments for both daytime and nighttime use as well as ready-to-wear, non-elastic, gradient compression wraps with adjustable straps, and compression bandaging systems applied in a clinical setting as part of phase one decongestive therapy. This rule would establish the initial HCPCS codes and the payment methodology for these items and propose how future coding, benefit category, and payment determinations for these items would be made. The proposed payment basis for lymphedema compression treatment items is the average Medicaid State agency payment amounts plus 20 percent. In the event that Medicaid State agency payment rates are not available, this rule proposes to base payment rates on the average of TRICARE and internet retail prices. If neither Medicaid nor TRICARE payment amounts are available, this rule proposes to base Medicare payment rates on the average internet retail prices for a lymphedema compression treatment item.
  • Medicare Definition of Brace: would also codify the longstanding Medicare definition of brace to provide clarification on the scope of the Medicare Part B benefit for leg, arm, back, and neck braces and as a result, would classify certain exoskeleton-type devices as braces for Medicare payment purposes.
  • DMEPOS Refill Policy: previously CMS instituted policies to require suppliers to contact the beneficiary prior to dispensing DMEPOS refills. CMS is proposing to codify its long-standing refill policy, with some changes. They are proposing to require documentation indicating that the beneficiary confirmed the need for the refill within the 30-day period prior to the end of the current supply. Additionally, they are proposing to codify their requirement that delivery of the items (that is, date of service) be no sooner than 10 calendar days before the expected end of the current supply. CMS is also seeking comments for consideration in future rulemaking on ways to balance beneficiary burden with the potential risks/burdens of not verifying the beneficiary’s actual need for recurring supplies for certain individuals with permanent health conditions.
  • Other Provider Enrollment Provisions Finally, CMS is proposing additional provider enrollment provisions, which include, but are not limited to, the following:
    • Reducing the period of Medicare non-billing for which a provider or supplier can be deactivated from 12 months to 6 months.
    • Strengthening the program integrity safeguards associated with a provisional period of enhanced oversight.

Click here for the Fact Sheet.

Click here for the entire online proposed rule, or here for the .pdf version.

Make sure to continue reading your SWMESA News You Can Use for more details on the proposed rule. SWMESA will work internally and nationally on comments to the proposed rule. The comment period ends on August 29, 2023.

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THE MEDICARE ORTHOTICS AND PROSTHETICS PATIENT-CENTERED CARE ACT, H.R. 4315 INTRODUCED

Last month, H.R. 4315, the Medicare Orthotics and Prosthetics Patient-Centered Care Act, was introduced by Representatives GT Thompson (R-PA), Mike Thompson (D-CA), Brett Guthrie (R-KY), and Angie Craig (D-MN).  At press time, the text of the bill was not available.

The American Orthotic & Prosthetic Association (AOPA) shared in a press release that through its three major provisions, the legislation would: prohibit “drop shipping” of custom orthoses and prostheses to Medicare beneficiaries; ensure Medicare beneficiaries can access the full range of orthotic care from one O&P practitioner rather than requiring patients to visit multiple providers when the treating orthotist or prosthetist does not have a competitive bidding contract and; ensure Medicare beneficiaries can access replacement custom-fitted and custom-fabricated orthoses when a change in their condition or clinical needs occurs.

The bill has been referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means.

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REMINDER - 2023 FINANCIAL BENCHMARKING SURVEY

Several times a year, members reach out to the office looking for benchmarking information. It is valuable information that is important when comparing your company to the rest of the industry.

To have great benchmarking reports – there needs to be nationwide participation in the benchmarking survey from HME News/VGM & Associates!

SWMESA is reminding members to participate in the one-of-a-kind industry survey tracks important benchmarks like sales compensation, total collectible HME revenue, days sales outstanding (DSO), revenue per full-time employee and more. The anonymous survey concludes with a 20+ page report packed with industry data, and all respondents get a free copy just for participating! All providers are strongly urged to take the survey so they can provide you with the most accurate picture of our industry.

Visit https://vgmgroup.checkboxonline.com/hme-news-2023-benchmarking-survey to take the survey now. Deadline: July 31st. 


SWMESA Complimentary Webinar Opportunity through our sister association MAMES

Wednesday, April 5, 2023 1 - 2pm central time

Audits after the PHE: What’s Next?

With the anticipated end of the public health emergency on May 11, 2023, and the end of multiple waivers that applied during the PHE, many providers are wondering how these changes will impact audits.  There are many questions, including:  Are there any changes/waivers that began during the PHE that will remain permanent or that will extend post-PHE?  Will claims with dates of service during the PHE-era be subject to audit and, if so, using what criteria?   Join Ann, Cora and Noel as they address these questions and more by unpacking the current guidance issued by the government.
 

In the presentation, they will review the types of audits to which DME/HME providers are subjected and provide a preview of what you may expect or the rest of 2023 and beyond.  They will provide practical easy-to-apply guidance to enable you to be “post PHE audit-ready,” based on information a available from CMS as well as on their collective e experience in audits and compliance in the industry.
Presenters: Ann Ford, Partner/Managing Director and Cora J. Colvin, Consultant, with HPS Advise;
Noel Neil, Vice President of Auditing and Corporate Compliance, ACU-Serve Corp.

 

Wednesday, April 5, 2023, 1pm to 2pm central time

Virtual event via Zoom

Cost: No charge for SWMESA Members - MUST USE PROMO CODE: SWA29 at checkout. $29 for non-members.

For online registration, click here.  Limit of participants: 100
Upon registration, you will receive confirmation email that has a link to register to get the Zoom login information.


COVID-19: DON’T REPORT CR MODIFIER AFTER PUBLIC HEALTH EMERGENCY

In case you missed it last week, CMS announced that with the end of the COVID-19 public health emergency (PHE) expected May 11, 2023, the CR modifier and DR condition code should only be reported during a PHE when a formal waiver is in place, plan to discontinue using them for claims with dates of service on or after May 12, 2023. CMS points to Section 10 of the Medicare Claims Processing Manual, Chapter 38

This could be problematic for rental claims that were set up during the PHE where billing systems automatically apply the modifier to those claims. 

There has yet to be any more information from CMS related to our industry on the end of the PHE as it relates to rentals set up during the PHE and customers still renting after the PHE ends, among other concerns. SWMESA will continue to push nationally to get timely information.

DISPOSABLE MEDICAL SUPPLIES – 2 IMPORTANT SURVEYS TO HELP PUSH FOR INCREASE REIMBURSEMENT

SWMESA frequently hears from members that their reimbursement isn’t keeping up with the ongoing costs increases, that unfortunately, seems to be here to stay. At the state and federal level, SWMESA along with our national association and stakeholders continue to educate that changes in reimbursement rates must change to not have access to care issues. 

For disposable medical supplies, there is a nationwide survey currently underway by AAHomecare that SWMESA wanted to share. 

The purpose of the survey is to capture the real-world market impact on the disposable supplies space, including costs of products, shipping, and labor. Insights from the surveys will be used in advocacy efforts to help payers understand the need for sustainable reimbursement and ensure end user access.

SWMESA is encouraging our members who provide the following product categories to take the respective survey(s):


The survey deadline is Friday, April 14, 2023.  Individual company responses will be CONFIDENTIAL, and data will only be shared in aggregate with the overall nationwide survey findings.  

If you have questions or need additional information on the survey, please contact Ashley Plauché, AAHomecare’s Director of Member & Public Relations, at ashleyp@aahomecare.org

UPCOMING MEETINGS/EVENTS

Listed below are the meetings and events coming up. All times listed are central time. As always, if you have questions about our committee meetings or other events, please reach out to the SWMESA office.

Thursday, March 23:
9am: Rose Schafhauser meets with the Jur A Council to prepare for Jurisdiction A DME MAC-Noridian meeting at Medtrade

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Rose Schafhauser AT MEDTRADE: If you will be attending Medtrade, we hope to see you there!

Tuesday, March 28:
11:15am: SWMESA & MAMES Rose Schafhauser leads AAH State Leaders Council meeting
2pm: SWMESA Rose Schafhauser participates in AAH Board meeting followed by Executive Session

Wednesday, March 29:
8am: SWMESA members participate in the Region D DAC meeting with Jurisdiction D DME MAC – Noridian
10am: SWMESA & MAMES Rose Schafhauser in booth #407 for AAHomecare State Straight Talk 9am-5pm. Specific to Rose being in the booth – Midwest Region at 10:20 and Southwest Region 11am; then again 3:30pm – 5pm
1pm: SWMESA Rose Schafhauser participates in the Jur A Council meeting with the Jurisdiction A DME MAC – Noridian
5:30pm: SWMESA Rose Schafhauser at AAHomecare Stand Up for Homecare Reception

Thursday, March 30:
8am: SWMESA Rose Schafhauser participates in the NSCAC meeting with the NPE East and West Contractors – guests are welcome to attend the meeting, but are not able to speak during the meeting. Email the SWMESA office, info@swmesa.com for the room number if you are interested

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UPDATED: March 14, 2023

STATE LEGISLATIVE NEWS

There is legislation in AZ, NM and TX that we impact DMEPOS/CRT that SWMESA is monitoring and wanted to bring to your attention:
AZ: 
  • HB2175- AHCCCS; complex rehabilitation technology - includes any willing provider for AHCCCS, rate changes
  • HB2401Tax exemption for feminine hygiene products and adult diapers (2 bills the mirror each other)

NM:
  • HB53– delivery of necessary diabetic resources: relating to health insurance; updating coverage for individuals with diabetes; requiring consistent and timely delivery of medically necessary diabetic resources
  • Passed House March 2. In Senate SHPAC: reported by committee with Do Pass recommendation.  
  • SB255– Medicaid Services Mileage Reimbursement: includes for DMEs who deliver to Medicaid patients and Home Modification separated out
  • SHPAC: Reported by committee with Do Pass recommendation with amendment(s)

TX:
  • SB340- Relating to a sales and use tax exemption for child and adult diapers.
  • Note, there are 2 other bills similar,HB199andHB48
  • HB300- Relating to an exemption from sales and use taxes for certain family care items. Note, another bill that includes Diapers, breast feeding supplies, breast pump, maternity etc.
  • Testimony taken 03/06/2023. H Reported favorably w/o amendment(s) 03/13/2023
  • SB1666- relating to an insurer's obligation under a preferred provider benefit plan for continuity of care for certain Medicaid recipients
  • Introduced 03/06/2023. Companion billHB3985.
  • HB3916- Relating to the reimbursement of certain durable medical equipment providers participating in the Medicaid managed care program. Rate floor legislation to reimbursement at least equal to 95 percent of the rate paid under the Medicaid fee-for-service fee schedule.
  • Introduced 03/07/2023. Companion billSB1915.


MEDICARE OXYGEN POLICY – RESOURCES TO EDUCATE BOTH STAFF AND REFERRAL SOURCES

In case you are still getting questions from your staff and/or referral sources regarding the changes in the Medicare Oxygen policy, below are links to resources that should be very helpful. 

SWMESA is asking members who provide oxygen to please let us know if you have further questions or suggestions on education. The Medicare Councils are meeting this week to finalize questions for their May Council meetings.  Please send questions/feedback to the SWMESA office, info@swmesa.com


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CMS-855S – NEW APPLICATION - REVISED DATE

Per list serve from the National Provider Enrollment East and West Contractors, there is to be a new CMS855S application that CMS extended the acceptance period of the previous CMS 855S version (11/21). Previous versions will be accepted until April 7, 2023. After April 7, 2023, only the current version may be accepted (01/22). 

Changes to the form include: 

  • Added Medical Record Correspondence Address to Section 4B2
  • Revised Section 2E: Products and Accreditation Information to collect whether the supplier fills orders, fabricates or fits items by contracting with other companies. 

The revised application will be posted on the CMS Forms List. Unfortunately, at press time, CMS still has not posted the updated application.


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PHILIPS RECALL UPDATES FROM MAMES/SWMESA MEMBERSHIP MEETING

Yesterday, MAMES & SWMESA members received the latest updates on the Philips recall in the MAMES/SWMESA/Philips monthly meeting. Here are the key takeaways from the meeting:

  • Ventilation Update
    • Remediation plan update: Trilogy 100 have submitted recommendations to the FDA and currently under review. Do not have resolution or timeline.
    • Loaner program update:  Continue EVO loaner process to provide units for patients impacted by the recall that need them. There has been an update to program – the language has been softened to use be able to use as physician sees fit. Recommend looking at the language of the program.
  • PAP Update
    • Production and distribution progress: Around 95% completed. Have components or equipment to meet current need.
    • Opened unit progress: For PAP inventory you have on shelf. Going through the list by alphabet and currently in the R’s of the providers/customer name. If you have a company name earlier than R – please reach out to account manager. There will be some investigation or other circumstances that will have to be investigated.
    • System One patients: The patients need to select option – 1) Financial payment for return of affected units, or 2) Continue remediation path to receive a replacement device.
      • They have to go into the patient portal or call hotline to indicate what their choice is.
    • Auto-adjusting CPAP program: for patients who have not provided prescription, the patients are given option to select auto-adjusting device.  Continue towork those for it speeds up the process and gets it to the patients sooner.
    • Non-responsive patients: know AutoSV, AVAP, etc. where you have reached out to patients, patients aren’t responding and have asked to send back. Do need to have a process – please be patient. Reach out to Recall coordinator or DME specific email address, recall.support@philips.com, the trained internal experts. Feel free to copy acct manager.
    • Reminder on exception process: who failed one check from their registration – last name different to how they registered, etc., they have been removing their serial number (not patient) from the DME CO in order to remediate e through this process. Once remediated, asked patient to contact you and put back into CO.
  • Leadership Letter: The March Leadership letter will be going out this week to providers. Click here for copy of the letter that will be going out.


Once again, SWMESA would like thank Philips for working with MAMES & SWMESA in getting these updates for what continues to be challenging.

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CRT MEMBERS – FRIDAY, MARCH 17 DEADLINE!
REMINDER TO SUBMIT COMMENTS ON PROPOSED COVERAGE OF POWER SEAT ELEVATION SYSTEMS

The following reminder is from NCART to get comments submitted by this Friday. At press time, there have been 1633 total comments submitted!  Comments on can be submitted here.

Since February 15, the CRT community has been hard at work providing feedback on the CMS proposed coverage determination for power seat elevation systems. For anyone who hasn't taken advantage of this opportunity to voice support for Medicare coverage of this critical technology, you still have time! Public comments are being accepted through this Friday, March 17. 

WE NEED YOU TO TAKE ACTION! 

1.) If you haven't already, please review the proposed decision memo from CMS and submit comments in support of the decision. The dedicated website at www.rise4access.org has been updated with a summary of the proposed coverage, suggested talking points, and instructions on how to submit your comments.

 2.) Please share this opportunity with others.  It is critical that CMS receives as many supportive stakeholder comments as possible from organizations, individuals who use wheelchairs, caregivers, clinicians, healthcare providers, suppliers, manufacturers, friends, family, and all other advocates! 

SWMESA would like to thank NCART for this reminder, and all the stakeholders that have already submitted comments!

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KICKBACKS TO PHYSICIANS

The following article is about kickbacks to physicians by Elizabeth E. Hogue, Esq. ph. (877) 871-4062.

The Department of Justice recently announced that a federal jury in Minnesota reached a verdict of $43 million against an ophthalmology distributor. The distributor was accused of greasing surgeons’ palms with luxury travel and sports tickets, among other kickbacks. This verdict triggers a possible liability of $485 million under the False Claims Act based on services rendered to patients referred by surgeons who received kickbacks. Here we go again! Relationships with referring physicians are “low-hanging fruit” for enforcers.  

Act now, as follows, to avoid these types of enforcement actions: 

Providers are likely to avoid violations if they meet the requirements of the personal services “safe harbor” under the federal anti-kickback statute and the contractual exception under the Stark laws. The safe harbor and exception generally require providers to pay consulting physicians who also make referrals to them based on written agreements for a term of at least one year that require payments at fair market value for services actually rendered without regard to the volume or value of referrals received. 

From a practical point of view, in addition to meeting the requirements described above, providers should do the following: 

  1. Providers should develop standardized agreements and use them consistently with all referring physicians who receive consulting fees from them. Providers cannot afford to use a variety of different agreements that may not meet the requirements described above. Staff must understand that they can use only the standard approved agreement and cannot modify it without advance written approval from a designated, knowledgeable individual.

2.Documentation of services rendered and the amount of time spent in these activities is crucial. Providers should develop and implement policies and procedures that permit payments to physicians only after appropriate documentation to support payments has been received from physicians and reviewed, including dates on which services were performed, descriptions of activities, and amount of time spent on each activity.

3.Providers should not have agreements for consulting services with physicians whose services they do not actually use, even if they make no payments to them. Providers should terminate the agreements if they do not need the services covered by the agreements. Otherwise, it may appear that the only purpose for the agreements is to induce referrals, as opposed to a documented need for services.

4.Although there are usually no limits on the number of consulting physicians/medical directors that providers can have at any given time, a large number is likely to invite scrutiny by regulators and should be avoided. How many is too many? The number should certainly bear some relationship to the size of the provider organization and the geographic area served. Beyond these general guidelines, common sense must prevail. The bottom line is: does the Agency have legitimate work for every consulting physician?

5.The commercially reasonable services consulting physicians are asked by providers to perform cannot be related to the volume and value of referrals made. Providers cannot, for example, ask referring physicians to assist with quality assurance activities that entail review by consulting physicians of the charts of patients they referred to the provider so that the more referrals made, the more money consulting physicians make.

Providers are more likely to avoid enforcement activities when they follow these practical guidelines. Violations hurt providers and referral sources alike. Expenditures of financial and other resources to get it right are certainly justified in view of the possible adverse consequences.

©2023 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.


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UPDATED: February 28 2023

LATEST UPDATES ON THE PHE ENDING MAY 11, 2023


Today, Feb 27, 2023, CMS published “What Do I Need to Know” regarding CMS Waivers, Flexibilities, and the Transition Forward from the COVID-19 Public Health Emergency. Here is a summary:

CMS if providing a new overview fact sheet on CMS Waivers, Flexibilities, and the Transition Forward from the COVID-19 Public Health Emergency.  Over the next several months, CMS will work to ensure a smooth transition back to normal operations. 

The CMS Waivers, Flexibilities, and the Transition Forward from the COVID-19 Public Health Emergency provides clarity on several topics including:

  • COVID-19 vaccines, testing, and treatments;
  • Telehealth services;
  • Health Care Access

In the coming weeks, CMS will be hosting stakeholder calls and office hours to provide additional information. Please visit the CMS Emergencies Page for continuous updates regarding PHE sunsetting guidance as information becomes available to the public. 

As always, SWMESA will continue to keep members updated in the NYCU on any current updates related to the expiration of the PHE.

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DMEPOS SUPPLIER STANDARDS REVISED


In case you missed it, the Medicare DMEPOS Quality Standards have been revised.
Here is what’s changed:

  • Discontinued Certificates of Medical Necessity and Durable Medical Equipment Information Forms
  • Added items that support medical necessity in a patient’s medical record
  • Replaced the National Supplier Clearinghouse with 2 National Provider Enrollment contractors

Although there is a link to the DMEPOS Quality Standards document on MLN Educational Tool, it takes you to the January 2018 document. At press time, only the MLN page had the changes. 

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COVERAGE FOR POWER SEAT ELEVATION – REMINDER TO SUBMIT COMMENTS

 

In last week's News You Can Use CMS released a proposed National Coverage Determination (NCD) decision on that would expand coverage for power seat elevation equipment on certain power wheelchairs to Medicare individuals. The proposed NCD is open for public comment for 30 days, which closes on March 17, 2023. 

If you haven't submitted comments on the power seat elevation - it is super simple – see the link below that takes you to the comment page. Get staff, clients, referral sources, etc., to comment as well. 

See www.rise4access.org for talking points - but we would imagine you all have experienced firsthand the importance of the technology for clients! 

The proposed NCD decision memorandum is available to review here

CMS is seeking comments on their proposed decision and is additionally seeking specific comments on whether power seat elevation equipment on Group 2 power wheelchairs primarily and customarily serves a medical purpose and thus also falls within the benefit category for durable medical equipment.  

Comments on can be submitted here

NOTE: At press time, over 663 comments have been submitted!

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UPDATE: AWARENESS OF THE RESUMPTION OF MEDICAID RENEWAL PROCESSES REMAINED LOW IN DECEMBER 2022
 

Part of the Consolidated Appropriations Act, 2023, the continuous Medicaid enrollment condition will end on March 31, 2023. CMS released key dates and activities guidance on the CAA for states back in January.

It will be important for SWMESA members to be aware that many individuals may be impacted and could potentially lose their Medicaid coverage and not be aware of it. The following is from the Urban Institute on what they found: 

On April 1, 2023, states can begin disenrolling Medicaid enrollees for the first time since March 2020, under provisions of the Consolidated Appropriations Act that unwind the pandemic-related Medicaid continuous coverage requirement and allow states to resume regular renewal processes. However, enrollees who are unaware of the change may be less prepared to complete the necessary steps to maintain coverage or, if they are no longer eligible, to obtain other coverage. In this fact sheet, we present updated estimates of awareness of the change based on the December 2022 Well-Being and Basic Needs Survey. We find the following:

  • In December 2022, more than 6 in 10 adults in Medicaid-enrolled families were not aware of an upcoming return to the regular Medicaid renewal processes, a rate that has not changed significantly since June 2022. Specifically, 64.3 percent of adults enrolled in Medicaid or with an enrolled spouse, partner, or child had heard nothing at all about the upcoming change in December 2022. An estimated 5.1 percent had heard a lot, 13.9 percent had heard some, and 16.0 percent had heard only a little.
     
  • Awareness was low across the country, regardless of region, state Medicaid expansion status or type of Marketplace operating in a state. Though fewer adults in the West were unaware of the upcoming change than in the Northeast (61.3 versus 66.5 percent), lack of awareness of the change was above 60 percent in all four regions of the country. Awareness was similar in state groups based on whether states had or had not adopted the Affordable Care Act’s Medicaid expansion (with 64.5 percent in expansion states and 63.7 percent in nonexpansion states unaware) or whether states used state-based or federally facilitated marketplaces (64.3 and 64.2 percent, respectively).

    Most adults in enrolled families had heard nothing about change, and awareness did not vary widely by state characteristics. These findings suggest the need for widespread outreach and education efforts.

Download the report here

 Hopefully since this report was published, more people are aware of the changes coming. States have been actively working on the unwinding for many months and have been communicating on updates to their enrollees, providers, stakeholders, and health plans.

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REMINDER - NSCAC CALL FOR QUESTIONS FOR THE NATIONAL PROVIDER ENROLLMENT (NPE)
 

As shared in last week's News You Can Use, we announced there is a call from the National Supplier Clearinghouse Advisory Committee (NSCAC) for questions/issues for both the NPE-East and NPE-West contractors. To submit a question(s) or issue(s), click here for the online form. If you have problems accessing the online form, please let the SWMESA office know, info@swmesa.com. Questions are due by next Thursday, March 9.

 

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CALL FOR MEDICARE QUESTIONS – DUE MARCH 9
 

SWMESA is a dues paying member of the Region D DAC and SWMESA, Executive Director, Rose Schafhauser provides the administration for the Region B Council. Both Councils work with their respective Medicare contractors, the Jurisdiction B DME MAC – CGS and the Jurisdiction D DME MAC – Noridian, on a quarterly basis. 

With SWMESA being a member of the Region D Council, SWMESA members have an opportunity to submit Medicare questions in order to get answers in writing from the DME MACs.

To have an idea for what kind of questions get submitted along with the answers provided, click here for the February 2023 Medicare Council Q & A’s from the Council meetings this month. 

The next quarterly Medicare Council meetings for the Region B Council and the Region D DAC are set for 2nd quarter 2023.

This is a call for questions! 

Click here for the online form to submit questions for the appropriate specialty A-Team(s) by product categories. There is no limit to the number of questions submitted.  

Questions are due to the Council office by close of business next Thursday, March 9, 2023. NO LATE QUESTIONS WILL BE ACCEPTED.

Again, questions must be submitted via the online form. If you have problems linking to the online form, please let the SWMESA office know at info@swmesa.com.

This is such a great opportunity to ask Medicare questions that you are not able to get answers through reviewing policies, articles, etc.


UPDATED: February 16 2023

SWMESA sets virtual meeting with Representative Schweikert - Mark your calendar!

SWMESA has set a virtual meeting with Representative David Schweikert. Representative Schweikert is on the House Ways and Means Committee and is Chairman of the Oversight Subcommittee and is also a member of the Joint Economic Committee.

This virtual meeting has been set for Tuesday, March 7, 2023. 5:30 - 6:30pm EST. 

Please watch for details and an RSVP request in the coming week.

 
 
A FEW MORE DETAILS ON THE PHE ENDING MAY 11, 2023


Here is the latest update from CMS to help prepare for the ending of the public health emergency (PHE) May 11, 2023.

Fact Sheet: COVID-19 Public Health Emergency Transition Roadmap | HHS.gov

  • Includes what will NOT be affected because of extended flexibility and actions, such major telehealth flexibilities continue to exist for those participating in Medicare or Medicaid.
  • Includes what WILL be affected, including certain Medicare and Medicaid waivers and broad flexibilities for health care providers are no longer necessary and will end. Coverage for COVID testing will also change and access to free over-the-counter tests will end for Medicare. The list is long and you will want to review it.


DME waivers: This document was last updated 02/01/23. Several have already expired. The exception is to the 75/25 non-rural rates that passed last year extending that reimbursement through 12-31-23. This gives us time to extend or have it permanently. Unfortunately, this document doesn’t cover all DME flexibilities. Refer to your respective DME MAC’s COVID-19 pages:


In last week’s Region B Council and Jurisdiction C Council meetings (SWMESA Executive Director, Rose Schafhauser participates in these meetings) with the respective DME MACs, as expected, they did not have any updates for they too, are waiting on CMS instructions. The DME MACs did hear some concerns from providers related to patients who were set up under the PHE with the items under the waiver, who most likely will have the items after the PHE ends. They do share the concerns with CMS.
 

As always, SWMESA will continue to keep members updated in the FYI on any new updates related to the expiration of the PHE.

 

OVER 35 MILLION PRIOR AUTHORIZATION REQUESTS WERE SUBMITTED TO
MEDICARE ADVANTAGE PLANS IN 2021
 

On February 2, 2023, The Kaiser Family Foundation (KFF) published a report Over 35 Million Prior Authorization Requests Were Submitted to Medicare Advantage Plans in 2021 that indicates some concerns that the requirements and processes may create barriers and delays to receiving care.

 

According to report, as part of its oversight of Medicare Advantage plans, CMS requires Medicare Advantage insurers to submit data for each Medicare Advantage contract (which usually includes multiple plans) that includes the number of prior authorization determinations made during a year, and whether the request was approved.

In the data for 2021, they found:

  • More than 35 million prior authorization requests were submitted to Medicare Advantage insurers on behalf of Medicare Advantage enrollees.
     
  • The volume of prior authorization determinations varied across Medicare Advantage insurers, ranging from 0.3 requests per Kaiser Permanente enrollee to 2.9 requests per Anthem enrollee.
  • Over 2 million prior authorization requests were fully or partially denied by Medicare Advantage insurers.
     
  • Just 11 percent of prior authorization denials were appealed.
     
  • The vast majority (82%) of appeals resulted in fully or partially overturning the initial prior authorization denial.
    1. Prior Authorization Requests Are More Common Among Certain Medicare Advantage Firms
    2. Firms Denied Between 3% and 12% of Prior Authorization Requests
    3. About 1 in 10 (11%) Prior Authorization Request Denials Were Appealed
    4. Across Most Firms, the Vast Majority of Prior Authorization Request Denials that Were Appealed Were Overturned

They compared Anthem, BCBS Plans, Centene, CIGNA, CVS, Humana, Kaiser Permanente, UHC, and others on the following items and provided 4 figures of the data for each:

  1. Prior Authorization Requests Are More Common Among Certain Medicare Advantage Firms
  2. Firms Denied Between 3% and 12% of Prior Authorization Requests
  3. About 1 in 10 (11%) Prior Authorization Request Denials Were Appealed
  4. Across Most Firms, the Vast Majority of Prior Authorization Request Denials that Were Appealed Were Overturned


Here is the full report: Over 35 Million Prior Authorization Requests Were Submitted to Medicare Advantage Plans in 2021 | KFF


So, what can we pull from this report?


With the 2 proposed rules CMS recently published in December (KFF includes links in the report), that include provisions related to PA’s, indicates CMS is looking for improvements in reducing overall payer and provider burden and improving patient access to health information. As an industry, there is a need to share what is happening, so when the opportunity arises to provide feedback to CMS and congress, that there is data to show the impact on your ability to provide care to Medicare Advantage patients.


Do you track what happens with your Medicare Advantage PA’s?

POWER SEAT ELEVATION SYSTEMS UPDATE -
CMS PROPOSED DECISION EXPECTED THIS WEEK


Back on August 15, 2022, CMS initiated a National Coverage Analysis (NCA) on Seat Elevation Systems as an Accessory to Power Wheelchairs on the formal request to consider both the benefit category and coverage for seat elevation systems and standing systems associated with Group 3 power wheelchairs. CMS decided to consider seat elevation at this time and coverage of standing system at the later date. 


According to the CMS timeline, the formal comment period was August 15 – September 14, 2022; and the Proposed Decision Memo Due Date is slated for this Wednesday. February 15, 2023. The Expected NCA Complete Date is May 16, 2023. 

In an update from NCART today, they shared that once the proposed decision is released, there will be another 30-day public comment period for stakeholders to provide feedback. After those 30 days, CMS will review any new evidence and make needed revisions before releasing a final decision.


SWMESA Executive Director, Rose Schafhauser will work with NCART to encourage providers to submit comments along with submitting comments on behalf of SWMESA. SWMESA thanks NCART for all they do for the industry!


Make sure to continue to read your SWMESA News You Can Use for updates on this important work that has been years in the making.

REGION B COUNCIL UPDATES

SWMESA Executive Director, Rose Schafhauser, participated in last week’s Region B Council hybrid meeting with the Jurisdiction B DME MAC, CGS. Rose serves as the administration for the Region B Council as well as the Jurisdiction A & C Councils and is active in Jurisdiction D.
 

The quarterly meetings highlight recent updates and provides a back on forth discussion on issues and challenges providers are experiencing.

Here a few important highlights from the Council meeting:

  • Claims that previously required CMN/DIF: CGS reported a Claim Payment Alert on Claims for HCPCS that previously required a CMN/DIF may have been denied in error for missing the CMN/DIF for dates of service on and after 01/01/2023. There was a large volume of claims that were affected and providers did not see the denials. CGS caught it early, held the claims, and got a fix out last week. All claims will be released for processing and no action is needed from providers. NOTE: all 4 DME MACs ended up with this issue.
  • Oxygen Policy: there continues to be back on forth discussions related to the policy. The Council was able to provide feedback on education that is being conducted and provided feedback on the major concerns of the industry. There will be an Oxygen FAQ that hopefully will be released soon that will address the hot topic questions providers have had on the policy.
  • Documents shared with Region B Council and Jurisdiction C Council – these are excellent tools:
     
  • Auditing Entities Chart
  • DME Whom to Contact List 

The next Region B Council meeting is set for May 23/24.

MEDICARE SECOND PAY (MSP) ALERT – FROM NORIDIAN
 

The SWMESA office was asked to share this Alert from Noridian Healthcare Solutions, LLC, the Jurisdiction D and A DME MAC:


CMS is encountering a severe issue where several providers, physicians and other suppliers are denying services and treatment to Medicare beneficiaries due to an open MSP record on CWF. This practice must not be followed. Please forward the below to your provider, physicians and other suppliers immediately.

 

To our providers, physicians and other suppliers,

 

 It has come to CMS’s attention again that there are some providers, physicians and other suppliers who are denying services to beneficiaries due to an open Medicare Secondary Payer record on the beneficiary Medicare record. Providers and suppliers shall not deny medical services or entry to a SNF or hospital after you discover that there is an open or closed GHP (whether the beneficiary is entitled due to age, disability, or End Stage Renal Disease) or NGHP (Liability (L), No-Fault (NF) or Workers’ Compensation (WC), MSP record found in the HIPAA Eligibility Transaction System (HETS)  270/271, or on CWF. You must continue to see Medicare beneficiaries if a claim that was previously mistakenly denied by Medicare due to an MSP occurrence. These claims may be appealed through the appeal process.

  • Provider, Physician and Other Supplier Billing. If services are covered under an open GHP or related to an NGHP MSP accident or injury incident, bill the primary insurer first. There are situations where providers bill for services related to a new accident or injury that are not related to an existing NGHP MSP record found on HETS or CWF. Physicians, providers and suppliers may need to use the same diagnosis codes that are found on the NGHP record in HETS and CWF. You may submit these claims to Medicare after you submit these claims to the appropriate GHP and/or NGHP insurer. The NGHP insurer may deny these claims if the claim is not related to the original accident or injury or the case has not been settled. After you submit these claims to Medicare, Medicare may mistakenly deny these services because the diagnosis codes on the claim are related to the diagnosis codes found on the NGHP MSP record on HETS and CWF. Physicians, providers and suppliers may appeal the inappropriately denied claim with your MAC. Physicians, providers and other suppliers must provide an explanation or a reason code to justify the services aren’t related to the accident or injury on record. Nonetheless, Physicians, providers and other suppliers must continue to see or provide services to the beneficiary if claims are mistakenly denied.

A Workers’ Compensation Medicare Set Aside (WCMSA) MSP record is not a reason to deny services, but instead it provides information as to who is the appropriate primary payer for that situation. A WCMSA is an agreement between the CMS and the CMS beneficiary about what value of settlement funds must be spent for care related to all settled WC injuries or illnesses before Medicare begins 270/271 transaction whether a “W” WCSA record exists. Where there is an indication showing a “W” MSP WCMSA record exists, the patient should have a WCMSA that may pay for services, and the provider bills the patient, directly. If the WCMSA does not pay for all of the services due to total exhaustion the provider may submit a Medicare bill indicating what the WCMSA paid. Medicare may then pay as a primary or secondary payer, dependent upon the WCMSA status and how much it paid on the claim. The provider submits a bill in accordance with the regular billing procedures indicating occurrence code 24 (insurance denied) and the date of denial in FL 31-36 (UB-04 claim form); and a supplementary statement calling attention to the fact that WCMSA denied payment or annotates FL 80 (UB-04 claim form), remarks, with the reason.

 

Billing no-fault, liability and worker’s compensation claims

 

When providers, physicians and other suppliers render services for beneficiaries whom have an open NGHP found on CWF, and in HETS, they must bills as follows:

 

If the NGHP record shows an indicator of  “Y” identifying there is Ongoing Responsibilities for Medicals (ORM), do not bill Medicare. The NGHP insurer should be billed first as they are the proper primary payer for claims related to the accident or injury.

  • If the NGHP record shows an indicator of “N” or “BLANK” identifying there is no ORM, bill the NGHP insurer first. If the NGHP insurer denies the claim and identifies the reason for the denial on the remittance advice, the denial should be placed on your claim to Medicare. This will assist Medicare in determining to make a conditional payment during the promptly payment period.
  • If there is an open employer Group Health Plan record on CWF and HETS, always bill the GHP insurer first even before you bill the NGHP for both ORM and non-ORM claims.

PHILIPS RECALL UPDATES FROM MAMES and SWMESA MEETING
 

Yesterday, SWMESA members were able to get the latest updates on the Philips recall in the MAMES/SWMESA/Philips monthly meeting. Here are the key takeaways from the meeting:

  • Ventilation Update
  • Loaner progress - Continue EVO loaner process to provide units for patients impacted by the recall that need them. Delayed orders or purchases for EVOs, having to continue to balance with production capabilities. Work directly with account manager.
  • There is not a pathway for the Trilogy 100 yet – have submitted engineering and processing to the FDA and they are reviewing that. Best case is to begin in May or June to remediate – could be sooner or later – depends on FDA.
  • Recall progress – 90% of the production of replacement devices and repair kits has been completed. Anticipate by the end of February on the plan for production for new products. Allows them to negotiate with the FDA to begin providing CPAPS again.
  • Did get approval on exception patients who haven’t been able to obtain prescription.
  • Auto-adjusting CPAP program – get approval from the patient to accept that option and they will get automatically get set up in Auto. They report up to 30,000 who have submitted the auto option. Once the decision is made, the process moves quickly.

Next meeting: is set for March 13 at 10am central time. An appointment request has gone out on Monday to members who have participated in these meetings in the past.


NOTE: If you do NOT have an appt request for this meeting, RSVP here. The meeting login details will be provided after you submit the RSVP. The login is the same for all meetings.  


Once again, SWMESA would like thank Philips for working with MAMES and SWMESA in getting these updates for what continues to be challenging.




Updated: November 16, 2022

An update from AAHomecare, November 15, 2023

Ask Your Legislators to Support Medicare Reimbursement Relief in Year-End Omnibus Legislation

As the dust settles from last week’s mid-term elections, Congress is turning its attention to crafting a year-end omnibus bill which will include language to extend the debt ceiling and keep the government funded.

As leadership on key committees of jurisdictions negotiate on what measures to include in omnibus legislation, it is critical that the HME community make its collective voice heard in support of reimbursement relief in former CBAs and in non-rural, non-CB areas that reflects the market reality for suppliers.

There is always a great deal of advocacy from almost every segment of the business and financial sector to see their interests represented in year-end legislation, and our sources on the Hill tell us that this is expected to be a narrower-than-usual package -- so it is imperative that we make a strong impression on legislators as negotiations begin.

To that end, please reach out to healthcare staffers for your Senate and House members with this ask:

Please support Medicare reimbursement relief for DME suppliers that reflects the increased costs for products, shipping, labor, local delivery/gas, personal protective equipment, and other rising costs associated with serving patients who depend on high-quality, home-based care. Specifically, I ask that you support including these measures in year-end legislative packages:

  • Including language from H.R. 6641 – legislation introduced by Reps. Markwayne Mullin and Paul Tonko to provide a 90/10 blended Medicare reimbursement rate for DME for suppliers in former competitive bidding (CB) areas.
  • Extending the 75/25 blended rate for Medicare reimbursement for DME suppliers in non-CB areas granted in the CARES Act  beyond the end of the current COVID-19 PHE.

DME rates have not received a meaningful adjustment since 2016, thanks to CMS’ decision not to not move forward with results from the latest CB round because results from the bidding process “did not achieve expected savings." Please support these measures to give DME suppliers Medicare reimbursement rates that reflect the market and cost environment facing them. This long-overdue relief is critically needed to effectively serve patients in our community.

You are encouraged to adapt this message in your own words, and to include your perspectives, experiences, and challenges. Please email Gordon Barnes at gordonb@aahomecare.org if you need contact information for healthcare staff for your representatives in the Senate and House and for any other assistance with your message.

If you were part of our virtual legislative conference in September, please follow up with the offices/staffers you met with.

If your legislators are members of the Senate Finance Committee, House Energy and Commerce Committee, or House Ways and Means Committee, your outreach is especially needed.

For additional perspective, please see related issue briefs on:

WHEN WILL THE PHE END?

This week we should know whether the public health emergency (PHE) will end in January or if it most likely will renew. Here is what we know at the time of this publication:

October 13, 2022: The PHE was renewed for another 90-days

January 11, 2023: Date of expiration or if it will be renewed for another 90-days.

  • November 12 – 60 days to January 11, 2023: The Secretary of Health and Human Services (HHS) sent a letter to governors back in 2021, that “…when a decision is made to terminate the declaration or let it expire, HHS will provide states with 60 days’ notice prior to termination.
    • Therefore, if there is no notice to the states this week, we can most likely assume the PHE may continue past January. If there is a notice, the PHE will expire and along with it, some challenges.


Last week, CMS published a Spotlight, “Medicare Fee-for-Service Claims Review When the Public Health Emergency Ends” that is on DME and what to expect regarding audits when the PHE ends.

Below is a FAQ that addresses how CMS review contractors (Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and the Supplemental Medical Review Contractor (SMRC)) plan to conduct medical reviews post PHE.

Q. At the end of the Public Health Emergency (PHE) how will CMS’ review contractors conduct medical reviews for claims billed during the PHE based on approved waivers or flexibilities?

A. CMS contractors (MACs, RACs, and SMRC) review a very small percentage of Medicare Fee-for-Service claims each year. During the PHE, flexibilities were applied across claim types. For certain DME items, this included the non-enforcement of clinical indications for coverage. Since clinical indications for coverage were not enforced for certain DME items provided during the PHE, once the PHE ends CMS plans to primarily focus reviews on claims with dates of service outside of the PHE, for which clinical indications of coverage are applicable. We note that we may still review these DME items, as well as other items or services rendered during the PHE, if needed to address aberrant billing behaviors or potential fraud. The HHS-Office of the Inspector General may perform reviews as well. All claims will be reviewed using the applicable rules in place at the time for the claim dates of service.

For more information about medical reviews and the claims process, please visit the Medical Review and Education page.

At the Jurisdiction B and C Council meetings last week with the CGS DME MACs, the Medical Directors heard from the Council members questions related to this publication, i.e., what happens with the rentals of those items that were covered under the waiver such as oxygen, where a patient was provided the oxygen during the PHE and still using it when the PHE expires. Of course, the DME MACs were not able to respond.

CMS and the DME MAC Medical Directors have received the industries questions/concerns in writing and the dialog will continue.

In the meantime, it would be best for all members to be prepared to move towards following the clinical indications for coverage for those items that were covered under the waivers if you haven’t already.

 

WHAT HAPPENS TO MEDICARE REIMBURSEMENT IN NON-RURAL AREAS?

As you know, tied to the PHE is the CARES Act that was signed into law on March 27, 2020, that revised the fee schedule amounts for certain DME and enteral nutrition HCPCS codes whose fees are adjusted using competitive bidding information during the COVID-19 PHE. 

Section 3712(b) of the CARES Act required the calculation for those items in non-rural contiguous non-CBAs based on a blend of 75 percent of the adjusted fee schedule amount and 25 percent of the unadjusted fee schedule amount for the duration of the PHE.

SWMESA has shared multiple times over the last year the work we were doing to get Senator John Thune (SD), who spearheaded this legislation in the CARES Act, to once again, introduce legislation to get the relief extended. 

There is a push to get legislation in a year-end package. It is dependent on getting a score on the legislation and get more support from Democrats on the Senate Finance Committee.

Also in play in the year-end package is HR6641, the legislation applies a 90/10 blended Medicare reimbursement rate for items in the 13 product categories whose bid results were not implemented in Round 2021.  These increased rates would apply from Jan. 1, 2022, through Dec. 31, 2023.

It is important to continue to share your story with your senators and representative(s), especially if they are on the Senate Finance Committee and House Ways and Means Committee, on the impact of either having reimbursement cuts when the PHE ends, and provide a little relief in former CBA’s.

As always, if you have any questions related to these legislative priorities, please let the SWMESA office know, info@swmesa.com. With less than a month left to get the end of year legislation done, please make sure to watch for any specific request for grassroots help from the SWMESA office if there is any need. 

MEDICARE POLICIES – MANY CHANGES COMING!

At the Region B Council and Jurisdiction C Council meetings at the respective CGS DME MAC office in Nashville last week, Council members were able to express the urgency in getting the Oxygen LCD and the further information on the elimination of the CMN’s/DIF’s.

The implementation date of the Medicare Oxygen NCD is January 3, 2023.  The Medical Directors shared they expected the LCD to be released most likely this week for there is a 45-day requirement prior to the implementation date of the NCD to get the LCD out.

With the oxygen LCD release, the DME MACs also shared there will be the updated PAP policy that is tied to the changes in the oxygen policy when the patient uses oxygen and CPAP.

The other big change upcoming is the elimination of the CMNs and DIFs effective with DATES OF SERVICE on or after January 1, 2023.

One of the back and forth discussions at the Council meeting was on the November 11, 2022 article Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs) Elimination – Common Questions and Answers.

The answer to the question about what happened if the supplier sent in a CMN/DIF after the effective date, the CEDI contractor will reject the claims.

The discussion was, why couldn’t the system just ignore the CMN/DIF?

The response was that since this is a date of service driven change, those claims with dates of service prior to January 1, 2023, would still be able to be submitted with the CMN/DIF. It is much easier to resubmit the claim that was kicked out on the front end edit report, than for it to go through claims processing risking denials, etc. 

There were several other questions that suppliers had, including the use of the KX modifier, so make sure to check out the article.

The Medicare Councils will be collecting questions for the 1st quarter rounds of meetings set to occur February 2023. Make sure to check out the SWMESA NYCU next week for a link to use to submit questions. 

 




Updated: August 3, 2022

CALL TO ACTION – DEADLINE FOR 02 TEMPLATE EXTENDED AUG 3.
AUGUST OF ACTION!

Two things for today that will make a huge difference for the HME Industry:

  1. OXYGEN TEMPLATE: Contact your Representative to sign on the Congressional letter from Reps Terri Sewell (D—AL) and Larry Bucshon (R—IN) asking CMS to streamline medical necessity documentation. Click here for the Dear Colleague and Congressional letters.  
  2. Key points:


    The deadline for signatures is extended to August 3rd.

    Please contact the staffer that deals with health care issues for your federal House legislator, and ask that they sign the Congressional letter to CMS. 

    HOW TO:  

    • Per CERT data, less than 1% of Medicare home oxygen therapy claims are improperly paid are due to failing to meet medical necessity requirements.
    • Suppliers are caught in the middle when claims aren’t paid because they are required to provide equipment since it meets Medicare’s medical necessity requirements, yet the contractors deny claims for the clinicians’ notes not meeting the contractor’s standards.
    • The solution is to remove the ambiguity by creating clear rules and forms that facilitate beneficiary access while protecting against fraud and abuse.  
    • The letter requests CMS to:
      • Establish a clear set of objective criteria to support medical necessity
      • Require contractors to rely solely on the Standard Written Order to establish medical need
      • Eliminate the medical record review
    • Precedence has already been set with success!  Pandemic flexibilities temporarily removed the requirement for medical record notes to be used to document medical necessity and instead use the prescription and standard written order.  
    • Endorsing stakeholders include several leading clinical and consumer organizations as well as AAHomecare, VGM, and CQRC.
    • Click here if you are not sure who your Representative is, and put in your zip code.
      • You will then be taken to a page with your Representative’s website/email links.
      • Call their office and ask for the person who handles the health care issues.
        • If they are not available to talk too, ask to leave a message and/or ask the staff for the persons’ email address.
        • Introduce yourself and your company and share your story on why you need them to sign onto this letter – see above key points and highlight what impacts your company the most.

Let the SWMESA office know, info@swmesa.com if you have questions or need assistance.

 

  1. AUGUST OF ACTION: Every year, Members of Congress take the end of summer to spend time in their state/districts and they want to hear from you! Now is the time to reach out to your Members of Congress to schedule a meeting during the August break.  It’s important to build these relationships so HME legislation can move more efficiently through governments at both levels. 2 ways to engage with your legislators:
  2. Invite them to a meet and greet event at your place of business!  The legislator wants vote and this is good opportunity to show your legislator the importance of home medical equipment.
  3. Attend town hall and meet and greet events. Your legislators typically host events in their state or district to hear their constituents’ concerns.  Visit your legislators’ websites or call their offices to find out where and when they hold town halls or other local events.
  4. Items you should discuss with your Member of Congress:
  5. Ask for support for H.R. 6641, DMEPOS Relief Act of 2022
  6. The reimbursement rates for HME during the COVID-19 public health emergency remain in place after the PHE is over
  7. Accessibility to quality services and products to Medicare beneficiaries
  8. Resources to support your discussions:
  9. Advocacy Resources – Helpful guides for meeting preparation, finding legislators’ info, and more 
  10. Cost of delivering HME– Survey results from VGM’s nationwide survey on costs associated with delivering HME
  11. HME Rooftop Historical Trend – FOIA data that shows the decrease of suppliers over the since 2013, by state. 
  12. DMEPOS Geographic Locations - View how physical locations of beneficiaries determine reimbursement rates for suppliers (Competitive Bid area, rural and non-rural areas)

Please let the SWMESA office know if you need assistance or have questions. SWMESA would like to thank our Grassroots Accountability Team from AAHomecare and VGM for their work on putting these resources together.



UNITED HEALTHCARE – COMMERCIAL PLAN CHANGES STARTING SEPT 1, 2022.

In a list serve message August 1, there are upcoming temporary changes coming for select commercial plan changes that impact some states  does not include AZ, NM or TX at this time. Here are the changes:

 

Starting Sept. 1, 2022, fully insured Individual and Group Market health plans for existing customers will begin the transition to UnitedHealthcare’s new commercial claims processing system. Transitions will occur monthly over the next year, aligned with the plan’s annual renewal date.

 

The September transition affects 5 fully insured business products in 9 states:

  • Products: Choice, Choice Plus, Core, Core Essential, Non Diff PPO, Options PPO
  • States: Alabama, Connecticut, Illinois, Minnesota, Montana, North Dakota, New Jersey, Oklahoma and South Dakota
  • Affected membership: Approximately 6,700 members

Click here for the UHC article that explains what you need to know should you or your clients have the referenced commercial plans.


A QUICK WAY TO IDENTIFY BILLABLE UPGRADES

The following article is from Andrea Stark, from MiraVista, on a common area of questions we get here at the MAMES office related to Medicare policy on upgrades.

 

Even experienced suppliers frequently find themselves stumped by the seemingly straightforward question, “What exactly is an upgrade?” At MiraVista, we use a simple strategy to identify upgrades properly so our clients are able to collect from the patient when appropriate and minimize the risk of recoupments for unsupportable payments.

 

Chapter 20, Section 120 of the Medicare Claims Processing Manual defines an upgrade as “… an item with features that go beyond what is medically necessary.” Upgrades are usually features or services that exceed Medicare coverage because they are:

  • In addition to the official code descriptor listed for the HCPCS procedure code, or
  • More expensive/extensive than what Medicare deems reasonable and necessary to meet the patient’s medical need.

I often say that Medicare pays for the patient’s needs but not the patient’s wants.

 

Let’s take a look at the typical cane covered by Medicare. The official description for E0100 reads:

E0100 CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIP.

In order to determine what components, if any, are upgrades, we must first tease out the descriptions or features that are part of the code (and therefore cannot be used for upgrading the product):

  • “… of all materials …” – because this is in the definition, suppliers cannot, for example, charge more for a metal cane than a wooden cane.
  • “… adjustable or fixed …” - suppliers cannot tout an adjustable cane as an upgrade over a fixed cane.
  • “…with tip” - suppliers cannot pass along a separate charge for canes with rubber tips at the bottom because those are included in the description.

An upgradable product must include a feature that exceeds the HCPCS code descriptor. Continuing with the cane example, suppliers could count as an upgrade a custom handle shaped from a mold of the customer’s hand because the descriptor does not mention hand grip variations.

 

When faced with whether or not a feature may be billable to a Medicare beneficiary as an upgrade, suppliers can get to the correct answer by asking:

  • Does this extra feature exceed the medical need covered by Medicare?
  • Is this feature already included in the description for the applicable HCPCS code?

SWMESA would like to thank MiraVista for this article!

 

POWER SEAT ELEVATION AND STANDING SYSTEMS – ROUNDTABLE DISCUSSION AUGUST 3
RSVP TODAY!

The National Council on Disability (NCD) is hosting a virtual public Roundtable on August 3 from 1:00 PM ET to 3:00 PM ET (12PM to 2PM Central Time) to promote Medicare coverage of Power Seat Elevation and Standing Systems.

Roundtable Agenda:

  • Opening Remarks
  • Perspectives from Congress
  • Perspectives from Persons with Mobility Disabilities
  • Perspectives of Clinicians who Evaluate and Prescribe Mobility Technology
  • Perspectives of Researchers and the Evidence Base
  • Perspectives on Legal and Policy Implications of Coverage
  • Next Steps on Pending Medicare NCD and Breadth of Support for Coverage
  • Closing and solicitation of written public comments

Additional details and the registration are available here:

NCD Medicare Coverage Roundtable: Power Wheelchair Systems Tickets, Wed, Aug 3, 2022, at 1:00 PM | Eventbrite.


CMS RELEASES LATEST ENROLLMENT FIGURES FOR MEDICARE, MEDICAID, AND CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)

If you find statistics interesting, or you are doing strategic planning, CMS released their enrollment numbers last week.

Here are the latest enrollment figures for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) per the release from CMS: 

Medicare

As of April 2022, 64,449,451 people are enrolled in Medicare. This is an increase of 88,177 since the last report.

  • 34,879,219 are enrolled in Original Medicare.
  • 29,570,232 are enrolled in Medicare Advantage or other health plans. This includes enrollment in Medicare Advantage plans with and without prescription drug coverage.
  • 50,011,957 are enrolled in Medicare Part D. This includes enrollment in stand-alone prescription drug plans as well as Medicare Advantage plans that offer prescription drug coverage.

Over 12 million individuals are dually eligible for Medicare and Medicaid, so are counted in the enrollment figures for both programs.

Detailed enrollment data can be viewed here: https://data.cms.gov/summary-statistics-on-beneficiary-enrollment/medicare-and-medicaid-reports/medicare-monthly-enrollment

Medicaid and Children’s Health Insurance Program (CHIP)

As of April 2022, 88,274,847 of people are enrolled in Medicaid and CHIP. This is an increase of 375,152 since the last report.

  • 81,195,571 are enrolled in Medicaid
  • 7,079,276 are enrolled in CHIP

For more information on Medicaid/CHIP enrollment, including enrollment trends, visit https://www.medicaid.gov/medicaid/program-information/medicaid-chip-enrollment-data/medicaid-and-chip-enrollment-trend-snapshot/index.html.

See the latest coverage totals across all CMS programs at https://www.cms.gov/pillar/expand-access. This information is updated on a monthly basis. Enrollment data for CMS programs are compiled on different timelines owing to the unique nature of each program.

 

PHILIPS RECALL: FOLLOWUP FROM LAST WEEK
NEXT MEETIGN SET FOR AUGUST 22

In last week’s News You Can Use, we shared the latest update from the monthly MAMES/SWMESA/Philips meeting. Due to an office email issue, there was a delay in getting a copy of the letters discussed in the meeting:

Next meeting: the next meeting will be Monday, August 22 at 10am central time. We have sent an appointment request to those who have participated in previous meetings. NOTE: If you DID NOT get an appt request for this meeting, RSVP here. The meeting login details will be provided after you submit the RSVP. The login is the same for all meetings.

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Updated: July 26, 2022

CALL TO ACTION – DEADLINE THIS FRIDAY, JULY 29!

This is an important call to action from the Grassroots Accountability Team through AAHomecare and VGM.

Reps Terri Sewell (D—AL) and Larry Bucshon (R—IN) are spearheading a Congressional letter to CMS asking that they streamline medical necessity documentation to protect patient access for home oxygen therapy.  This would make a huge impact for the HME Industry and those we serve. 

Click here for the Dear Colleague and Congressional letters.  

Please reach out to your federal House legislators to encourage them to sign onto the Congressional letter!

Key points:

  • Per CERT data, less than 1% of Medicare home oxygen therapy claims are improperly paid are due to failing to meet medical necessity requirements.
  • Suppliers are caught in the middle when claims aren’t paid because they are required to provide equipment since it meets Medicare’s medical necessity requirements, yet the contractors deny claims for the clinicians’ notes not meeting the contractor’s standards.
  • The solution is to remove the ambiguity by creating clear rules and forms that facilitate beneficiary access while protecting against fraud and abuse.  
  • The letter requests CMS to:
  • Establish a clear set of objective criteria to support medical necessity
  • Require contractors to rely solely on the Standard Written Order to establish medical need
  • Eliminate the medical record review
  • Precedence has already been set with success!  Pandemic flexibilities temporarily removed the requirement for medical record notes to be used to document medical necessity and instead use the prescription and standard written order.  
  • Endorsing stakeholders include several leading clinical and consumer organizations as well as AAHomecare, VGM, and CQRC.


The deadline for signatures is this Friday, July 29.

Please contact the staffer that deals with health care issues for your federal House legislator, and ask that they sign the Congressional letter to CMS. 

HOW TO:  

  • Click here if you are not sure who your Representative is, and put in your zip code.
  • You will then be taken to a page with your Representative’s website/email links.
  • Call their office and ask for the person who handles the health care issues.
  • If they are not available to talk too, ask to leave a message and/or ask the staff for the persons’ email address.
  • Introduce yourself and your company and share your story on why you need them to sign onto this letter – see above key points and highlight what impacts your company the most.
    If you have any questions, or need assistance in reaching out, please let the SWMESA office know, info@swmesa.com.

 

Click here for more information on the Grassroots Accountability Project.


MEDPAC 2022 DATA BOOK ON MEDICARE SPENDING

If you like to do deep dives on Medicare data, the Medicare Payment Advisory Commission (MedPAC) released its 2022 data book on health care spending and the Medicare program. The publication provides data on Medicare spending, demographics of the Medicare population, beneficiaries' access to care, and quality of care in the program, among other information. 

 

According to the data book, Medicare was the largest single purchaser of personal health care for 2020.

Medicare accounted for 22% or $754.5 billion of the $3.4 trillion spent on personal health care.

 

Durable medical equipment spending was referenced in Section 1, National health care and Medicare spending. On page 4 of the section, “While Medicare’s share of total personal health care spending was 22 percent in 2020 (see Chart 1-1), its share of spending by type of service varied, from 20 percent of spending on durable medical equipment to 34 percent of spending on home health care.”

 

The chart shows 16% for Medicaid and CHIP, and 64% for “Other” which includes private health insurance, out-of-pocket spending, and other private and public spending.

 

Click here to view the Data Book: Health Care Spending and the Medicare Program. Durable Medical Equipment is mentioned in Section 1:  National health care and Medicare spending.

 

PHILIPS RECALL: UPDATES

SWMESA and MAMES members were once again able to get the latest updates on the Philips recall. There were 30 people participating in the MAMES/SWMESA/Philips bi-weekly meeting on Monday, July 25. Here are the key takeaways: 

  • Trilogy remediation:
  • 2 Important forms needed:
  • Ship to Form – you may have received this document from Respironics through account manager. Includes list of serial numbers that have been registered. Some may have been missed in Managed Unit template. It is important that all impacted serial numbers are included, whether on the shelf or on the patient, and are units that are yours, not units you are renting from others. If you have multiple ship locations – must have separate form for each.
  • Currently have 116,000 registered – expect around 160,000. Bottleneck is getting the devices in. Communicate with your Respironics account manager for questions. 
  • Agreement – compensation tied to the remediation.
  • 3,500 remediated as of last week. This is low because the number of units Respironics is getting back.
  • Data points on the recall:
  • Recommended to keep visiting Philips Recall Website for updates:
  • 3 million repair kits and replacement devices produced to date globally
  • 1,400,00 devices shipped in the US as of July 22  
  • And, more
  • Continue to experience patients not being matched to a DME:
  • Still have many of those – reach out to account or direct manager.
  • Shared New Patient Letter – the letter provides information on the recertification process for all CPAP, BiPAPs and all devices. Includes: “Your replacement Device – warranty etc; Cleaning and Caring; Device accessories and return.” NOTE: due to the MAMES email issue not being resolved by publication time, the MAMES office will provide a copy of the letter to those who have participated in MAMES/Philips meetings once our email situation has been resolved. We apologize for the inconvenience


Next meeting: the next monthly meeting will be in September, date to be announced. The SWMESA office will continue to provide any urgent updates through the SWMESA News You Can Use newsletters along with future meetings.

 

SWMESA would once again like to thank Philips Scott Pearcy and Glen Abrams for their time and commitment to keep members informed! We appreciate their time and their efforts this past year which continues to be very challenging for everyone involved. 

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Updated: July 18, 2022

PHE EXTENDED

As expected, Xavier Becerra, the Secretary of Health and Human Services (HHS), renewed the public health emergency (PHE) for COVID 19 effective July 15, 2022. This will take the PHE through October 13, 2022.

As we have previously reported, HHS will provide states with at least 60 days’ notice to the states prior to termination of the PHE. So, the next date to watch as it relates to when the PHE continues to be extended through the end of the year, will be around August 14th.

Click here for all the information related to the “Unwinding and Returning to Regular Operations after COVID-19.”  It includes unwinding guidance for the states that includes of Medicaid/CHIP coverage.

MEDICARE PHYSICIAN FEE SCHEDULE PROPOSED RULE CONTAINS DMEPOS CHANGES

On July 7, 2022, CMS published the Calendar Year (CY) 2023 Physician Fee Schedule Proposed Rule that includes several changes that will impact the DMEPOS industry. Although work is being done internally by AAHomecare in reviewing the proposed rule, they wanted to share the proposals on enrollment and payment conditions for DME suppliers, HCPCS coding procedures, RTM codes, and Telehealth post-PHE. Click here for the unpublished version of the purposed rule (the document is scheduled to be published in the Federal Register on 7-29-22).Here is a quick overview of the two sections related to DME:

  • Enrollment and Conditions of Payment for DME suppliers
    • (1) expanding the bases for denying or revoking a provider’s or supplier’s Medicare enrollment;
    • (2) subjecting a greater number of providers and suppliers, such as skilled nursing facilities, to the highest level of screening, which includes fingerprinting all 5 percent or greater owners of these providers and suppliers; and
    • (3) denying payment to DMEPOS suppliers that are not appropriately licensed. These changes are necessary to help ensure that payments are made only to qualified providers and suppliers and that owners of these entities are carefully screened.
       
  • HCPCS Coding Procedures for Wound Care
    • (1) that the assignment of A codes to all wound care management products (that are not regulated by FDA as drugs or biological products that would otherwise be eligible for separate payment under section 1847A of the Act) would continue with respect to products for which a HCPCS Level II code is requested for the first time, as well as for wound care management products to which were previously assigned a Q code;
    • (2) to discontinue all existing Q codes for wound care management products;
    • (3) to, prior to the assignment of an A code, require products with an existing Q code that were described by the applicant as a 361 HCT/P to submit a HCPCS Level II re-application within 12 months of the effective date of the final rule (that is, January 1, 2024);
    • (4) to require a recommendation letter from the FDA’s TRG to be submitted as part of the HCPCS Level II application for all wound care management products described by the applicant as a 361 HCT/P, regardless if it is a first time application or re-application for a product with an existing Q code; and
    • (5) to evaluate HCPCS Level II coding applications for all 361 HCT/P wound care management products through our biannual coding cycles for non-drugs and nonbiological. products, rather than on a quarterly basis, beginning January 1, 2024.


AAHomecare reports they have a group that is reviewing the rule and will let the Medicare Councils know if there are needs for additional commenting needed from the industry. MAMES would like to thank AAH for this update and their work on this enormous proposed rule.


NCART NEW EXECUTIVE DIRECTOR, WAYNE GRAU

According to an NCART Announcement July 7th, Wayne Grau will be the new Executive Director who will begin his role in August.

SWMESA congratulates Wayne and looks forward to continuing to collaborate in the future with NCART!

SWMESA thanks Don Clayback, current Executive Director who will be retiring, for his years of working for the industry!.

Also included in the NCART Announcement is their election of officers. Congratulations to the officers!

AMEND, SUPPLEMENT AND/OR CORRECT RECORDS BEFORE SUBMISSION!

The following article is about correcting and amending patient records before submissions to auditors and reviewers from Elizabeth E. Hogue, Esq. ph. (877) 871-4062.

UPICs, CERTs, TPE, focused medical review, OIG, RACs, MACs and more! Many people are looking over providers’ shoulders these days and they are very picky indeed, to say the least. Before providers send records to reviewers, therefore, providers should go through those records with a fine-tooth comb and amend, supplement and/or correct them. The Medicare Program Integrity Manual, Chapter 3 – Amendments, Corrections and Delayed Entries in Medical Documentation, Section 3.3.2.5 says, “Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected or entered after rendering the service.” 

This section goes on to say that when making review determinations, reviewers and auditors shall consider all submitted entries that comply with the widely accepted Recordkeeping Principles. They shall not, however, consider any entries that do not comply with the Recordkeeping Principles, even if such exclusion leads to claims denials. The Recordkeeping Principles recognized in the Manual are as follows:

B. Recordkeeping Principles

Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted…containing amendments corrections or addenda must: 

  • Clearly and permanently identify amendments, corrections or delayed entries; 
  • Clearly indicate the dates and authors of amendments, corrections or delayed entries, and 
  • Clearly identify all original content, without deletion.


When correcting paper medical records, providers should: 

  • Using a single line strike through so that the original content is still readable; and 
  • Authors of alterations must sign and date revisions. Amendments or delayed entries to paper records may be initialed and dated if the medical record contains evidence associating the practitioners’ initials with their names.

Records from electronic systems containing amendments, corrections or delay entries must: 

  • Distinctly identify any amendment, correction or delayed entry; and 
  • Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.


It is also important to note that all late entries are written only if clinicians recall the omitted information or have notes to jog their memories. And, of course, backdating is not allowed!

Practitioners may be concerned that changes to records will be obvious to reviewers. This is exactly the point! But, as the Manual points out, changes must be considered by reviewers.

The time to review and “fix” records is before they are sent to reviewers and auditors. Do it consistent with the above principles.

©2022 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.

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July 12, 2022

SUPPLY CHAIN ISSUES IMPACTING PATIENT CARE?
 PLEASE RESPOND TO CMS’ REQUEST!

Last week, CMS offices in Denver and Chicago reached out to SWMESA, other associations and DME’s asking for feedback on issues related to supply chain shortages and the impacting it is having on patient access to timely care.

The SWMESA office received an invite from the CMS Chicago LEA team who is hosting a short call this Tuesday, July 12, 2022, at 10:00 CT to hear from the industry on the call or via email.  

The CMS Denver office is also seeking this information as well and has asked SWMESA to get feedback from our members.

ACTION: Please send an email to the SWMESA office, info@swmesa.com, on specific examples of the items that there are supply chain issues that has impacted patients access to the timely care.

Example: CPAPs supply chain disruption for well over a year due to a massive recall from Philips Respironics and a chip shortage that impacts all manufacturers of CPAPs. The impact has been on patients needing the therapy end up waiting lists for new set ups. Some providers report large waiting lists that could take days, weeks or longer to get patients set up. There are many more issues with items needing chips, including complex rehab, etc.  

Please send your examples to the SWMESA office by this Thursday, July 14. SWMESA will summarize the feedback we receive and share it with both the CMS Chicago and Denver offices on Friday, July 15.  

PROVIDE OSTOMY SUPPLIES PROMPTLY 
A RESOURCE TO USE FROM CMS IF YOU HAVE ISSUES GETTING TIMELY SWO’S

In case you missed it, in the MLN Connects newsletter for Thursday, June 30, 2022, there was an article “Provide Ostomy Supplies Promptly” that was directed towards healthcare professionals the importance of orders for ostomy supplies. 

The article explains that CMS will deny the claim if the supplier bills for an item without first getting a completed standard written order (SWO). If you have issues with getting those orders, this would be a great article to share with those offices.

ANNUAL REPORT ON HEALTH CARE FRAUD

Last week, the Department of Health and Human Services and The Department of Justice released their Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2021

In the Executive Summary, for FY 2021, the Federal Government won or negotiated more than $5.0 billion in health care fraud judgments and settlements, in addition to other health care administrative impositions. Because of these efforts, as well as those of preceding years, almost $1.9 billion was returned to the Federal Government or paid to private persons in FY 2021. Of this $1.9 billion, the Medicare Trust Funds received transfers of approximately $1.2 billion during this period, in addition to the almost $98.7 million in Federal Medicaid money that was similarly transferred separately to the CMS due to these efforts. 

If you search the 129 page report, there are 15 mentions of DME cases surrounding entities providing orthotic braces; those involved in Operation Brace Yourself; NIV’s; mail order diabetic testing supplies; and medical supplies. 

Also included in the report is the work being done related to provider enrollment, screening and site visits along with the prior authorization program for PMD’s, pressure reducing support services and newly added 6 lower limb prosthetic codes.

Overall, DME is continues to be the target of investigations and by reviewing the cases in FY 21 shows what they were looking for. We would expect that with the COVID-19 PHE and the temporary waivers that were in place that allowed providers/suppliers to get enrolled without the normal screening processes and waivers on respiratory policy that there may be more recoveries on the way in FY 22.

OXYGEN DECISION MEMO RELEASED

In case you missed it, on July 8, 2022, CMS released a Decision Memo on the Home Use of Oxygen.  

Included in the Memo, CMS amended the period of initial coverage for patients who blood gas values or oxygen saturation is above at or above 56 or 89% went from 120 days to 90 days. The first paragraph of section D of the NCD will state:

Effective July 8, 2022, the MAC may determine reasonable and necessary coverage of oxygen therapy and oxygen equipment in the home for patients who are not described in section B or precluded by section C of this NCD.  Initial coverage for patients with other conditions may be limited to the shorter of 90 days or the number of days included in the practitioner prescription at MAC discretion. Oxygen coverage may be renewed if deemed medically necessary by the MAC.

Also included in the Decision Memo under section D. Other: is the information regarding recertification for those same patients.