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| A Penton Media Property | |
| August 27, 2007 | Volume 13, Issue 40 |
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ADVERTISEMENT The Cost of Doing Business Just Went Down! Now you can obtain the same software used by industry leaders for FREE! Run the software at your location or access our servers from the Internet and further reduce your costs. This is a limited time offer so call Fastrack today @ 1-800-520-2325. www.onlyfastrack.com  In This Issue: Flash Inspections Jeopardize Accreditation Process, Attorney Warns Confusion over HHS Crackdown on Infusion Providers Lambert's Ready to Take on the Government--Again Proposed Privacy Legislation Speaks to Health IT Fears In Brief Coming Up For more industry news, features and highlights from our latest issue, please visit our Web site at www.homecaremag.com. Headline News Flash Inspections Jeopardize Accreditation Process, Attorney Warns HIALEAH, Fla.--According to Florida health care attorney Javier Talamo, some HME companies seeking accreditation are being given "cursory" inspections that could undermine the integrity of the process. Although he did not name the accrediting organizations involved, Talamo, of law firm Kravitz & Talamo, said he had been informed that some of the surveys lasted only 20 to 40 minutes. "It is grossly unfair to have some companies subjected to rigorous two-day inspections while others are given a free pass. I understand that accreditation is a business, but it must be conducted in an ethical manner," Talamo said. Tom Cesar, president of the Accreditation Commission for Health Care--one of CMS' approved DMEPOS accrediting bodies--confirmed that he believes inspections of that brevity are taking place. "There's someone out there that, as I understand it, is spending a short amount of time looking at things and then moving on," he said. Cesar said he understood CMS had been informed of the situation, but at press time, the agency had not responded to HomeCare Monday's request for comment. Late last year, CMS named 11 accrediting organizations to enforce its supplier quality standards and gave them "deeming authority" to accredit HME providers. Two of the accreditors merged in January, leaving 10 on the list. (See HomeCare Monday, Jan. 22.) Under the agency's competitive bidding program, providers participating in the 10 initial bidding areas must be accredited by Oct. 31 in order to be selected for Medicare contracts. And at some point as mandated by the Medicare Modernization Act--although CMS has not yet set a deadline--all providers who wish to do Medicare business must be accredited. "If CMS is to impose mandatory accreditation, it must monitor its AO's and it must ascertain that patient care is not being compromised," Talamo said, adding that "if we do not protect the accreditation process, it will soon become irrelevant." A HomeCare comparison of four industry accreditors existing in 2005 showed that all four typically spent at least one day on a survey for a small, single-location HME. The report showed the inspections could run even longer depending on the size and complexity of the operation. (See "Thinking About Accreditation," HomeCare, October 2005.) While some accreditors say they have streamlined internal processes to help providers comply with CMS' bidding timeline, the time it takes to complete onsite surveys isn't one of them. Raul Lopez of Bayshore Dura Medical in Miami Lakes, Fla., and president of the Florida Association of Medical Equipment Suppliers, said the association had heard rumors of short inspections, but "most of the FAMES members who have given us feedback are telling us [their surveys] are just as strict" as ever. Lopez said he had also heard promises of speedy accreditations, like a "we can get you accredited in three weeks type of thing ... but what they're doing to fast-pace it, I don't know." Others in the industry said they also had heard talk of the flash inspections. Accreditation consultant Mary Ellen Conway, president of Capital Healthcare Group, Bethesda, Md., said she had heard rumors about brief surveys, though she didn't know who was conducting them. "People have to step up and say who the providers are that are getting the free pass and who's giving it to them," Conway said. "It diminishes the process for all." Walt Gorski, vice president, government affairs, for the American Association for Homecare, shared a similar sentiment. "We believe that the accrediting organizations must fulfill their responsibilities to do the job they were tasked with," Gorski said. "If any of these allegations are true, it undermines the whole process." According to Conway, it can take from four to six months for an HME company to prepare for an accreditation survey. "One-day surveys are really tough when there's any home business involved, so I don't know how anybody could do a 40-minute visit and have the information validated," said Conway. "It just doesn't make sense to me." For a list of CMS' approved accrediting organizations, click here. CMS' registration deadline for suppliers who want to participate in the first round of competitive bidding is TODAY. Suppliers interested in bidding must first register and receive a user ID and password before they can access the Internet-based bid submission system. For registration information, go to www.dmecompetitivebid.com. Confusion over Crackdown on Infusion Providers WASHINGTON--On Monday, the Department of Justice, the Department of Health and Human Services and CMS announced the details of a two-year initiative designed to eliminate deceptive providers of infusion therapy in South Florida. The agencies are zeroing in on the area because of a steep surge in fraudulent Medicare billing for infusion, particularly infusion treatments for HIV/AIDS patients, officials said during a press call for health care journalists. Medicare billing for infusion services in South Florida is disproportionately high, HHS said, tripling from 2004 to 2005 to 15 percent of national billing. HHS said its latest anti-fraud initiative follows similar demonstration projects that target fraudulent billing by DMEPOS suppliers in South Florida and Southern California, and home health agencies in the greater Los Angeles and Houston areas. According to HHS, "these geographic areas have shown a high frequency of DMEPOS or home health care fraud. South Florida is also one of the high-risk areas for fraudulent billing by providers of infusion therapy." Under the demonstration, providers in several South Florida counties will be required to reapply to be qualified Medicare infusion therapy providers within 30 days of notification from CMS or their billing privileges will be revoked, Herb Kuhn, the agency's acting deputy administrator, said during the call. But the National Home Infusion Association said it has asked CMS "for an immediate and public clarification that home infusion therapy providers are not the subject or the target of the planned demonstration program." Indeed, an HHS fact sheet released Monday defined "infusion providers" subject to the demonstration as "clinics or solo practitioners located in South Florida who provide intravenous infusion therapy and/or intramuscular and subcutaneous injections in the office setting." The fact sheet said "infusion providers shifting from infusion to other procedure codes to avoid detection and bypass administrative actions" would also be included. According to a press release posted on the NHIA Web site: "Unfortunately, the 'infusion providers' at issue were not described in any detail in the materials released to the public, but virtually every media story following the announcement assumed that CMS was referring to home infusion therapy providers. After speaking with CMS officials and others, it is now apparent that home infusion therapy providers were not the entities that CMS and DOJ investigated or which will be subject to the new demonstration program. "The National Home Infusion Association (NHIA) has asked CMS for an immediate and public clarification that home infusion therapy providers are not the subject or the target of the planned demonstration program. Several media organizations have mistakenly interpreted the materials released to the public as an indictment of the home infusion therapy industry. Particular home infusion therapy providers are being cited in the press as examples of the types of infusion providers that CMS is targeting in its demonstration program. CMS should act promptly to clarify this situation. Home infusion therapy providers should not [be] lumped together in the public's mind with entities that are being accused of committing serious acts against beneficiaries and the Medicare program. Likewise, the patients being served by home infusion therapy pharmacies should not have to endure unnecessary stress over concerns that need not exist." In its newsletter last week, the American Association for Homecare noted that "HHS and CMS offices expect only a 1-2 percent overlap in those applying for both infusion therapy and HME provider status, according to the CMS officials at the press conference." To view the HHS press release about the demonstration, click here. To view the NHIA press release in full, click here. What is your opinion of HHS' proposal to require a $65,000 surety bond from DME suppliers? To vote in HomeCare's monthly Web poll, visit www.homecaremag.com. Lambert's Ready to Take on the Government--Again REDDING, Calif.--A California HME provider who sued the Department of Health and Human Services over K0011 wheelchair documentation--and won in federal court--is now taking on the Medicaid program over a little-known law that appears to invalidate Medi-Cal fee schedules. Tom Lambert, president of Maximum Comfort in Redding, said some Medi-Cal auditors are telling providers they are violating state law by submitting power wheelchair claims that exceed state law limits, even though the claims adhere to Medi-Cal fee schedules and, in many cases, have been pre-approved. The agency is asking for the money back, to the tune of $469,000 in Lambert's case. A source who asked not to be named said at least 12 providers of power wheelchairs have been assessed between $50,000 and $500,000 in repayment for alleged overbilling dating back to 2004. Letters received by providers from Medi-Cal clearly state that the repayment is not being sought because of fraudulent claims, but because of unintentional overbilling. The repayment notices couldn't have come at a worse time. Providers in California are still recovering from lengthy delays in receiving reimbursement when Noridian Administrative Services took over as the Jurisdiction D Medicare contractor early this year. And the state of California is more than a month behind in its payments because legislators could not agree on a budget until a week ago. "I'm getting calls from providers from all over," Lambert said. "We need to try to get a moratorium on [audits and recovery actions] so we can sit down and re-educate everyone. We're dealing with two sets of instructions here. They can't have it both ways." At issue is Title 22, a state law passed in 2003 that establishes upper billing limits for HME. According to Bob Achermann, director of the California Association of Medical Product Suppliers, the law was enacted as a way of combating Medi-Cal fraud. "This was done at a time when the state was paying $4 for heel protectors and they were costing providers eight cents," Achermann said. "[Legislators] thought that the only thing they could do was to put a cap on what a provider could charge." While CAMPS fought the effort and succeeded in getting a carve-out for rental HME, Achermann said, Title 22 was nevertheless enacted. It essentially places a ceiling on what providers can bill Medi-Cal; what that ceiling is, however, is a point of debate. Lambert said he understands the ceiling is 100 percent above invoice for power wheelchairs and accessories and 67 percent above invoice for all other HME. Achermann said the limit is 100 percent across all HME. Either way, those limits appear to be in conflict with the published Medi-Cal fee schedules. "If a dealer buys a power wheelchair, the average cost is $1,500 to $1,800 and he'd bill about $4,800 under the fee schedule," explained Lambert. "But the maximum under the state law would be $3,000 to $3,600, so by billing under the fee schedule, you're violating the law." Providers contend they either knew nothing about Title 22 or thought it was superseded when, in 2004, California adopted a fee schedule that was no more than 80 percent of that allowed by Medicare. For Lambert, as for other dealers, the discrepancy came to light during a recent audit when the auditor, after reviewing Lambert's invoices and documentation, informed him he was in violation of Title 22. Lambert, who had been audited the previous year without incident, questioned the auditor's assertion. The only way to adhere to the Title 22 regulation would be to do manual pricing and submit catalogs or invoices with each claim, he said. "What they are saying is that we should be doing manual pricing [and] submit our invoices with these requests so they can figure out what [the reimbursement should be], but that's not required. No one is asking for it," Lambert said. In fact, he and other stakeholders pointed out, Medi-Cal's own Web site clearly states that no manual pricing and no catalog or invoice is required if there is a code for the product. Products with codes are simply billed electronically. Further, when the 2004 changes were made, providers were instructed to bill the allowables, they said. Lambert also questioned why the fee schedules themselves do not adhere to state law. "If you have a state law, the bureaucrats don't have the authority to do it another way," he said. "But who do you listen to? We are following [Medi-Cal's] directions to the 'T' and getting into trouble because of it ... I don't think that since I was doing it by the book, I should have to repay $469,000." Achermann agrees that the whole issue is confusing and perhaps even unfair. To date, CAMPS has heard complaints from half the providers who have so far been hit with repayment notices. "We think the auditors are using some [unusual] interpretations of the provision," he said. "We don't think they are interpreting it correctly." Achermann did not rule out further discussions with the California Department of Health Services on the matter. Lambert said he had written a letter to that state agency complaining about the billing issue and was told to take his case to the Joint Legislative Audit Committee. "We have to go through the interior appeals process before we can go to a state or federal court," he said. "Meanwhile, [Medi-Cal] has offset $165,000 from us. We've asked for a payment plan, but we haven't heard a thing." Lambert said he wants to form a coalition of providers to work to settle the issue. He's contacted some providers by phone and others by letter. "For the past two years, the state of California has been auditing dealers and found that most dealers were ... billing listed, coded items with a price on file electronically rather than manually pricing at a percentage over cost and filing a paper claim," Lambert wrote in his letter. He added that by billing in this manner, providers "have probably exceeded the upper billing limits set by state law." He cautioned that "rather than taking any action to resolve the problem that exists at every level of the Medi-Cal system ... and re-educating everyone within the system, they have chosen to go after dealers, one at a time, who are simply following the billing instructions of the California Department of Health Services." Already, Lambert said, nine other HME companies have pledged to pay into a legal defense fund should one become necessary. While the issue currently affects only power wheelchair providers, stakeholders are fearful that it could spread to encompass all of HME. "Theoretically, it could apply to anything," Achermann said. Lambert believes it will. "The ones that haven't been hit yet, it's just a matter of time," he said. Lambert, who has been in business since 1989, doesn't really relish having another battle on his hands. In 2003, he sued HHS for requiring additional documentation beyond a CMN for K0011 claims. A U.S. District Court judge sided with Lambert in a June 2005 decision. HHS appealed that decision; the appeal is still under review in the 9th District Court of Appeals. It will take some months, perhaps years, before that case is finally resolved, Lambert said. Ironically, he has worked to pare his reliance on Medicare revenue and now deals more with Medi-Cal. But Lambert has no intention of giving up on HME. "I chose when to get into this business and I'll choose when to get out," he said. For details of Lambert's fight with the government over power chair CMNs, see HomeCare Monday, July 12, 2004. Proposed Privacy Legislation Speaks to Health IT Fears WASHINGTON--Last month, Sens. Edward Kennedy, D-Mass., and Patrick Leahy, D-Vt., introduced a bill that would create new privacy safeguards for patients' protected health information that, if enacted, could have a big impact on how providers work with patient data. The bill, called the Health Information Privacy and Security Act of 2007, would create tighter HIPAA rules, giving patients the power to decide when, and to whom, their health information is disclosed. "In America today, if you have a health record, you have a health privacy problem," said Leahy. "The ability to easily access health information electronically--often by the click of a mouse, or a few key strokes on a computer--can be useful in providing more cost-effective health care, but it can also lead to a loss of personal privacy." The legislation is the latest in the ongoing saga of health information technology, which many see as crucial in controlling spiraling health care costs. Earlier this year, a CMS Office of the Actuary report predicted that health care expenses would double by 2016, reaching $4.1 trillion, or $1 of every $5 spent in the U.S. "America's per capita health spending is the highest in the world," HHS Secretary Mike Leavitt said regarding the findings. "[T]here is simply no place on the economic leader board for a nation that spends a fifth of its domestic product on health care." The potential for IT to make the U.S. health industry more efficient and less prone to medical errors has been touted by supporters for years. Nonprofit think tank Rand Corp. has predicted that the country's health care system could save more than $81 billion a year, as well as improve the quality of care, if computerized medical records were widely adopted. Leavitt has said that a standardized health IT system is key to improving care and lowering costs, and is "pivotal" in "transforming our health care system." President Bush has set a goal for most Americans to have electronic health records, reiterating in his State of the Union address this year his goal of reducing costs and medical errors by improving health IT. However, privacy concerns--along with those of system interoperability, physician reluctance, provider licensing, implementation costs and possible liabilities--have emerged as obstacles to the implementation of a widespread, unified health IT system. A study by the California HealthCare Foundation, an independent philanthropy, found that 67 percent of Americans are highly concerned about the privacy of their personal health information. The study also found that consumers are more trustworthy of information stored in paper files than in electronic records: 66 percent think the former is more secure. But the survey also found that, despite those concerns, consumers have a positive view of health IT and are "willing to share their personal health data when it offers a benefit, such as improving the coordination or safety of their care." Sixty-five percent of those surveyed acknowledged that computerization could possibly cut down on medical errors. Advocates say shared electronic records have the potential to support consumers and manage patient care more effectively across settings from homes to physicians' offices and hospitals. Still, the road to that kind of secure interoperability is anything but smooth. A study released Aug. 9 by RTI International and HHS found that, while EHRs could save money and reduce fraud and inadvertent errors in medical billing, current technology and performance standards don't measure up to the task. The study team recommended 14 requirements to health industry leaders for more secure EHR systems. And on Wednesday, the State Alliance for eHealth, a division of the National Governors Association, urged state legislators and other officials to standardize state privacy rules--while ensuring consumer protection--for exchanging electronic health information. Meanwhile, in a statement about the privacy legislation he and Leahy introduced--and had spent 10 years working on--Kennedy said "a delicate balance must be struck. "On one hand, we must allow the sharing of information necessary for effective health care. At the same time, however, we must protect Americans' right to have their health records and individual health information kept private. For too long, the balance has been tilted too far against patient privacy, and our bill is a needed effort to correct that imbalance." The measure has been referred to the Committee on Health, Education, Labor and Pensions. In Brief Nearly 50 HME providers and industry executives attended a fundraiser last week that raised almost $70,000 for Sen. Charles Grassley, R-Iowa. Attendees at the reception, held at the Waterloo, Iowa, home of VGM CEO and Founder Van G. Miller, told Grassley they are counting on him to protect the HME community from further cuts. Grassley told the group that he plans to meet with Senate Finance Committee Chair Max Baucus, D-Mont., when Congress reconvenes to convey the industry's concerns. The nation's lawmakers will soon take up an expansion of the State Children's Health Insurance Program, or SCHIP. The House version of the bill includes provisions that would reduce the oxygen rental cap to 18 months and eliminate the first-month option for power wheelchairs as a means of funding the measure. Released Wednesday, CMS' final rule for home health providers reduces some payments over four years. The agency said the reduction will offset changes in services that are not related to the "actual clinical condition" of home health patients. Beginning in 2008, the reduction will be 2.75 percent for the first three years, then 2.71 percent for the fourth year in 2011. The rule will be published in the Federal Register on Aug. 29. According to a report in the Wall Street Journal, some bariatric surgeons "are setting their sights on a burgeoning new market: diabetes patients." The Aug. 22 report said studies have found that more than 75 percent of type 2 diabetes patients who have bariatric surgery no longer have symptoms and do not require insulin or other medications. But the Journal also reported that both supporters and critics of the controversial surgery said it is "too early to recommend it for the broad mass of diabetics" because it can lead to serious complications, and because there are effective, noninvasive treatments for diabetes. Coming Up CMS will hold a Home Health, Hospice & DME Open Door Forum at 2 p.m. ET on Wednesday, Aug. 29. To participate, call (800) 837-1935 and use Conference ID 3650599. Show officials have issued a call for presentations at Medtrade Spring 2008, which will take place May 7-8 in Long Beach, Calif. To submit suggestions, click the following link: http://www.goeshow.com/medtradespring/abstract.cfm. The deadline for speakers to submit topics is Aug. 31. The American Association for Homecare and the Ohio Association for Medical Equipment Services (OAMES) will hold a Reimbursement and Medicare Survival Toolkit seminar Sept. 5-6 in Cleveland. For more information, call (703) 535-1887 or visit www.aahomecare.org. The Wisconsin Association of Medical Equipment Services (WAMES) will hold its annual conference and trade show Sept. 5-7 in Wisconsin Dells, Wis. For more information, call (715) 366-7500 or visit www.wames.org. From the HomeCare staff, have a cool and relaxing Labor Day. HomeCare Monday will resume publication Sept. 10. ADVERTISEMENT |
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