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Headline News
TriCenturion Expands K0823 Probe; No Easy Button Here
COLUMBIA, S.C.--TriCenturion announced last week that it will continue a widespread pre-payment review of K0823 power wheelchairs after a probe review showed sky-high denial rates of 87.51 percent for Jurisdiction A and 93.36 percent for Jurisdiction B. (See HomeCare Monday, June 11.)

The Jurisdiction A/B DME program safeguard contractor said its pre-payment review for the code--Group 2 standard captain's chair with patient weight capacity up to and including 300 pounds--will continue in both regions.

"What this means is that the small sample size from the widespread probe will be increased to encompass virtually all claims for K0823 in Jurisdictions A and B," said Tim Pederson, CEO of WestMed Rehab, Rapid City, S.D., and chair of the American Association for Homecare's Rehab and Assistive Technology Council.

In a bulletin posted on its Web site Sept. 17, a chart comparing medical review determinations in TriCenturion's pre-payment probe showed that more than 60 percent of the claims in Jurisdiction A and more than half in Jurisdiction B were denied as "non-covered." More than 30 percent of claims in Jurisdiction B and more than 10 percent in Jurisdiction A were denied as "not medically necessary."

A list of reasons TriCenturion gave for denials included physician orders on which the date of the face-to-face evaluation was not documented or there was no date stamp to verify the supplier's receipt within 45 days. Other reasons included that functional limitations were not addressed in the evaluation, that letters of attestation were submitted without supporting information from the medical record and that some suppliers created mobility evaluation forms as a substitute for information from the medical record.

Issued last year, CMS' new power mobility rule replaced the power mobility CMN with a face-to-face exam and a doctor's prescription. But under new documentation requirements, providers are responsible for gathering patient records that prove medical necessity for the equipment.

Seth Johnson, director of government affairs for Pride Mobility Products, Exeter, Pa., said the probe "speaks volumes about the need for the policies and procedures currently in the interim final rule to be reexamined. I think it also clearly shows the need for CMS to do some extensive education with providers and, even more importantly, with the physicians. Clearly, the documentation expectations by the Medicare contractors are not clear to anyone when you have denial rates in the 90-percentile range.

"The biggest complaint that we hear from providers is the difficulty that they have in getting this information from physicians," Johnson continued. "Physicians just are not in the practice of providing so much information for other items they prescribe."

Eric Sokol, executive director of the Power Mobility Coalition, said the Washington-based organization has "real concerns" with CMS' lack of analysis of the paperwork burden on providers in gathering PWC documentation. According to Sokol, while CMS said there would be no tangible difference in the burden on suppliers under the new rule as in obtaining a CMN, he said, "that is certainly not the case."

The coalition has submitted comments on the matter to the Office of Management and Budget, which is currently reviewing the paperwork burden, Sokol said.

"Right now, it's just a documentation requirement that's amorphous, that's never-ending as far as what CMS wants, and it creates a claims processing system where CMS holds all the cards and all the claim reviews are subjective," Sokol said. He added that he hopes CMS will work with the industry to come up with a tool where a physician could complete all necessary steps, then the provider could submit that along with any supporting documentation and have "a reasonable expectation of payment."

Pederson said the degree to which physicians, therapists and providers are confused about PWC documentation requirements should be more certain after providers complete the appeals process on claims denied in the preliminary probe. "Certainly these providers will appeal the findings of the probe," Pederson said. "It will be interesting to follow the group of claims through the appeal process to find out what the final percentage of denials ends up to be."

In addition, Pederson said, "we need to know what the final medical necessity denial rate is versus [the] documentation error rate." That data, he said, "will tell us what the shortcomings are of the educational efforts of CMS, manufacturers, trade associations, group purchasing organizations and providers themselves ...

"We need to keep in mind that the overhaul of the power mobility device policy was sweeping and comprehensive," Pederson continued. "It is evident that at least some of the providers in our industry did not adequately prepare for providing power wheelchairs under our new reality ... Personally," he added, "I think we are seeing the results of what happens to those providers who respond by wishing for the 'easy button' instead of facing our current reality and changing the way they do business."

Pederson said the industry is seeing PMD utilization down "around 20 percent from two years ago. This is a direct result of the new PMD policies and their related documentation requirements. We can't wish this situation away. We need to move forward and do what is asked of us or we will not get paid or be allowed to keep our payments after an audit."

TriCenturion said providers whose claims are selected for review will receive an Additional Documentation Request letter "asking for specific information to determine if the item billed complies with the existing reasonable and necessary criteria." Failure to supply the information within 30 days of the request will result in denial of the claim, the PSC said.

To view the TriCenturion bulletin in full, click here.

To access the CBIC Web site, click here.

CMS Fields Competitive Bidding Survey
BALTIMORE--CMS is conducting a supplier survey to satisfy a requirement of the Medicare Modernization Act that mandates an evaluation of the DMEPOS competitive bidding program.

Administered by CMS contractor Abt Associates and endorsed by the American Association for Respiratory Care, the survey is one of two currently underway. The second, CMS said, is a beneficiary survey.

"Basically, it's about make and model, more detail than we get on a claim," a research analyst at CMS' Office of Research, Development and Information said of the supplier survey.

The survey includes providers located both inside and outside the first 10 competitive bidding areas so the agency "can do stronger types of comparisons about isolating [the] impacts of competitive bidding," the analyst said, adding that not all 10 CBAs are being surveyed since that was "prohibitively expensive."

While the CMS analyst could not reveal further details about the survey, some industry observers suggest the agency is worried providers will offer lower-quality products to beneficiaries under competitive bidding. The survey will allow CMS to compare the results about equipment with a quarterly report required of suppliers within a CBA that includes make, model and part numbers for all products supplied to Medicare beneficiaries.

According to a letter accompanying the survey sent to an oxygen provider, CMS is randomly selecting 1,000 suppliers to receive the survey and will pay $75 for its completion, an industry source said.

AARC Director of Government Affairs Cheryl West said the association was approached by CMS staff--first in 2006, though the survey never went forward, then again this spring--asking for its support to encourage survey responses.

"With input from the leadership of the home care section, AARC decided that it was important that CMS gather this data," West said. "Therefore, with the caveat, which I personally made very clear to CMS staff, that as long as they did not infer in any way that we endorsed the competitive bid program, they could use our name to encourage people to complete the survey."

In May of 2006, CMS explained in a Paperwork Reduction Act document that it would fulfill the MMA's competitive bidding evaluation requirement with beneficiary and supplier surveys, focus groups involving suppliers and referral agents, and discussions with beneficiary groups, CMS officials and others.

In an article posted on its Web site, Waterloo, Iowa-based VGM Group said at least one medical equipment supplier association has been contacted by Abt. According to the posting, a written contact to the association president stated: "You are being asked [to] participate in a 45-minute interview about your perspective and experiences from (the association's) standpoint. We would be willing to come to your place of business. The interview will not be audio or video taped. The discussion will be confidential."

VGM said the notice continued: "Data collection will take place before competitive bidding begins and again one year after it is implemented. The aim of the interviews is to learn about the experiences and perspectives of durable medical equipment suppliers, health care professionals who order durable medical equipment for their Medicare patients, Medicare beneficiary advocates, and CMS/CBIC officials. The interviews will help CMS understand the affect of the program on suppliers, referral providers and Medicare beneficiaries."

Kelly Wolf, VGM vice president, key accounts, said the group is not overly concerned about the data being collected.

"At VGM we feel, though the surveys suggest future monitoring, the data collected will in no way impact our members' ability to choose which products they offer their customers. As the final rule states, providers must provide Medicare recipients the same products that are provided to other customers. As long as providers utilize the same products for all of their customers they retain their ability to change products as needed."

Abt Associates, Cambridge, Mass., is the contractor that developed the first draft of CMS' new supplier quality standards.

NPI Registry Down
ATLANTA--CMS closed down its new Internet registry of National Provider Identification numbers last week because of "recent instability," the agency said.

The registry, which was developed as a resource to providers submitting Medicare claims, is expected to be back in operation sometime this week, CMS said in a statement. The agency had initially announced that it would take down the NPI Registry for one day only on Sept. 18. Friday's announcement extended the period.

"Many of you have noted the recent instability of [The National Plan and Provider Enumeration System] and the NPI Registry," CMS said in its notice. "CMS has begun implementing changes that should eliminate the instability. We expect that these changes will be completed next week. NPPES will remain in operation while these changes are being made, but the NPI Registry will remain down until all changes have been implemented. We expect the NPI Registry to be back in operation sometime next week. We apologize for the inconvenience."

The registry allows health care providers to locate their referral sources' NPI numbers for the purpose of submitting Medicare-compliant claims.

While some providers said they did indeed find it helpful, according to others, the system, which debuted Sept. 4, contains a troubling issue: It also reveals National Supplier Clearinghouse identification numbers, which could allow access to a provider's proprietary information (see HomeCare Monday, Sept. 17).

A spokesman for CMS said that furnishing the NSC numbers was optional. "Providers can remove their NSC numbers from NPPES whenever they wish. Once they remove them, those numbers will not appear in the NPI Registry because the NPI Registry is a 'real time' system," the spokesman said.

However, CMS did not respond to a question about what effect removing an NSC number from the NPI registry would have on verifying the NPI-legacy number pairs currently necessary for claims payment.

Texas Company Puts CPAPs on Auction Block
HOUSTON--A new Internet auction site that links buyers and sellers of sleep apnea equipment went live Sept. 4.

The site, CPAPAuction.com, "is designed for HMEs who want to liquidate excess inventory, as well as dealers who want an extremely low-cost, low-risk method of entering the online space," said Johnny Goodman, general manager of Houston-based U.S. Expediters. The company is parent to CPAPAuction.com as well as CPAP.com, an Internet CPAP store; CPAPtalk.com, a patient education and support site; and BillMyInsurance.com, a CPAP Web site that accepts popular insurance plans for CPAP items.

New and used CPAP, APAP and bilevel machines, masks and related equipment are available on the site. Sellers can post photos and detailed information, including the condition of the used items. "Until Oct. 1, sellers may post virtually unlimited listings for a one-time registration fee of $1," Goodman said.

Sellers work out arrangements for payment and delivery directly with the buyers.

Goodman said the new site was prompted by patients who either were asking where they could sell equipment or were swapping equipment on support forums.

"Our strong existing Web presence put us in a good position to build an auction site that makes buying and selling CPAP easy," Goodman said.

Although giant Internet marketer eBay does not allow sale of CPAP devices, Goodman noted that CPAPAuction.com can manage prescriptions. That is one of the safety precautions in place on the site, he said.

"CPAPAuction.com uses an auction feedback system and a proprietary prescription management software system to ensure that our marketplace is safe and efficient for both buyers and sellers," Goodman said.

Patients must have a prescription on file before bidding on prescription items.

"Patients who wish to bid on prescription items can upload, fax or e-mail their prescriptions to us," Goodman said. "We review the prescription, assign the product categories the prescription qualifies for and inform the buyer of the results of our review. In this way, sellers listing prescription products know that all bids from consumers on the product are legitimate."

So far, Goodman said, the site has gotten good response. As of Sept. 12, it had 633 registered users who placed 759 bids for 187 items; 122 transactions were closed successfully via 43 registered sellers, Goodman said.

The site is averaging more than 1,200 visitors a day, Goodman said, and "we expect that CPAPAuction.com will continue to grow from here as word spreads."

Legislation Would Strengthen False Claims Act
WASHINGTON--On Sept. 12, Sen. Chuck Grassley, R-Iowa, introduced legislation that would amend the False Claims Act to make it easier for whistleblowers to bring lawsuits.

Called the False Claims Correction Act of 2007, Grassley said the legislation is in response to recent court decisions that threaten to limit Congress' 1986 update of the False Claims Act, which has recovered $20 billion for the government.

The 1986 amendments empowered "qui tam relators," or whistleblowers, to bring false claims complaints.

"It's been proven time and again that without the courage and willingness of these individual citizen whistleblowers, the federal government would not have known what was going on or been able to pursue successful cases against those who defrauded the government, including contractors and state and local governments. These settlements have returned tens of billions of dollars that would otherwise be lost and gone forever," Grassley said in a statement.

"Our new legislation works to make sure recent court decisions won't weaken the government's ability to recover tax dollars lost to fraud, whether it's in health care, defense or another [area] of spending."

One provision of the bill would remove a requirement that false claims be presented directly to a government employee. This problem arose following the D.C. Circuit Court of Appeals decision in U.S. ex rel. Totten v. Bombardier Corp., which barred government recovery of funds because the false claims were submitted to employees of a government grantee (Amtrak) and not a direct government employee.

"This correction ensures that any government money lost to fraud, waste or abuse can be recovered using the FCA regardless of whether the individual making the false claim directly represents such a claim to a government employee," Grassley said.

Another measure in the bill would strengthen the FCA after a Supreme Court decision in Rockwell International Corp. et al. v. United States held that the whistleblower in the case could not share in any recoveries unless that person was the original source of all claims ultimately settled.

"The feds recoup millions of dollars every year from whistleblower activity. In recent years, the [Office of Inspector General] and [the Department of Justice] have taken a hard line with their interpretation of the False Claims Act, which governs rewards to whistleblowers. Grassley's bill is an effort to broaden the scope of the whistleblower law by removing some of the justification the feds have used to deny whistleblower payments," commented health care attorney Neil Caesar of the Health Law Center, Greenville, S.C.

"This legislation would result in more whistleblower activities. It is important for home care companies to remember that the people who work for them and with them can be their best allies or their worst enemies," Caesar continued.

According to Caesar, "most of the time" whistleblowers only go to the government after they have tried to get any problems addressed within the company. "The best way to minimize this danger is to have effective lines of communication, to encourage personnel to point out problems and to investigate and act on problems effectively," Caesar said.

The bill, S. 2041, is cosponsored by Sens. Dick Durbin, D-Ill.; Patrick Leahy, D-Vt.; Arlen Specter, R-Pa.; and Sheldon Whitehouse, D-R.I. Companion legislation will be introduced in the House of Representatives by Rep. Howard Berman, D-Calif. Grassley and Berman were the sponsors of the 1986 amendments to the False Claims Act.

"President Lincoln signed the False Claims Act into law in 1863 to prevent war profiteers and others from defrauding the government and the nation's taxpayers. Sadly, 144 years later, 'Lincoln's Law' is still needed," Durbin said. "This bipartisan bill modernizes and strengthens the False Claims Act, and will help "Lincoln's Law" continue to serve as an effective tool against fraud."

To read the full text of the bill, visit the Congressional Web portal at thomas.loc.gov.

In Brief
Sponsored by HomeCare, Accreditation Central at Medtrade will feature many of CMS' approved accreditation organizations whose representatives will be on hand during exhibit hall hours all three days of the show. Medtrade 2007 will be held Oct. 2-4 at the Orange County Convention Center in Orlando. Don't miss the chance to find the accrediting organization that's right for you. For a list of participating accreditors and a schedule of their presentations, click here.

While it discontinued assigning Unique Physician Identification Numbers as of June 29, CMS said last week it will maintain the UPIN "look-up" functionality and registry Web site through May 23, 2008, at www.upinregistry.com. National Provider Identifier, or NPI, numbers, will replace UPINs and other existing legacy numbers.

This is National Adult Immunization Awareness Week. This annual health observance is a great opportunity to promote the importance of adult immunizations. CMS reminds health care professionals that Medicare provides coverage for flu, pneumococcal and hepatitis B vaccines and their administration. According to CMS, all adults 65 and older should get flu and pneumococcal shots, and people who are under 65 but have chronic illness including heart disease, lung disease, diabetes or end-stage renal disease should get a flu shot. People at medium to high risk for hepatitis B should get hepatitis B shots. CMS asks that you help by talking with your Medicare patients about their risk for these vaccine-preventable diseases and the steps they can take to help reduce their risk of contracting these diseases, including getting vaccinated. For more information about Medicare's coverage of adult immunizations and a list of related educational resources, click here.

Have lunch with Louis from 11:30 a.m. to 1 p.m. ET on Nov. 1, 8 and 15! Grab a sandwich (or morning coffee if you're on the West Coast) and gather around the speakerphone for the first complete Sales Training Strategies program presented as a live teleconference series with HME sales training guru Louis Feuer, Dynamic Seminars & Consulting. Don't let competitive bidding and constant industry changes allow you to lose focus on what builds business--a well-trained sales team. With three individual sessions, it's never been easier and more convenient to train your sales staff. You need them now more than ever. For more information, click here.

Coming Up
AAHomecare's Reimbursement and Continuum of Care conferences are scheduled Oct. 1 at the Orange County Convention Center in Orlando, Fla. For information, call (703) 836-6263 or visit www.aahhomecare.org.

Medtrade 2007 will take place Oct. 2-4 in Orlando, Fla. For complete information including a schedule of educational sessions and an exhibitor list, visit www.medtrade.com.

AAHomecare's Stand Up for Homecare 2007 reception will be held Oct. 2 from 5:30 to 7:00 p.m. at the Orlando Peabody Hotel during Medtrade. The proceeds will support a comprehensive public awareness campaign to promote the mission of the home care industry. For information, contact Kim Kianka at kimk@aahomecare.org or (703) 535-1887.

The National Association for Home Care & Hospice (NAHC) will hold its 26th Annual Meeting in Denver Oct. 6-10. For information, call (202) 547-7424 or visit www.nahc.org.

The American Health Information Management Association (AHIMA) will hold its Annual Convention and Exhibit Oct. 6-11 in Philadelphia. For information, visit www.ahima.org.

The American Health Care Association/National Center for Assisted Living (ACHA/NCAL) will hold its Annual Convention & Exposition Oct. 7-10 in Boston. For information, call (202) 842-4444 or visit www.ahca.org.

CMS will hold a Home Health, Hospice & DME Open Door Forum at 2 p.m. ET on Oct. 10. For information on Open Door Forums, visit www.cms.hhs.gov/OpenDoorForums.

Sponsored by the USC School of Pharmacy, online seminars from www.hmeeducation.com include "How to Create a Compliance Plan," "Retail HME Cash Sales" and "Accreditation is Here" on Oct. 10, 11 and 17 respectively. For information, visit www.hmeeducation.com.

The National Community Pharmacists Association (NCPA) 109th Annual Convention & Trade Exposition will be held Oct. 13-17 in Anaheim, Calif. For information, call (703) 838-2686 or visit www.ncpanet.org.

The Healthcare Distribution Management Association (HDMA) will hold its Annual Leadership Forum Oct. 24-28 in Phoenix. For information, visit www.healthcaredistribution.org.

The Midwest Association for Medical Equipment Services (MAMES) will hold its Fall Conference Oct. 25-26 in Bloomington, Minn. For information, call (651) 351-5395 or visit www.mames.com.

To revisit this news any time during the week, go to www.homecaremonday.com.

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