WITH A FOCUS ON COMPLEX REHAB TECHNOLOGY

Transcription

1 TRENDS IN FUNDING POLICY AND HOW IT IMPACTS ACCESS TO CRT Rita Stanley, VP Government Relations April 17, WITH A FOCUS ON COMPLEX REHAB TECHNOLOGY Latest news from DC Latest news and trends related to Medicaid Latest news and trends related to Medicare Why you should care and what you can do to engage 2 1

2 SPONSORSHIP? 35 Years Employed by Sunrise Medical that pretty much sums it up! 3 WHAT S UP IN DC? WHAT YOU WON T LEARN ON TWITTER 4 2

3 LEGISLATION THAT MATTERS Direct Impact H.R Restores pricing to 2015 rates plus CPI U for accessories used with CRT manual wheelchairs Indirect Impact EMPOWER Care Act (S.2227) Money Follows the Person (MFP) Medicaid demonstration H.R. 750 Establishes a Separate Medicare Benefit Category for CRT Bi partisan Budget Act of 2018 Repeals application of the Medicare outpatient therapy caps H.R Delays payment in rural and non bid areas to 2019 for all DME payment reduction based on CURES ACT. 5 MEDICAID CHANGES AND TRENDS CURES Act Update States are assessing current spending and taking steps to mitigate risk of federal share decline Several States have submitted State Plan Amendments (SPAs) to CMS to adjust rates Does not apply to Managed Medicaid; Managed Care is an island. 6 3

4 WHAT WE KNOW TODAY* States Already At Or Below Medicare Rates (5) DC Mississippi Nevada Virginia West Virginia States Not Changing Rates (11) Florida Georgia Hawaii Michigan Minnesota North Carolina Ohio Pennsylvania South Carolina Tennessee *Info provided by NCART and AAHomecare 7 WHAT WE KNOW TODAY States Changing Rates to Medicare (10) Vermont All HCPCS Montana All HCPCS but CRT Working with State on Utilization to potentially change Washington All HCPCS but CRT Colorado Cures Codes Only Iowa Cures Codes Only Working with State on Utilization to potentially change Kentucky All Cures and other various codes North Dakota Cures Codes Only Connecticut Cures HCPCS 100% of Medicare Follow up Meeting on 4/10 to make proposal Maine Need information on which codes Massachusetts Need Information on which codes 8 4

5 EQUAL ACCESS MANDATE REMAINS 9 MEDICAID ACCESS MANDATE The Social Security Act requires states to: assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area; 10 5

6 ADDITIONAL REQUIREMENTS FOR MEDICAL SUPPLIES, AND EQUIPMENT The term suitable for use in the home is not a limitation on the location in which items are used, but rather refers to items that are necessary for everyday activities and not specialized for an institutional setting. States may not deny requests for the items based on the grounds that they are for use outside of the home. States may continue to establish medical necessity criteria to determine the authorization of the items. 11 WHAT THAT MEANS FOR MEDICAL SUPPLIES, AND EQUIPMENT States may have a list of preapproved medical equipment, supplies, and appliances for administrative ease but not as an absolute limit on coverage. States must provide and make available to individuals a reasonable and meaningful procedure for individuals to request items not on the list. Individuals must be informed of their right to a fair hearing. 12 6

7 YOUR RESPONSE MAY BECOME DEFAULT POLICY Frequent s from suppliers demanding we reduce our prices to allow provision at 65% of Medicare fee schedule Frequent s requesting free products: Transit option Attendant Control Seat elevation Frequent s asking me to change the assigned HCPCS code on an invoice or quote because the payment for the code used is too low 13 MANAGED CARE IS AN ISLAND 14 7

8 MANAGED MEDICAID TRENDS Increased Managed Medicaid Not all Medicaid rules apply to Managed Care Ability to negotiate rates Variation in coverage and payment policies increases billing complexity Lack of CRT medical review expertise Lack of understanding regarding legislative mandates and inadequate enforcement 15 MEDICARE NEWS: NORIDIAN SPECIFIC WHAT? Pre-Claim Hotline: Number: A service for suppliers regarding Advance Determination of Medicare Coverage (ADMC), Power Mobility Device (PMD) Prior Authorization (PA) Demonstration, Condition of Payment (COP) PA or other mobility related inquiries. Acceptable use of the hotline includes: Questions a supplier may have during the preparation of an ADMC, PMD PA Demonstration or COP PA submission, Questions on a decision that was received or information on coverage criteria. Calls will be directed to a voic . You must provide the below information. Call backs within 5 business days o o o o o o Beneficiary Name Supplier Name Phone Number Hours of availability and time zone Beneficiary Medicare Number or Medicare Beneficiary Identifier (MBI), if applicable Brief description of the question/issue 16 8

9 MEDICARE TRENDS Bundling Table ICD 10 or diagnosis driven policies Payment reductions based on CB Grouping DME and CRT into single HCPCS code Policy driven to allow claims processing filters No 3 rd level or individual consideration medical review 17 RECENT POLICY ARTICLES REVISED Manual Wheelchair Revisions: Added: Clarification of what is included in a manual wheelchair base code A complete frame Propulsion wheels Casters Brakes A sling seat, seat pan which can accommodate a wheelchair seat cushion, or a seat frame structured in such a way as to be capable of accepting a seating system A sling back, other seat back support which can accommodate a wheelchair back cushion, or a back frame structured in such a way as to be capable of accepting a back system Standard leg and footrests Armrests Safety accessories 18 9

10 RECENT POLICY ARTICLE REVISIONS Manual Wheelchair Revisions: Added: Clarification of titanium unbundling in manual wheelchair bases Wheelchair Seating Revisions: Revised: Positioning cushion language placement for clarification Added: Wheelchair seat and back cushion codes are all inclusive: Wheelchair seat and back cushion codes are all inclusive. Use of HCPCS code K0108 or any other HCPCS code to separately bill for added components such as the foam blocks, gel packs, air cells, or equivalent material is incorrect coding. 19 RECENT POLICY ARTICLE REVISIONS Power Mobility Device Policy Revision Revised: ADMC eligible base codes to conform to the Condition of Payment PA Program Added: Prior Authorization of Power Mobility Devices (PMD) Demonstration and Condition of Payment PA Program information Wheelchair Options and Accessories Revision: NON MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Added: 42 CFR language previously in Policy Specific Documentation section CODING GUIDELINES: Revised: Coding Guidelines for E1012 Added: PDAC contact information IMPORTANT NOTE: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination

11 EXAMPLE OF HCPCS CODING BARRIERS Foot Box Technology Requested Codes: Prefabricated Single; Wheelchair positioning accessory, foot box, prefabricated, single, with fixed attaching hardware, each Prefabricated Double with or without divider; Wheelchair positioning accessory, foot box, prefabricated, full, with or without divider with fixed attaching hardware Custom Fabricated; Wheelchair positioning accessory, foot box, custom fabricated with fixed attaching hardware Gap Fill Calculation Result MSRP Single (Sunrise, AEL, Comfort Company, Therafin, Miller s) $ $ $ (2016) Median Retail $ Fee Schedule MSRP Double $ $ (2017_ Median Retail $ Fee Schedule Custom individual consideration 21 CMS DECISION Add a Single Code E0954 Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot Fee Schedule Approximately $50.00 each foot 22 11

12 CMS TRENDS RELATED TO CRT Bundling products Mono Back, Dynamic Back included in the price of the base, Handrims included in the price of the basenot separately billable Defining HCPCS Codes any type and complete Using comparable products to establish fee schedules Center Mount Power ELR/ALR (E1010) E0953 Lateral Thigh or Knee Pad (E0956) E0954 Foot Box (E0951+E0952+K0038) 23 COMPARABLE? 24 12

13 COMPARABLE? 25 DO MEDICARE AND MEDICAID TRENDS DENY ACCESS? Suppliers What procedures or policies exist? How are you monitoring billing and payment? What conversations are occurring with your customers? Clinicians? ABN usage? Change in assignment rates? Changes in technology provision? Clinicians Do you still evaluate for all medical and functional needs even if not covered or if reimbursement inadequate? How do you engage your patient/caregivers in the technology conversation? Do you document the need for items that may not be provided? 26 13

14 HOW ARE YOU INVOLVED? Advocacy? Strategic Planning with stakeholders in your area? Deciding limitations on provision? Engaging consumers? Tracking changes in products and services provided?

15 URGENT WE NEED YOUR HELP! Examples where you have been forced to refuse to provide an item. Examples of when you had to provide a less costly item, particularly if that item is a WC cushion, or where you can demonstrate that the item provided was less than optimal for the beneficiary. Examples where a skin protection cushion provided has needed to be replaced before the 5 year replacement period has passed. 29 ADVOCACY 30 15

16 REFERENCES 42 CFR Part 440 [CMS 2348 F] RIN 0938 AQ36 Medicaid Program; Face to Face Requirements for Home Health Services; Policy Changes and Clarifications Related to Home Health 42 CFR Part 447 [CMS 2328 FC] RIN 0938 AQ54 Medicaid Program; Methods for Assuring Access to Covered Medicaid Services CURES State Data: NCART and AAHomecare 31 QUESTIONS Until medicine proves otherwise, technology is the cure. Steve Saling