Accreditation: Medicare's requirement not foolproof

Thursday, September 29, 2011

YARMOUTH, Maine – WellPoint, a health plan that owns and administers Blue Cross Blue Shield (BCBS) plans in 14 states, has thrown a monkey wrench into the operations of certain HME providers.

WellPoint recently notified providers in Georgia that to remain part of its network they must be accredited by one of these three accreditation agencies by March 1, 2012: The Joint Commission, ACHC and CHAP. Though it only notified providers in Georgia, industry stakeholders say the requirement is a “national policy” that applies to all the states where it has a presence.

“I’m angry,” said Mary Nicholas, executive director of HQAA. “And my providers are angry. It’s another blow, in addition to the audits and the other threats to their businesses.”

In 2009, through a bill called the Medicare Modernization Act (MMA), Medicare started requiring that HME providers be accredited by one of 10 “deemed” agencies. The Joint Commission, ACHC and CHAP were on the list, but so were HQAA, The Compliance Team and five others.

As it stands right now, providers that aren’t accredited by one of the three agencies must become accredited by an additional agency or switch agencies to meet WellPoint’s requirement.

“We have numerous providers that are already part of WellPoint’s network,” said Sandy Canally, president of The Compliance Team. “This means they have to leave the network and re-enroll once they’re accredited by one of the three agencies.”

Because Medicare has no jurisdiction over WellPoint, at first blush, it would seem HQAA and The Compliance Team and their accredited providers don’t have a leg to stand on. But consider this: What about Medicare beneficiaries who buy supplemental plans from commercial insurers to help with 20% co-pays?

“The story here is: The provider is following all the rules put forth by the MMA, then here comes this supplemental plan that says you only have three choices, not 10,” Canally said. “So the tail is wagging the dog.”

Both HQAA and The Compliance Team have contacted WellPoint. They’ve also had providers write letters to the health commissioner in Georgia and to lawmakers, and had meetings with lawmakers.

“We’ve been hitting this at many different levels,” Canally said. “WellPoint has said they’re re-evaluating the requirement, so we’re waiting for their latest read at this point.”