Bill provides ammo for audit reform

‘Hopefully it will spur CMS to do something more quickly’
Friday, May 29, 2015

WASHINGTON – HME stakeholders have accomplished the first of two goals in their bid to reform Medicare’s audit program.

Rep. Marsha Blackburn, R-Tenn., introduced a bill on May 19 that would require prior authorizations for certain high-cost DME, including oxygen. The bill would also exempt DME that has gone through that process from pre- and post-payment audits.

“There are two components to reform: one is prior authorization, and the other is clinical inference,” said John Gallagher, vice president of government relations for The VGM Group.

Stakeholders are also working with Rep. Renee Ellmers, R-N.C., to introduce a bill that would reinstate clinical inference to the audit program. Ellmers, along with Rep. John Barrow, D-Ga., introduced a similar bill last year.

Elements of Blackburn’s bill, H.R. 2437, include aligning the prior authorization process with best practices from commercial managed care and Medicare Advantage plans, which already have such processes in place; providing emergency review for certain items, including oxygen; and ensuring stakeholder input.

“Stakeholder input is huge,” said Jay Witter, senior vice president of public policy at AAHomecare. “When they first developed (the current demonstration project requiring prior authorizations for power mobility devices), it was a nightmare. It turned around when they started working with us. Now our folks love it.”

H.R. 2437 was necessary, stakeholders say, because, although CMS currently has a PMD demo in place in certain states, it expires in August. Additionally, the agency published a proposed rule in May 2014 outlining its plans to require prior authorizations for 134 DME codes, but it doesn’t plan to take the next step, publishing a final rule, until 2017.

“Hopefully the bill will spur them to do something more quickly,” said Cara Bachenheimer, senior vice president of government relations for Invacare.

Relief can’t come fast enough for providers like Thom Harvill, co-owner of Riverside Medical in Savannah, Tenn., who worked with the staffs of Blackburn and Sen. Lamar Alexander, R-Tenn., on the bill for more than a year.

“With Medicare HMOs, all we do is fax everything in to their utilization department and within 24 hours we have a reply, ‘Yes, this patient does meet qualifications; here’s your authorization; it’s good through 2099,’” he said. “The more I thought about it the more I thought, ‘Why can’t CMS do this.’”

If CMS continues to drag its feet, stakeholders say a prior authorization process for a broader spectrum of DME has bi-partisan support in Congress, including from Rep. Kevin Brady, R-Texas, who sits on the Ways and Means Subcommittee on Health, and Sen. Ron Wyden, D-Ore., who sits on the Finance Committee.

“From what we’re gathering, some kind of prior authorization package could be included in the hospital improvement program they’re working on,” Gallagher said.