Bill seeks improvements to vent category

Friday, July 15, 2016

WASHINGTON – A bill that would create medical necessity standards and boost payments for ventilators was introduced in the Senate July 14.

The “Beneficiary Respiratory Equipment Access and Transparency to Home Ventilator Care (BREATH) Act of 2016” was introduced by Sens. Bill Cassidy, D-La., and Chuck Grassley, R-Iowa.

“This is a simple bill,” said Stephen Cooper, counselor at K&L Gates, which helped draft the legislation.“It requires CMS to implement medical necessity standards and to increase payments next year. It’s not more complicated than that.”

In response to a spike in utilization for vents—from 60,000 beneficiaries in 2010 to 178,000 in 2014—CMS has overhauled the product category, reducing the number of codes from five to two, and reducing payments by about 33%.

At the core of the issue: CMS believes HME providers have been wrongly using ventilators, instead of CPAP machines, to treat sleep apnea patients, says Cooper.

“Part of the problem is we don’t have good medical necessity standards,” he said. “(The bill requires) standards that say, ‘We’ll pay for the vent when the patient has these clinical indications.’”

The policies and standards for appropriate use of ventilators would be developed in consultation with medical experts. Cooper says he believes that the standards would help reduce utilization by 20%.

The bill would also increase payment amounts by 20% on Jan. 1, 2017.

“We tried to be conservative,” said Cooper, of the decision to not seek a full increase of 33%. “It has to be budget-neutral. If the use of vents doesn’t go down 20% in 2017, then the industry’s rates will be cut in 2018 by the difference between 20% and the actual decrease.”

Lawmakers broke for summer recess July 15. When they return in September, they will likely take up some Medicare provisions in a bill that the BREATH Act could get included in, says Cooper.

“From what staff tells me, they would like to do a fairly modest but bi-partisan Medicare bill in the lame-duck session,” he said.