In brief: CMS limits scope of audits, O&P fight rages on
WASHINGTON – For redeterminations and reconsiderations of claims denied following a post-payment review or audit, CMS has instructed the MACs and QICs to limit their scope to the reason the claim or line item was initially denied, according to a recent MLN Matters article.
In the past, the MACs and QICs have had the discretion to develop new issues and review all aspects of coverage and payment related to a claim or line item.
“In some cases, where the original denial reason is cured, this expanded review of additional evidence or issues results in an unfavorable appeal decision for a different reason,” CMS states in MLN Matters Number: SE1521.
The guideline applies to redeterminations and reconsiderations received by the MACs or QICs on or after Aug. 1, 2015. It will not be applied retroactively.
CMS points out, however, that there are two instances where the guideline does not apply: 1.) claims denied in prepayment reviews (the guideline applies only to post-payment denials); and 2.) claims denied in post-payment review for insufficient documentation and appealed with never-before presented documents (the guideline allows these claims to be denied for an issue other than the issue that was initially denied).
Researchers, former senator join fight
WASHINGTON – Nine leading U.S. researchers and a former U.S. senator have put pen to paper in the fight against proposed changes to coverage for lower limb prostheses. The work of the researchers was used by Medicare to back up its decision to make the changes. “We would like to go on record as stating that the works referenced do not support any of the changes outlined in the proposal,” they wrote in a letter to the U.S. Health and Human Services Department. “We are extremely concerned that the draft rule was not based at all on the current literature and science associated with the provision of prosthetic care.” The researchers go on to say: “We strongly oppose the draft.” The researchers include Steven Gard, Ph.D., executive director of Northwestern University Prosthetics-Orthotics Center; and Jason Highsmith, associate professor at the School of Physical Therapy & Rehabilitation Sciences at Morsani College of Medicine at the University of South Florida, and president of the American Academy of Orthotists and Prosthetists. Former Sen. Bob Kerrey, D-Neb., an amputee, wrote in a blog posted to The Hill’s website, that the draft rule should be thrown out. “Instead, Medicare should undertake a real discussion with stakeholder groups to resolve any concerns it may have about the status quo,” he wrote. “Otherwise, this really is a case of the government creating a problem rather than solving it.” Kerrey, who served in the Senate from 1998-2001, was governor of Nebraska from 1983 to 1987. He served as a Navy Seal in the Vietnam War and received the Medal of Honor.
CMS targets Medicare Advantage for alternative model
BALTIMORE – CMS has announced plans to test a Value-Based Insurance Design Model to improve care and reduce costs in Medicare Advantage plans.
The model will test whether giving MA plans flexibility to offer supplemental benefits or reduced cost sharing to enrollees with specific chronic conditions can lead to higher quality and more cost-efficient care. It will focus on enrollees with chronic conditions like diabetes, congestive heart failure, COPD, past stroke and hypertension.
“The Medicare Advantage Value-Based Insurance Design Model fills an immediate need for testing ways to improve care and reduce cost in Medicare Advantage Plans and offers the prospect of lower out-of-pocket costs and premiums along with better benefits for enrollees in Medicare Advantage,” said Patrick Conway, M.D., MSc, CMS deputy administrator and chief medical officer.
The model will begin Jan. 1, 2017, and run for five years in Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee.
VBID models are increasingly used in the commercial insurance market and evidence points to the model as an effective tool, CMS says.
Stealth prioritizes ALS orders
BURNET, Texas - Stealth Products, a division of Quantum Rehab, will begin offering expedited handling and shipping for all ALS orders, the manufacturer announced today. “At Stealth we understand the struggles facing patients fighting ALS and the rapid pace at which this terrible disease can progress,” said Lorenzo Romero, president, in a press release. “Because of this, Stealth wants to take this step to help get ALS patients the medical devices they need quickly to help make their lives as comfortable and manageable as possible.” Depending on the complexity of the order, the company is committed to completing ALS orders within 48 hours and custom orders within three to five days. It will also expedite shipping to arrive within two business days.
‘Get Out’ winners announced
ATLANTA – Erik Kondo won top honors in the 2015 Get Out, Enjoy Life contest for his side-wheelie photo taken during an off-road handcycling event in Vermont. His submission beat out more than 500. The photo will be featured on this month’s cover of Sports ‘N Spokes. Kondo sustained a spinal chord injury from a motorcycle accident in 1984. Amanda Timms took second place for her photo taken during a seven-day canoe trip around the Bowron Lakes in Canada; and Kim Harrison placed third for her photo entitled, ‘Target Practice.’ Sponsored by UroMed’s nonprofit program Life After Spinal Cord Injury, At Home Medical’s iPush Foundation, Sports ‘N Spokes Magazine and Wheel:Life, the five-year-old contest asks wheelchair users to submit photos of their favorite wheelchair accessible hot spots, wheelchair sporting events or recreational activities.
Sigvaris rallies behind ‘Lymphedema Act’
PEACHTREE CITY, Ga. – Sigvaris recently sponsored a group of advocates, including Robyn Bjork, a wound care and lymphedema specialist, to educate Rep. Jim Cooper, D-Tenn., about the condition and The Lymphedema Treatment Act. “We are proud to support patient needs in regards to better treatment and diagnosis for people with lymphedema and other leg diseases,” said Scot Dubé, president and CEO for North America, in a release. “We believe that regular use of compression and early intervention can improve lives and reduce related long-term health care costs.” The group shared personal stories about living with lymphedema and explained how compression garments could prevent infection and hospitalization.If passed,the act would amend Medicare statute to allow for coverage of compression supplies, improving coverage for the treatment of lymphedema from any cause.
Ascendant makes fifth pharmacy buy
DALLAS – Ascendant Solutions, an investment firm, and its healthcare subsidiary, Dougherty’s Holdings, has acquired Springtown Drug in Springtown, Texas, it announced Aug. 31. The acquisition is expected to add $4 million to Ascendant’s annual revenues and boost sales for Dougherty’s to more than $43 million in 2015, according to a press release. It’s the fifth such buy for Ascendant. In July, it bought The Medicine Shoppe pharmacy in McAlester, Okla.
Brightree, ResMed announce further integration
ATLANTA – Brightree and ResMed have enhanced the integration capabilities of Brightree’s HME billing and management software with ResMed’s U-Sleep compliance solution. “As the healthcare industry transitions from a fee-for-service to an outcomes-based reimbursement model, providers are constantly seeking to improve patient outcomes and increase operational efficiencies,” said Dave Cormack, president and CEO of Brightree. The two companies began working together in 2013 to automate the onboarding of patients that use ResMed S9 PAP devices into U-Sleep and have announced several enhancements since that time, including the integrations of ResMed’s AirView patient management systems into Brightree’s systems in February.
Aeroflow fundraises for hospital
ASHVILLE, N.C. – Aeroflow Healthcare has raised more than $6,100 for Mission Foundation in support Mission Children’s Hospital. The foundation helps to ensure children receive care, regardless of ability to pay. Aeroflow has created outlets, including “Blue Jean Friday,” for employees to become involved in its fundraising efforts. “Patient care has always been Aeroflow’s No. 1 priority,” said Casey Hite, CEO. “We want to ensure that the people of Western North Carolina and beyond are receiving the care they need. By supporting Mission Children’s Hospital, we can help make sure more patients receive the care and treatment they need to be healthy.” Aeroflow recently earned a first-time spot on the Inc. 5000 list of fastest growing companies.
COPD patients benefit from app, same-day treatment
PHILADELPHIA – Early intervention facilitated by a digital health application provides key benefits for COPD patients, according to the results of a two-year clinical study by Temple University. COPD patients who used an app to report their daily symptoms and received same-day treatment recommendations from their healthcare provider experienced fewer and less severe exacerbation symptoms, leading to an improvement in daily symptom control, lung function and activity status. “Previous studies at other sites have questioned the efficacy of various telemedicine solutions in COPD patients, but those studies have not used a solution that enables same-day treatment in response to worsening patient symptoms,” said Dr. Gerard Criner, founding chairman of the new Department of Thoracic Medicine and Surgery at Temple University School of Medicine, director of the Temple Lung Center and the principal investigator of the study. The app allows COPD patients to report their respiratory symptoms and peak expiratory flow measurements, which are then assessed by a computer algorithm and compared with initial values to achieve a symptom deviation score—a measure of how serious the symptoms are relative to the baseline metrics. Scores in excess of a predetermined threshold are reviewed by a nurse and referred to a physician to prescribe treatment. The technology used in the study is a precursor to a solution currently offered by Temple University spin-off company HE Health Care Solutions.
Performance Health is on TRAC
AKRON, Ohio – Performance Health held its 17th annual Scientific Advisory Committee meeting, known as TRAC, in Vancouver, Canada, recently. Seventeen researchers and clinicians with expertise in physical therapy, chiropractic, exercise science, athletic training and massage therapy presented their research on Performance Health products. This year’s research focused on TheraBand CLX Consecutive Loops—its force characteristics, the biomechanical analysis of associated exercises; its integration with deep tissue massage and its ability to strengthen outcomes—and TheraBand Kinesiology Tape with XactStretch technology—skin blood flow following its application, its adhesive properties and its effectiveness.