In brief: CMS ‘locks door to vault,’ stakeholders raise alarm on proposal to weaken Medicaid oversight

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Friday, September 6, 2019

WASHINGTON – CMS has issued a final rule that creates several new revocation and denial authorities to bolster the agency’s efforts to stop waste, fraud and abuse in Medicare, Medicaid and CHIP.

The Program Integrity Enhancements to the Provider Enrollment Process, CMS-6058-FC, contains a new “affiliations” authority that allows CMS to identify individuals and organizations that pose an undue risk of fraud, waste and abuse based on their relationships with other previously sanctioned entities. For example, a currently enrolled or newly enrolling organization that has an owner/managing employee who is “affiliated” with another previously revoked organization can be denied enrollment, or if already enrolled, can have its enrollment because of the problematic affiliation.

“For too many years, we have played an expensive and inefficient game of ‘whack-a-mole’ with criminals—going after them one at a time—as they steal from our programs,” said CMS Administrator Seema Verma. “These criminals engage in the same behaviors again and again. Now for the first time, we have tools to stop criminals before they can steal from taxpayers. This is CMS hardening the target for criminals and locking the door to the vault.”

The rule also includes other authorities that will improve CMS’s fraud-fighting capabilities by providing a basis for administrative action to revoke or deny Medicare enrollment if:

·      A provider circumvents program rules by coming back into the program, or attempting to come back in, under a different name (e.g. the provider attempts to “reinvent” itself);

·      A provider bills for services/items from non-compliant locations;

·      A provider exhibits a pattern or practice of abusive ordering or certifying of Medicare Part A or Part B items, services or drugs; or

·      A has an outstanding debt to CMS from an overpayment that was referred to the Treasury Department.

Additionally, the rule gives CMS the ability to prevent applicants from enrolling in the program for up to three years if a provider is found to have submitted false or misleading information on its initial enrollment application.

Furthermore, the rule expands the reenrollment bar that prevents fraudulent or otherwise problematic providers from re-entering the Medicare program. CMS can now block providers who are revoked from re-entering the program for up to 10 years instead of three years, and for providers revoked a second time, up to 20 years.

The rule goes into effect Nov. 4.

Stakeholders raise alarms on two CMS proposals

WASHINGTON – Industry stakeholders urge providers to comment on a proposal that would rescind certain Medicaid regulations regarding a state’s obligation to assess and monitor beneficiary access when requesting approval to reduce or restructure payment rates.

AAHomecare has submitted comments on CMS-2406-P2, “Medicaid Program; Methods for Assuring Access to Covered Medicaid Services-Rescission,” and NCART plans to.

“This would be a major setback, dramatically minimizing the steps that a state currently must perform to conduct a proper ‘access impact analysis’ before proposing Medicaid changes,” NCART stated in a recent bulletin.

AAHomecare argues that without the current Access Monitoring Review Plan Regulation, CMS will have insufficient information to enforce compliance with equal access requirements. Additionally, the association believes managed care organizations need specific oversight by state Medicaid programs to ensure that federal dollars being spent on this program give patients access to care.

“Contrary to the assertion that underlies the proposed rule, the AMRP does not eliminate or even hinder a state’s ability to administer its plan for medical assistance,” AAHomecare stated in its comments. “The AMRP is simply providing oversight into how states are assuring they have adequate rates and a program that ensures access. If CMS is interested in achieving a reduction in regulatory burden, it could limit the number of years of tracking rate adjustments or benefit redesign to two years.”

NCART is also asking providers to comment on another proposed rule, CMS-1713-P, which, among other things proposes a new methodology that Medicare would use to establish payment rates for new items/codes.

“While we agree a new methodology is needed, we have major concerns with this approach and data that is being proposed,” the group stated.

Submit comments through Sept. 13 for CMS-2406-P2 at https://www.federalregister.gov/, searching for proposal number. Submit comments through Sept. 27 for CMS-1713-P.

CMS adds clarification to calculator

WASHINGTON – CMS has added a clarifying note on the lead-item pricing calculator for 14 non-lead item codes.

The codes, several of which are included in two categories in Round 2021 of the competitive bidding program, are:

Standard manual wheelchairs: E0955, E0985, E1020, E1028, E2228, K0015, and K0070
Standard power mobility devices: E0955, E0985, E1020, E1028, E2368, E2369, E2370, E2375, and K0015
Support surfaces (Groups 1 and 2): E0197

Walkers: E0140 and E0149.

The codes were converted from the inexpensive and routinely purchased payment class to the capped-rental class after 2015. However, to comply with federal regulations, CMS used the 2015 fee schedule to determine the relative ratios for the non-lead items in each product category.

As a result, the relative ratios for the 14 affected codes were calculated using the average of the purchase amounts (i.e. NU modifier) in all areas from the 2015 fee schedule, since these codes were still in the IRP payment class in 2015.

Providers with questions should call the Competitive Bidding Implementation Contractor (CBIC) customer service center at 877-577-5331 between 9 a.m. and 9 p.m. EST, Monday through Friday.

The bid window closes Sept. 18.

HandyQuip offers online marketplace for rentals

PONTE VEDRA, Fla. – HandyQuip is a new online marketplace designed to make it easy for people to rent medical equipment like wheelchairs, scooters, walkers and bath safety products, according to the Ponte Vedra Recorder. Stephane Poussou worked with a software engineer to design algorithms that match people with the equipment they need at a good price, but don’t overwhelm them. Visitors to www.handyquip.com choose what type of equipment they need, select rental dates from a calendar and type in their location. “Quinn” helps visitors through the process. Right now, delivery is available throughout northeast Florida, from Jacksonville to Ponte Vedra and Nocatee.

Aeroflow donates extra products

ASHEVILLE, N.C. – Aeroflow Healthcare’s urology division will donate more than 1,250 cases of diapers to support families living in Buncombe County. The provider, which is headquartered in the county, will donate diapers to Buncombe County Health & Human Services to be distributed among local families in need of supplies for their children. “Having access to diapers is critically important in the day-to-day lives of families with young children,” said Mica Phillips, director of Aeroflow Urology. “But the high cost involved can create a real strain, especially to low-income families. We are honored to be able to help, even in a small way.” One in three families in the U.S. struggles with “diaper need,” according to a survey by Huggies, in partnership with the National Diaper Bank Network. “We can’t think of a better way to use these extra products,” Phillips said.

Oventus ready to hit US market with oral device

BRISBANE, Australia – Oventus Medical has received regulatory clearance from the U.S. Food and Drug Administration for its O2Vent Optima oral device to treat obstructive sleep apnea. “We are thrilled to have received FDA clearance, which enables us to sell the O2Vent Optima in the U.S.—a core market for Oventus, alongside Canada and Australia,” said CEO Dr. Chris Hart. “We look forward to officially launching our material agreements within U.S. sleep channels and working with them to deliver the device to patients across their various treatment sites.” O2Vent Optima is a customized 3D-printed, medical grade nylon oral appliance that offers the comfort and simplicity of a mandibular advancement device, but with a separate airway that adds further stability to the upper airway throughout the night. Robin Randolph, the company’s senior vice president of sales and marketing, has introduced a dental-sleep program for sleep labs and HME providers who want to provide patient choice and/or an alternative treatment.

WellSky solution provides insights

OVERLAND PARK, Kan. – WellSky has launched an enhanced data analytics solution for home health care providers called WellSky Home Health CareInsights. The solution is powered by algorithms based on historical data from more than 7 million home health patient episodes. It provides both care managers and clinicians with predictive insights on patient real-time hospitalization risk, social determinants of health, care setting suitability and low utilization payment adjustment or LUPA risk. “After collaborating with our home health clients, we recognized that providers needed meaningful data beyond the population level to truly understand patients and their individual circumstances,” said Wes Little, vice president of analytics for WellSky. “Our purpose-built CareInsights solution delivers vital population- and patient-level insights to clinicians at the point of care, so they can make informed, individualized clinical care decisions to improve patient experience and outcomes.” The solution includes CareAssist, a feature that equips home health clinical staff with a real-time snapshot of each patient’s clinical and non-clinical risk factors directly within the client’s WellSky Home Health EHR software.

Payer Relations Council sets agenda

WASHINGTON – AAHomecare’s Payer Relations Council met for the first time in Arlington, Va., last week, to establish objectives for 2020, including educating the payer community on the value of HME. “There is a great opportunity for the HME sector to help lead efforts to deliver comprehensive quality care, while achieving overall cost savings across the healthcare continuum,” the association stated. “The council will spearhead efforts to educate payers, policymakers, providers, vendors and patients on the value of HME and develop compelling and consistent messaging to support that work.” The council’s 25 members also identified as objectives: expanding on recent success in managed care rate protection in Kentucky; focusing initially on Medicaid and MCO plans; establishing and leveraging what can be achieved at the national level vs. state-by-state; and evaluating what is required by Medicare Advantage plans and educating the provider community to hold these plans accountable. “As reimbursement in our industry continues to become increasingly complex, it is imperative that providers have a resource to help them navigate these new payment models and vast bureaucracies,” said Jason Morin, director of reimbursement for Home Care Specialists, and a member of the council.

VMI gets exclusive for Mobility Networks lifts

PHOENIX, Ariz. – Vantage Mobility International, a manufacturer of wheelchair accessible vehicles, is now the sole provider of Mobility Networks’ products sold in the United States, Canada and Mexico. As part of the exclusive distributor agreement, VMI will offer Mobility Networks’ products for installation on many of the most popular vehicles for both consumer and commercial applications, including the Dodge Promaster and Ford Transit full-sized vans. “Installing Mobility Networks’ products on VMI vehicles ensures that we are giving our customers the best and safest products on the market that fit their unique needs to achieve greater independence,“ said Mark Shaughnessy, CEO of VMI. “This exclusive arrangement with Mobility Networks will also simplify our product line, enabling VMI and our authorized dealers to maintain an inventory of ready parts for efficient installation, service and repair.” Customers will be able to order products for installation on vehicles shipped from VMI’s factory locations in Tucker, Ga., and Clarkston, Mich. United Kingdom-based Mobility Networks’ products include the iCLASS platform lifts, which come in several design configurations: split, solid and fold. The company is also working on adding proprietary advanced technology that will enable remote ramp operation.

SoClean sets up second shop

PETERBOROUGH, N.H. – SoClean will add operations in Kalispell, Mont., in October, with plans to hire up to 100 people there in its first year, according to Montana Public Radio. Chief Information Officer Keith Brown told the radio station that the company, founded in 2011, is growing and needs a second North American office. “It’s primarily going to be sales, customer service, some technical folks,” he said. “I imagine we’ll have, eventually, marketing and other areas here in Kalispell also.” Initially, SoClean wants to fill 15 to 20 positions at the 78,000-square-foot building, according to the radio station.

EZ-Walk now available at Walmart, Amazon

CHICAGO – The EZ-Walk Cane & Crutch Pad is now available at Walmart and Amazon. The device, a lightweight, flexible rubber disc that is easily fastened to traditional cane and crutch stems, makes it easy for users to navigate beaches and other uneven terrain. The EZ-Walk, created by Jerry Vasilatos, an amputee, was nominated for a 2019 Chicago Innovation Award. "Knowing that solving my own problem has helped thousands of others who use canes and crutches stay active is one of the most fulfilling dreams I could have ever hoped for," said Vasilatos.

Goodwill HME adds incontinence supplies

LAWRENCEVILLE, N.J. – Goodwill Home Medical Equipment now offers incontinence products online and in-store for women and men. The inventory includes incontinence pads, briefs and disposable undergarments. Goodwill HME is a nonprofit organization headquartered in Bellmawr, N.J., that collects, refurbishes, sanitizes, and sells gently used medical equipment and unopened medical supplies at affordable prices.

Cash-only CPAP provider debuts

MIDDLEBURGH HEIGHTS, Ohio – Miguel Semidey has opened a retail store here called CPAP EquipSource to sell CPAP machines, masks, nebulizers, supplies, POCs and more to cash-paying customers, according to cleveland.com. “Right now, we’re trying to attract that out-of-pocket customer who doesn't want to deal with an insurance company,” he told the website. “A lot of patients, for whatever reason, don’t have options. They come to us and see different options in person, as opposed to online.” Semidey also provides home sleep apnea testing. He told the website he used his decade-long experience operating Medicina Medical, a respiratory therapy equipment business, to build CPAP EquipSource.

Funding expands ‘peer buddy’ program for sleep apnea patients

TUCSON, Ariz. – Sairam Parthasarathy, MD, a past keynote speaker at the HME News Business Summit, has been awarded nearly $1.4 million for a peer-support program for sleep apnea patients. Parthasarathy, a professor at the University of Arizona College of Medicine-Tucson, and his team will use funding provided by the Patient-Centered Outcomes Research Institute to implement the findings of a previous research project through which peers were trained to help patients starting treatment for sleep apnea. “Our biggest barrier to treating sleep apnea is helping individuals use a CPAP machine,” said Parthasarathy, director of the UA Health Sciences Center for Sleep and Circadian Sciences and medical director of the Center for Sleep Disorders at Banner-University Medical Center Tucson. “We are creating a therapy program that trains ‘peer buddies’ to educate and support new CPAP patients on how to use a CPAP machine.” The program will be made available to patients at Banner-University Medical Center Tucson clinics and will later be expanded to 11 centers in six states within the Banner Health System. The system conducts more than 11,000 sleep studies and sees more than 9,000 patients annually. Parthasarathy's study was selected for funding through PCORI's dissemination and implementation portfolio, in which funding is awarded to projects to increase awareness and promote the use of PCORI research findings to improve healthcare practices and health outcomes.

HomeCare Connect builds home mods staff

WINTER PARK, Fla. – HomeCare Connect, a company that manages the quality and cost of home health, DME, home modifications, O&P and medical supplies for workers’ compensation patients and payers, has hired Michelle “Nickcola” Wallace as complex care transition manager. She will ensure that seriously injured workers receive appropriate home modifications and DME in a timely and cost effective manner. “Early intervention is key,” said Wallace, a certified aging-in-place specialist or CAPS, a designation program that teaches technical, business management and customer service skills related to modifying homes for the disabled and/or aging populations. “The sooner the home is prepared for the injured worker, the sooner they can be discharged. Being at home is better for the injured worker and their family, and can save thousands of dollars a day on facility fees.” For the past 12 years, Wallace has held high-level positions with complex care companies in group health and workers’ compensation, most recently as home modification specialist, catastrophic/complex care for Orchid Medical.