Devil in the details: Stakeholders await guidance on bid relief

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Friday, December 9, 2016

WASHINGTON – Now that a rollback of a second round of Medicare reimbursement cuts in rural areas is a foregone conclusion, the big question is: How will CMS follow through on Congress’ directive?

At press time on Friday, the 21st Century Cures Act was on its way to a supportive president for his signature, after sailing through the House of Representatives on Nov. 30 and the Senate on Dec. 7. The huge bill will, among many other things, roll back cuts that went into effect in non-competitive bidding areas from June 30, 2016, to Dec. 31, 2016, allowing providers in those areas to recoup six months worth of payments.

“I think there’s a strong argument that can be made that CMS should do it on its own—they can pull by code and by zip code, and automatically reprocess the claims that way,” said Cara Bachenheimer, senior vice president of government relations for Invacare. “That would be far more preferable, and far less of a hassle on providers.”

The other possible scenario: Providers will have to do the heavy lifting and re-file the claims themselves.

Until CMS has the statute in front of them, it’s not likely they’ll offer guidance, stakeholders say.

“Once it’s signed into law, we’ll contact CMS and sit down with Laurence Wilson, (director of CMS’s Chronic Care Policy Group), as soon as possible,” said Tom Ryan, president and CEO of AAHomecare. “It’s a good question.”

If providers are forced to re-file claims, they might look to how CMS handled a recent snafu in processing claims for accessories for complex power wheelchairs. Providers had to re-file claims for those products for Jan. 1, 2016, through June 30, 2016, because the agency couldn’t put a stop to a previously planned shift to bidding-derived pricing until July 1.

On the plus side, stakeholders say, CMS did allow providers to use an Excel spreadsheet to lump together their claims and submit them all at once.

“I know there have been some minor issues, but based on everything we have heard, by and large, the process has worked quite well,” said Seth Johnson, senior vice president of government affairs for Pride Mobility Products. “Payments weren’t as quick as many of us would have liked, but it has worked quite well.”

Speaking of accessories, stakeholders believe another provision in the Cures Act that further delays CMS’s plan to use bidding-derived prices for these products for another six months is less up-in-the-air, even as the agency last week released a 2017 fee schedule that does not include the KU modifier, the “fix” it put in place to pay for accessories at the original amounts.

“In this scenario, it’s just an extension of the current policy,” Bachenheimer said. “They just have to stop the change for those codes from going into effect Jan. 1. It’s a much more streamlined process.”

It behooves CMS to tread lightly on both issues, stakeholders say.

“If CMS takes the same tack with the DME rollback that they took with CRT, they’re going to get a lot of congressional pressure,” Johnson said. “Considering how knowledgeable (Rep. Tom Price, president-elect Donald Trump’s nominee for secretary of Health and Human Services) is and his position on these issues, I think they’ll be more timely with guidance and do whatever they need to do.”

Comments

<p>My question is how can you legally go back and upcharge someone for a service that they have already signed an assignment of benefits form and a delivery ticket with a specified rate on it ? From a DME point of view this would be a logistic nightmare on top of everything else we are dealing with.&nbsp;I really appreciate the effort in this bill process though.&nbsp;We are finally getting some traction our way after all these years that may&nbsp;pay off down the road but I just do not see being able to backtrack and collect on services that are already done.</p>