HME industry: loss of CMN is no 'happy medium'

Sunday, August 28, 2005

WASHINGTON -- Shock turned to skepticism for the HME industry, in the wake of news that CMS plans to drop the CMN for scooters and wheelchairs and replace it with a prescription.

HME providers called Wednesday's announcement by CMS Administrator Mark McClellan "unexpected," but as they plowed through CMS's 45-page interim final rule, providers began to scratch their heads over how they would also keep supporting documentation on hand to prove medical necessity.

"The amount of information that has to be conveyed to the providers is incredible," said Sharon Hildebrandt, executive director of the National Coalition for Assistive and Rehab Technology. "I can't see that doctors are going to be willing to provide all of that information. And so that's going to leave the provider in a quandary, because if the physician is not willing or able to provide all of the documentation, where does that leave the provider when the beneficiary needs the equipment?"

Per the rule, physicians must give providers supporting documentation comprising "pertinent parts of the medical record," which may include history, physical examination, diagnostic tests, a summary of findings, diagnoses and treatment plans. In most cases, information culled from a face-to-face exam will suffice, but, for example, if a physician has treated a patient over an extended period of time, notes from previous exams would be needed, the rule states.

The industry isn't comforted that CMS will only ask for supporting documentation under certain circumstances, such as a review or audit, because a provider's hands will be tied until he has that information on file, said Cara Bachenheimer, vice president of government relations for Invacare.

"They say they're putting the responsibility more on the physician, but we don't believe that's necessarily the case," she said. "It's still going to be the provider who's going to have to assess the adequacy of the documentation and make a business decision on whether or not they're going to take the risk and provide the product."

CMS will have to conduct a large educational campaign to school physicians on providing the right supporting documentation to providers, said Seth Johnson, director of government affairs for Pride Mobility. The planned Medlearn Matters article, Open Door Forum and further guidance issued through the DMERCs may not be enough.

"One of the most significant hurdles will be physician education," he said. "This really represents a huge change in the role that the physician plays in providing this equipment."

Another hurdle is the timeline for transitioning from CMN to prescription. Implementing this interim final rule before the local coverage determination is issued is "unrealistic," Johnson said.

"We've been telling CMS for weeks that's there's an appropriate system that needs to be followed to implement all of these different pieces so that Medicare beneficiaries' access isn't jeopardized," he said.

CMS may be motivated by a recent district court decision in California, during which a judge decided that the CMN was the only document required to prove medical necessity for power wheelchair claims, according to Tim Pedersen, owner of WestMed Rehab.

"It appears to me that, perhaps, CMS took that ruling to heart and decided to do away with the CMN so that they could have more in-depth information kept on file," he said.

In a statement issued late on Friday, a spokesman with the Scooter Store said the rule is "a step in the right direction."

"The previous system had become unworkable and punitive," stated Dan Gibbens. "The new rule underscores the principle that a physician or treating practitioner is the right person to decide a patient's needs."

While others agree that the CMN is outdated, and they understand CMS's need for adequate documentation, the agency's decision to drop the CMN and replace it with a prescription and supporting documentation is still "huge," Hildebrandt said.

Pedersen, who expects numerous providers to take advantage of the rule's comment period, as well as events like the Open Door Forum, agreed, saying "There has to be a happy medium."