Industry attempts to rescind new Medicare cushion allowables
October 18, 2004
WASHINGTON - The HME industry has begun efforts to convince CMS that its new allowables for seating and back cushions are so woefully inadequate that they should be rescinded.
“At this point, reimbursement is too low,” Sharon Hildebrandt, executive director of the National Coalition for Assistive Rehab Technology, said last week. “Providers can not supply some of the products so access is being denied.”
NCART has asked CMS to rescind the new cushion allowables. AAHomecare has also asked CMS to delay implementing the codes for 180 days.
“This is critical,” Hildebrandt said. “We’ve had communications with CMS. They understand that there is a problem, andwe hope to hear something in a few days.”
“My grandest dream is that someone [at CMS] says, â€˜We had a glitch in the system and that the allowables are wrong and we are going to fix it and everything will be fine,’” said Jerry Keiderling, vice president of VGM’s U.S. Rehab.
On July 1, 20 new codes covering wheelchair seat cushions, back systems and some accessories went into effect, but providers didn’t have to start using them until Oct. 1.
Originally, CMS intended to attach allowables to the new codes on Jan. 1 2005. During the three months between Oct. 1 and Jan. 1 2005, providers expected CMS to use the codes but to consider products individually for pricing. Instead, CMS developed the interim fee schedule, which will be in place until Jan. 1.
Providers blame the low prices in the interim fee schedule on CMS’s practice of using “gap filing” in determining new reimbursements. Using this mandated methodology, CMS determines the median price of the products in a particular code. It then deflates that price back to what it was or may have been in 1986. From there, CMS uses a formula that considers annual CPI increases to determine the new price.
In determining a new reimbursement, gap filing doesn’t consider Medicare CPI freezes. Consequently, new allowables are often artificially deflated, say providers.
Additionally, in establishing the new seating and back cushion allowables, the SADMERC had yet to assign codes to many of the affected products. As a result, the median price used to determine the new price did not reflect the market, Hildebrandt said.
NCART wants CMS to rescind the interim allowables and use individual consideration until more seating and back cushion products are coded and a more accurate median price can be established.