The industry's 'single biggest issue'? Gap filling

Tuesday, May 31, 2005

ALEXANDRIA, Va. -- Industry efforts to change CMS's methodology for setting new allowables-- gap filling -- have shifted into high gear.
By April 18, power wheelchair manufacturers were to have submitted product pricing to Muse & Associates. The consulting firm is working with AAHomecare and PWC manufacturers to develop a price-setting methodology that more accurately reflects today's technology. Results of the analysis are expected out this summer, said Seth Johnson, Pride Mobility Products' director of government affairs.
"This is one of our highest priorities," said Cara Bachenheimer, Invacare's vice president of government relations. "It is critical."
Providers have long complained that gap filling -- described by one industry watcher as a "dismal" methodology that uses "archaic" inflation and deflation formulas -- is inaccurate and often underprices new technology. Because Medicare has created 49 new power wheelchair codes that are scheduled to go into effect Jan. 1, 2006, gap filling is now a bigger concern than ever. Unless CMS adopts an alternative, they will use the current gap-filling methodology to determine a fee for these codes.
CMS's new national coverage determination for wheelchairs is "big" but revamping gap filling is the industry's "single biggest issue," said Don Clayback, the MED Group's vice president of networks. If CMS doesn't remedy gap filling, the allowables for the 49 new PWC codes will be "erroneous and irrational."
CMS officials have acknowledged gap filling's shortcomings but have no immediate plans to change it.
For AAHomecare, replacing or tweaking gap filling to make it more accurate is an immediate short-term goal. Long term, the association hopes its work with Muse will pave the way for a better working relationship with CMS on its reimbursement policy, said Michael Reinemer, AAHomecare's communications director.