Let the physician delegate face-to-face responsibilities

Thursday, September 30, 2004

The point of the ‘face-to-face’ provision in the Medicare Modernization Act, which CMS now plans to apply to all DMEPOS, is to reduce fraud and unnecessary utilization of power wheelchairs. In reality, this is going to be a significant challenge to beneficiaries, to physicians and to lawful suppliers of DMEPOS, and it’s likely to fall short of the intended objective.

Although the rule may have an impact on utilization, it’s not likely to prevent unethical suppliers from committing outright fraud. Take, for example, the well-publicized case in Harris County Texas, in which a physician was allegedly part of this outrageous scam. It’s doubtful that this new provision would have prevented these accused criminals from submitting fraudulent claims, given the suspected physician involvement. Crooks will simply find new ways to circumvent this provision. CMS must find ways to detect and punish fraudulent actions of criminal suppliers without causing undue restrictions to Medicare beneficiaries and law abiding suppliers.

This proposal is likely to result in significant delays to beneficiaries with legitimate needs for DMEPOS. It’s likely to result in additional costs to the Medicare system for physician office visits. And, it is likely to place additional burdens on suppliers who are already subject to burdensome demands for collection of documentation from the medical record.

To require a beneficiary who needs DMEPOS to make an appointment with their physician sounds reasonable at first. But for many beneficiaries, it can mean weeks or even months to get an appointment, arrange transportation and see the physician. This would be especially difficult for homebound recipients who have complex and or catastrophic medical conditions or who live some distance from their physician. It also seems particularly unreasonable for many types of DMEPOS that are usually recommended by a professional other than the physician.

Take, for example, the beneficiary who receives home health therapy, and needs DMEPOS equipment because of an increasingly unsteady gait and risk of falls. The home health therapist recommends a walker or bedside commode to the beneficiary. The beneficiary would have to make a visit to his physician to obtain those devices. It is entirely possible that the beneficiary would wait several weeks or months to get the necessary equipment, instead of the usual few days. During this waiting time it’s not unlikely that some beneficiaries will experience falls and thus incur additional expense to Medicare for treatment and even hospitalization that would otherwise be preventable.

Perhaps the greatest responsibility and challenge for this proposal falls upon the DMEPOS supplier. They are the ones who will be required to try to facilitate the face-to-face visit and to obtain documentation that this has indeed happened. DMEPOS suppliers will have the burden of educating physicians and their patients of this new requirement. They will be placed in the awkward position of trying to tell the physician how to conduct their practice. Most of all they will have to restrict needed DMEPOS for beneficiaries because they have not seen their physician or more likely because they cannot obtain the necessary documentation that confirms that such a meeting has occurred. And who will likely bear the brunt of the beneficiaries and physicians’ frustration? It’s more likely to be the supplier than people at CMS.

So what is the solution? How can CMS insure that the physician is involved without dictating to them how to conduct their practice? It’s a difficult problem.

One solution is to allow the physician to delegate this responsibility (face-to-face) to another qualified professional. It is common practice for a physician to refer their patient to an occupational or physical therapist for an evaluation for DMEPOS equipment. This is in fact the model that is used for the provision of Speech Generating Devices (SGD). The physician refers their patient to a speech and language pathologist (SLP) who conducts a face-to-face evaluation, and then sends their report to the physician. The physician then verifies that they have reviewed the SLP’s report by checking off an area on the CMN for the SGD. It would allow beneficiaries to get needed equipment without the inevitable delays that will result in this proposal. This process could be used for certain highly utilized or complex DMEPOS, but it is unreasonable to require this for ALL DMEPOS.

Another solution is for CMS to step back re-think it’s position. Congress did not intend this to be applied to all DME, and CMS needs to recognize the ‘real world’ implications of what this proposal would mean. HME

- Dan Lipka is a CRTS at Miller's Assistive Technologies and president of NRRTS.