Medicare relaxes regs governing when docs can prescribe neb meds

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Wednesday, April 30, 2003

COLUMBIA, S.C. — In what’s being called a “shocking” reversal by one vendor, Medicare no longer requires physicians to document that a meter dose inhaler (MDI) was considered prior to prescribing a nebulizer and nebulizer med.

Language was recently removed from the Nebulizer Local Medical Review Policy (LMRP) which stated that an MDI must be considered before a physician can issue nebulizer medication. The change will go into effect April 1, 2003 and effects all four Medicare regions. The previous policy had been in place since July 1, 1997.

“The MDI requirement was removed as most physicians normally consider an MDI as good practice standard,” said Elaine Hensley of Palmetto GBA, Region C DMERC.

Hensley also said other reasons for the change were because some beneficiaries were unable to use the inhaler properly and found it difficult to manipulate.

But while the reversal is considered a positive note for providers and physicians due to a reduction in costs and reimbursement paperwork, Mickey Letson, president and chairman of Letco Medical / Respiratory Homecare Providers Association (RHPA), can’t help but be a bit skeptical.

“It’s a shocking reversal is what it is,” said Letson. “It’s good news for providers, but such a quick reversal — I get a bad feeling.”

Letson said the MDI requirement has been a “hot topic” for the last six to nine months due to Medicare being in the middle of a number of audits claiming an MDI was not considered before physicians prescribed nebulizer medication. Providers and physicians had complained that the language, which states an MDI must be considered, was too broad and did not explain what “considered” meant.

“With all (the audits) going on, why would (Medicare) all of a sudden reverse it,” Letson said.

By way of explanation, Letson believes that either Medicare was tired of losing too many audit cases at the ALJ level or the reversal may be a distraction until stronger language or a diagnosis change can be adopted.

Mark Sheehan, president of Cape Medical in Sandwich, Mass., said he is also suspicious of Medicare, but supports the reversal. He said only a few of his claims for nebulizer reimbursement have faced denials.

“It’s one less thing that we have to concern ourselves with,” Sheehan said about the reversal. “But I am always suspicious of (Medicare). You never know what their motivation is.”

Hensley said that the reversal does not call for any standard system changes and she assures providers that any consideration to go back to the MDI requirement would go out for feedback prior to any action. “If the requirement is revisited in the future, the LMRP will go out for comment as it is considered a restriction,” she said.

But some providers are content with the reversal decision, saying it is the first step toward improving the process of getting patients better care.

“It’s going to improve access to proper care,” said Chris Horne, president of Advanced Home Respiratory. “Not everyone needs an MDI trial from the beginning. The physicians know the right treatment.”

Sharon Nelson, government affairs officer for Home Medical in Grants Pass, Or., agreed. “Glad to hear it,” she said about the reversal. “It’s been a challenge to get the information from a physician. It’s the first step down a long road.”

Nelson said the reversal shows that while Medicare’s moves are questioned from time to time, this move indicates its efforts to stay on top of important issues that effect the industry.

Horne agrees, adding that Medicare is run by “smart people” and that the reversal cleans up confusing language which caused some providers to face audits even though many thought they were following the rules. “It’s a minor victory for medicine,” he said. HME

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