Memo to CMS: Don't 'rush' to put NCB in place

Sunday, May 28, 2006

BALTIMORE - CMS plans to release its final quality standards for DME providers by the end of June and roll out mandatory accreditation first in the 10 cities where competitive bidding begins in 2007, Medicare officials said last week.

The comments came during a meeting of the Program Advisory and Oversight Committee (PAOC) on competitive bidding. The meeting turned up few specifics on how competitive bidding will be rolled out. In fact, other than naming a date for the release of the quality standards, officials offered no hint of how the program will progress. All that's really known is that sometime between now and Oct. 1, 2007, as mandated by the Medicare Modernization Act (MMA), Medicare must roll out competitive bidding in 10 metropolitan statistical areas (MSAs).

For that to happen, among other things, CMS must develop a final bidding plan, pick the 10 MSAs and products that will be put out to bid, and choose organizations that will accredit providers in those 10 MSAs.

"They have so much work to do, and we don't want them to rush through it," PAOC member Asela Cuervo said.

Following the PAOC meeting, AAHomecare offered the following summary of some key points:

-- Quality standards and accreditation: CMS listed several key issues that they pulled from comments submitted on the draft quality standards last November. More than 5,600 stakeholders commented on the draft standards. The most common comment was that the standards were "too prescriptive." CMS officials said in the meeting that they agreed with this and are working to make the standards less so. Another common comment: Responding to a beneficiary call within 60 minutes is unrealistic. CMS said it was not the agency's intent to suggest that providers had to arrive at a patient's home within 60 minutes, and they agreed to clarify this or change the wording.

-- Regarding qualifications (licensure and credentialing) for staff and companies: CMS said it is taking comments into consideration from a number of accrediting bodies and others. CMS officials are also considering a number of comments on the business-standards portion of the draft quality standards document, including the general concern that they are overly burdensome and that some of the standards should be left to state and local laws. CMS also reported on beneficiary focus groups it held in which, according to CMS officials, many of the 44 "actively participating" beneficiaries viewed their homecare provider as "no more than a delivery person." Many comments were made by attendees at the PAOC meeting who pointed out a number of flaws in the design and interpretation of these focus groups. The target date for CMS to release the final quality standards is June 2006.

-- CMS officials could not comment at this stage about several topics, including whether providers in MSAs selected for the first round of competitive bidding could be "grandfathered in" if already accredited. CMS said they would provide further guidance on this point and will announce the solicitation of accreditation organization applications after the final rule has been published. CMS said they would phase in the accreditation process and require accrediting organizations to prioritize their surveys to accredit providers in the initial MSAs and competitive bidding areas. Officials said they "plan on having all competitive bidding awardees accredited prior to awarding contracts." But several attendees questioned how this is logistically feasible given the timeframe. In addition to accreditation concerns, attendees and members of the PAOC had a number of concerns about the bidding process and selection of winning bids, the selection of MSAs and administration of the program within an MSA, mail order issues, the development of provider networks, and many others.

-- Rebates: The rebate provisions proposed in the proposal prompted several PAOC members to express opposition to the idea, citing serious concerns about legal and administrative issues. Under the rebate program, providers who submit a bid below the single payment amount would be allowed to offer a rebate to beneficiaries equal to the difference between the provider's actual bid and the single payment amount. CMS said the rebates would allow providers to be more competitive. PAOC member Dave Kazynski, President of VGM's HomeLink, commented that beneficiaries are chiefly concerned about quality, not a small rebate. And homecare providers, he said, "are not looking at market share--they're looking at survival."

-- Sustainability: Several PAOC members also said they are worried that unrealistically low bids would distort the process. Attorney Asela Cuervo, who represents the AA Homecare on the PAOC, said, "There is no provision in the methodology to determine whether the winning amount is sustainable."

-- Submitting comments about the proposed rule: Many more questions and concerns remain unanswered. It is critical for all homecare stakeholders to submit their comments to CMS by the comment deadline of June 30, 2006. AAHomecare councils and committees have begun work on gathering comments for CMS and will share key concerns with the homecare community before the comment deadline. The AAHomecare Regulatory Committee met in Alexandria, Va., last week to outline key concerns about the proposed competitive bidding rule. The draft competitive bidding provider forms and other details are located on the CMS Web site,, under PAOC Meetings, 5/22/2006 - 5/23/2006. The target date for CMS to release the final rule is Oct. 1, 2006.