Modification, not elimination

Sunday, January 22, 2012

It's never a good feeling when we send our January issue to the printers in mid-December and it has three stories about a new power mobility device demonstration, including a front-page story, and CMS decides on Dec. 29 to postpone said demo "until further notice."

I mean, it was good news for the industry, but bad news for HME News.

Upon learning the news, Managing Editor Theresa Flaherty said rhetorically: "Don't mind all of those stories on the PMD demo in our January issue. They're now obsolete."

They are--and they aren't.

CMS still plans to move forward with the demo, which it believes will "strengthen Medicare by aiming at eliminating fraud." But it has realized, based on the number of comments it received, including a good number from the HME industry I'm sure, that it had better take more time to think about how it wants to implement the demo.

There may have been a hint that this was to come during a teleconference shortly after CMS announced the three-year demo in seven states. Agency officials were asked why they couldn't start the prior authorizations on Jan. 1, and they said their systems weren't ready to do that. They planned to buy themselves up to six months of time by starting off with something their systems were ready to do (prepayment reviews).

Of course, in CMS's eyes, prepayment reviews aren't just a warm up for prior authorizations. The agency believes this double-whammy is key to lowering a 75% error rate for PMD claims. CMS, not to mention the Obama administration and countless lawmakers, are hell bent on reducing Medicare fraud, and what taxpayer in his or her right mind can blame them.

If prepayment reviews remain part of the demo, however, it will be much to the chagrin of the HME industry, which would like CMS to drop them completely.

I guess there's no harm in shooting for the moon, but past experience with flawed CMS programs would indicate this strategy rarely works. Just look at competitive bidding. For years now, the industry has worked tirelessly yet unsuccessfully to eliminate the program; it wasn't until last year that the industry began working to modify the program instead. The verdict's still out, but it wasn't until the industry starting talking modification instead of elimination that it has been taken seriously by some on the Hill.

With that in mind, the HME industry might be better off if it took this delay in the demo as an opportunity to lobby CMS to reshape prepayment reviews, not eliminate them. The industry is already taking a more constructive approach to prior authorizations: It wants CMS to keep those, but allow providers, not physicians, to submit requests, and allow physicians to use templates to submit documentation.

What's probably not constructive: Lobbying CMS to drop prepayment reviews completely.

So how can the HME industry make prepayment reviews fairer? For example, should it lobby CMS to complete prepayment reviews within a certain amount of time to minimize the impact on cash flow and access?

 This may seem a little like dealing with the devil, but let's face it, a lot HME providers already feel like they're in hell.

Before you think I've gone off the deep end: We've had several readers email us to say that the demo isn't such a bad move. There are numerous comments online that also say this. One story, "Wheelchair providers react to new demo," has 16 comments; that has to be a record. One of our readers emailed me:

"This program would be good for everyone, including patients, dealers and Medicare. We are idiots for fighting every proposed program that comes down the pike. This program will improve so many areas, from fraud and abuse to patients getting improper equipment. We better become part of the solution and stop fighting everything proposed."

CMS says it will give 30 days notice before it implements the demo. Whenever that happens, we're crossing our fingers that it aligns with our publishing schedule.