Stakeholders draft legislation to fight vent changes

Friday, February 26, 2016

WASHINGTON – CMS needs to dial back the wholesale changes it has made to ventilators with little input from the industry, stakeholders say.

In January, CMS switched from five ventilator codes to two, and reduced reimbursement by about 33%.

“When they are creating codes, providers should have some role in that,” said Stephen Cooper, counselor at K&L Gates, a law firm representing about 30 providers. “Right now, it’s somewhat of a black box approach.”

K&L Gates has drafted legislative language that would, among other things, involve providers in the process of creating codes; require more transparency when establishing allowables; and implement a more formal process for determining clinical guidelines for medically necessary.

Currently, the DME MACS are saying patients who can be off a vent for more than four hours don’t need one—a standard that isn’t based on any clinical literature, say stakeholders. At a recent meeting, CMS officials agreed to take a closer look at how the MACs are interpreting the policy.

“Our clients want a bright line,” said Cooper. “Just tell us what the standard is. Whatever it is, it should be based on clinical data.”

In the meantime, providers are working denials for vents through the appropriate channels, rather than turning patients away.

“They are dealing with the audit issues and are just trying to see if they will make it through the appeals,” said Kim Brummett, vice president of regulatory affairs for AAHomecare. “We haven’t seen them try to get patients to sign ABNs, but that’s definitely coming if we get nowhere and they can’t afford to do it for free.”

K&L Gates is currently building support for its legislation, which it hopes to move as quickly as possible.