Survive first phase of PMD demo

Thursday, December 22, 2011

WASHINGTON - The only way to survive the first phase of the power mobility device (PMD) demonstration project is to make sure your documentation is up to snuff, stakeholders say.

The first phase, set to go live Jan. 1, requires providers in seven states to go through a prepayment review process for PMD claims.

"Having good documentation doesn't negate the fact that they're going to have to put the product out and wait 20 days to get the results of the prepay review," said Elizabeth Cole, director of clinical rehab services for U.S. Rehab. "But it means they might not have to provide more information and wait longer to be paid." 

Peggy Walker, a billing and reimbursement adviser for U.S. Rehab, says she sees the same documentation mistakes again and again. 

One of the most common: bad handwriting.

"You've got to have legible information," said Walker. "If the information is not legible, then don't send it in. Get it corrected."

Some suggestions from stakeholders: Have someone in the doctor's office transcribe progress notes and have the doctor sign off on it; create a field for the doctor to print his or her name after the signature; and use attestation statements from the doctor verifying his or her signature. 

Other common documentation problems: using incorrect codes and not completing the process within the time limits.

"Watch signatures, watch dates," said Walker. "And if it's not correct, don't give the chair to the patient."

Providers often protest that doctors won't send them referrals if they refuse to put out wheelchairs without correct documentation, Walker said.

But "it isn't going to do you any good to get referrals and then get denied," she said. 

While they need to be prepared for the demo, providers should also continue to fight it, said Seth Johnson, vice president of government affairs for Pride Mobility Products.

"This is a major cash flow problem and many providers are still in transition from the switch from the purchase option to the mandatory 13-month rental," he said. "We're encouraging providers to reach out to legislators and consumer groups in their states."




What kind of suggestions is this "...Have someone in the doctor's office transcribe progress notes and have the doctor sign off on it". I would challenge any provider to call a doctor's office and propose this suggestion. I am fairly confident the success rate would be close to zero. Unless a physician office transcribes progress notes as a regular course of business, no one in that office will adhere to this "helpful" suggestion. It's obvious that the individual who proposed this nonsense has never successfully acquired paperwork from a physicians' office. Unbelievable.

We need to fight as an industry to get the paperwork nightmare to stop. 90% failure on audits as nothing to do with providing people equipment they need, nor proventing any freud or abuse of the system. The paperwork is now more important than the patients or there benifits and anyone can find a minor error in any file. Our industry needs to fight to simply get some sanity restored.

I completely agree with Jim&#39;s comments. If a college professor failed 90% of his class, he would no longer have a job at that university. Yet, CMS routinely fails 70-90% of their class and do not adjust any of their policies except to make them more strict and rigid. If your patient file is not absolutely 100% compliant to an LCD (determined by people who have never been a DME provider), then CMS gives a failing grade and requests a full refund. Where is the logic in that? Not a single industry operates on such a flawed level of incompetence, except for Medicare and CMS. <br />
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What CMS is not telling you is the underlying reason for such a high fail rate: our government does not have the fiscal capacity to pay for health care costs including the DME benefit. Compare the state of our industry today and that from 10 years ago. It&#39;s not that 90% of providers today are fraudulent or abusive; it&#39;s that current government capacity to pay for health care costs is 90% less than it was 10 years ago. The government simply does not have the funds to pay for these services and will do everything in their power to eliminate these expenditures under the unified slogan of "fraud and abuse". We are almost powerless to stop the "paperwork nightmare" as CMS desire to severely cripple or eliminate the DME benefit from its fiscal program. That&#39;s the unfortunate truth.<br />

Jim and Leo are correct. Look at the very high percentage of audit denials that are overturned at the ALJ judge and you will see that initial denials don&#39;t have a lot to do with proving medical necessity. No offense to the author of this article, but her suggestions weren&#39;t very helpful for the real world. If you are in one of the states with a 3 month period of 100% prepays then my advice is to shut your office down for 90 days and start again fresh when you are dealing with PAs. It will be cheaper then spending money on equipment you will not get paid on for 2+ years. And if you are one of the poor souls in the states with a 7 month 100% prepay review period and you aren&#39;t sufficiently diversified then you need to close down your shop now and declare bankruptcy if needed. The longer you wait, the longer it will be until you can start over and attempt to rebuild your life.

We are looking at this all wrong. Yes CMS has to look at every possible way to cut costs. They are running out of money and they have to prioritize spending. I get it. Yes the current political environment is driven by what is best for the taxpayers and not the patients. These points are a given. But I still say that when utilization of standard power mobility devices is cut beyond a certain tipping point then it will actually cost the taxpayers more than they are paying right now for the end of life healthcare costs of our seniors.<br />
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Standard power mobility is not just fluff. It&#39;s not just an elective luxury. It allows moblity impaired seniors to stay in their homes longer by assisting them in the performance of their activities of daily living. <br />
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Cutting it&#39;s utilization beyond a certain point will have financial consequences. When the system is operating properly, standard power mobility is an excellent cost mitigation tool because it allows us to reduce utilization of nursing homes and hospitalization, surgery and physical therapy related to traumatic falls. The first 100 days in a skilled nursing facility will cost the taxpayers at least $40,000. A year of nursing home costs after that will be at a minimum of $55,000-$60,000 per year. And the hospitalization, surgical and therapy costs after a fractured hip or wrist or leg can easily run into the tens of thousands of dollars and be compounded by the fact that many of these fall patients will never get back to full strength and end up going to a nursing home sooner and racking up all the costs mentioned above. By way of comparison, a standard power chair costs the taxpayer a little over $3,000.<br />
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Now I&#39;m not saying that mistakes aren&#39;t made in this industry like all others. Show me an industry that is blameless on a national level. But we are comprised of a lot of honest, ethical people who are trying to do the right thing against terrible head winds. And show me an industry whose value cannot be distorted by a selective presentation of it&#39;s worst examples. But if we get it right less than one out of ten times then we are more or less a push for the taxpayers. And if we get it right half the time then we are a huge taxpayer savings. So at a certain point scaring providers away fom putting powerchairs on people who really need them is working against the taxpayer&#39;s interests.<br />
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But don&#39;t take my word for it. Assume the worst about me because I disagree with you if you like. But you can measure what I am saying for yourself. Trust observable data. Of the demonstration states there are 3 that will be in 100% prepay audits for 7 months (Texas, Florida and North Carolina). That is enough time with drastically lower utilization to actually see what I am talking about. If the people at CMS truly and sincerely care about taxpayer savings then I hope they will measure the change in utilization of skilled nursing home days and costs related to traumatic falls (hospitalization, surgery and therapy) and decide for themselves.<br />
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We are indeed passing a tipping point in these 3 states and shame on us if we cannot prompt anyone to measure the damage being done to the taxpayers with this policy. If we have any chance of saving the other states, then this will be it.<br />
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I do not believe the people at CMS are bad. I just believe they are operating under some mistaken assumptions. If we can get them to see how a certain policy is counterproductive to taxpayer interests then we might actually have a chance of finally working together with these guys instead of always feeling like they are working against us.

Frank, although I agree with everything you have said, realistically what are the chances that CMS will run a comparative study of power wheelchair utilization versus increase of SNF days and stays? At the end of the "demo" period, all CMS will come out with is the amount of dollars that they have saved taxpayers by conducting this backwards audit. Furthermore, how would you propose we make CMS aware to conduct such a study? It all sounds good in theory, but in reality the DME lobbyists are probably the weakest group in Washington today and have no power or influence to control CMS actions. We all say we want things to change for the better, but in the past 5 years it&#39;s only getting worse and worse. In fact, for the past 5 years almost every article in HME News (or any other DME publication) talks about the negative implications for our industry. The positive stories are few and far in between. I am not trying to sound glib, but I just don&#39;t see how things can turn around.<br />
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p.s. You are correct about diversification. If you are not well diversified in terms of product offerings and payers, then you must look to do something else.

You are probably right Leo. Our DME lobbiest do not have enough cash to grease the right palms in DC. Federal politics is definitely a pay to play game and we don&#39;t have enough cash to stay in the game. It&#39;s depressing. And most likely no one will do a comparative analysis. I&#39;m just a tired old fool yelling for help in the dark at this point.