Texas: 'We're not going to be bottom dwellers'

Monday, April 26, 2010

HOUSTON – Providers in the Houston area say Evercare, a Medicaid HMO, puts their businesses and patients at risk with a cheaper-is-better approach to providing HME.

“Their philosophy is to pay for the least expensive, medically justifiable piece of equipment possible, which is such a gray area,” said James DuBose, owner and president of J&R Medical in Bellaire, Texas. “It puts us between a rock and a hard place, and it leaves the patient without a choice.”

Within the past year, providers had to start participating in a bidding system to provide HME to Medicaid patients. Here’s how the system works: When Evercare receives a bid from a provider to supply HME to a patient, it turns around and solicits a second bid from another provider. Nine times out of 10, whichever provider has the lowest bid wins the patient, providers say.

DuBose provided this real-life example of Evercare’s approach:

We had a patient who had been with J&R for almost three years and she needed a new wheelchair and some other equipment. We sent our ATP to her house to do a home evaluation and we submitted a bid to Evercare. Then Evercare priced it out. The other provider spent maybe 10 to 15 minutes with the client; they didn’t measure the bathroom doors; they didn’t measure for ramps. We lost the bid by $2,000 because we recommended a Columbia bath system and they recommended a bath bench.

For complex power wheelchairs, it gets even worse, says provider Patrick Boardman. Even if the equipment has been ordered by a hospital’s physical therapist and provided by an ATP, Evercare still solicits a second bid from another provider and that provider often downgrades the equipment and, therefore, Evercare’s bill.

“Their techs will ask a paraplegic to get out of bed to try a Group 2 power wheelchair with a Captain’s seat when they need a head array,” said Boardman, director of business development for Active American Mobility and Medical Supply in Houston. “I’ve been in this business for 15 years, and I’ve never seen anything like it. It’s crazy.”

Evercare is the only Medicaid HMO in the state to take this approach, providers say.

“It’s gotten to the point that, if we receive a fax from Evercare asking us to bid out a product, we don’t do it,” DuBose said. “We’re bidding at the Medicaid allowable or, if it’s a miscellaneous code, at MSRP minus 20%. We’re following the guidelines. We’re not going to be the bottom dwellers of the industry or undercut our competition."