Wheelchair providers react to new demo

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Thursday, December 8, 2011

YARMOUTH, Maine - Wheelchair providers may be in favor of the prior authorization phase of the new PMD demo--if they can survive the prepay review phase.

One major concern for providers about prepay reviews: the potential cash flow problems.

"It's going to be a tough one," said Tim Pappert, manager of Spring Hill, Fla.-based Mrs. Mobility. "We can't wait three to six months to be paid for everything. It could potentially put us under." 

CMS's PMD demo, which kicks off Jan. 1, calls for three to nine months of prepay reviews for PMDs in seven states, followed by a prior authorization process for the rest of a three-year period.

At least with the prior authorization process, which will be completed by physicians, providers will have some assurance of payment.

"I think it's a terrific idea," said Randy Freeman, owner of Fort Worth, Texas-based Mediwell. "We're in a very intense audit situation now and the rules keep changing. It's really frustrating, so I think this could potentially be a very positive thing for the industry--knowing up front whether you're going to get paid or not."

Franklin Trammell, president of Matthews, N.C.-based Carolinas Home Medical Equipment, is more cautious about providers' prospects under the demo. If it's implemented the way some audits are now, it could force him out of the PMD business, he said. 

"If they're looking for fraud and abuse that's one thing, but if they're looking just to be picky, that's totally different," said Trammell. "It could be ugly. Hopefully it won't be."

Some providers may not feel the effects of the demo as strongly as others, even if they're in one of the affected seven states. Provider Jene Sego said, as a contract supplier in a competitive bidding area, many of his claims come under prepay review already. His advice: Don't put out a wheelchair without having all your ducks in a row. 

"We make sure every bit of documentation is very strong and it's all in our hands before any kind of PMD leaves our facility," said Sego, owner of Titusville, Fla.-based Sego's Home Medical Equipment.

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Comments

It will take 6-26 months to get paid on everything done for this 3-9 month period and the providers will have to pay an extremely high percentage of what is collected on both internal and external billing costs. This is an industry killer. The only good point is that the new PA rules will be a problem for the nationals who already have strained relationships with many physicians.

The pre-payment review must be enforced to stop the self-righteous providers from delivering PMD’s to people who don’t need them. The (Provider from New Braunfels, TX) has become a SALES organization putting enormous pressure on their sales team (oops I mean Mobility “Consultants”) and their operations staff to deliver every order that is generated. When an order is sent to the local Distribution Center, it must be delivered or there is a lot of explaining, forms to submit and other red tape required as to why this delivery was not completed. Many times, the local delivery team is then instructed to return and make the delivery anyway. I'm sure many providers are sincere and are doing the right thing, but the loudest in boasting that they are the best in the industry regarding compliance are not what they claim to be. Questionable deliveries, over-billing on service repairs by unqualified "technicians", and celebration cruises funded mainly by the company from profits generated by Medicare needs to be stopped. In my opinion, the pre-pay review is the perfect answer to ensure all providers are ALWAYS Doing The Right Thing.

It's too bad congress has become nothing more than corporate representatives. When Aetna and blue cross and PHERMA gvs 900,000,000.00. To congress so that they can write this so called health insurance bill and use Medicare and the tax payers as their dumping ground..! Why does Medicare only take 65 and older and the handicapped!? We're ranked 47 in the world in healthcare because Insurance companies run healthcare not the Physicians. This is why we have competitive bidding so private insurance can follow Medicare reduced fee schedule. If congress really wanted to fix healthcare and mk Medicare solvent then they would simply lower the eligibility to let's say when we start paying FICA ur eligible. Medicare wud Hv so much $ they wudnt b sweating a industry that is only 1.6 percent of their budget..! Only deep pockets running nationwide commercials explaining these issues will mk the difference. Our industry doesn't Hv deep enough pockets to afford those senators but we cud take our plea to the public.

I agree insurance has become the parasite on society! Their profits have doubled while they bleed our society. No one chooses to sick and when u r some of these deductibles they have are outrageous and many people can&#39;t even use It. Why Hv a deductible in the first place. We all pay monthly premiums. It&#39;s design solely so people won&#39;t b able to use their policy or just to increase the ins profits. When did our nation become more concerned bout the profits of private insurance over the health of our nation!? I&#39;m with scott I think the big players in the industry shud run commercials explaining our situation to the public. Hvn Sumone call a senator doesn&#39;t get a lot done as we Hv seen. Nation wide commercials that senators themselves will see plus people they know and care bout. <br />
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For Scott<br />
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This is a letter I wrot to Senator Specter formerly a Senator from PA. I had also sent a copy to other various Senators & Congress people.<br />
<br />
Dominic P Rotella<br />
Hazleton, Pa 18202<br />
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Date: June 13, 2007<br />
<br />
Senator Arlen Specter<br />
711 Hart Building<br />
Washington, DC 20510<br />
<br />
Dear Senator Specter,<br />
<br />
I have worked in the health care industry for over 30 years. I have seen it when almost everyone had some form of health care insurance to where we are now with over 40 million people without it. Currently I am one of the 40 million people. I know many people have inundated you with a variety of ideas but I would appreciate it if you could give a few minutes of your time to read my suggestion. <br />
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Offer medicare to everyone and for those who are without a stable income or below the poverty level have the premium paid from their accrued social security benefit account as if they were 65 providing they have the accrued benefit. If a person desires after they may obtain gainful employment they would be able to replenish their social security trust fund account from future income. An insured may also stop this benefit at any time and they would be allowed additional contributions back to the social security trust fund to bring their social security account current as if they had never used it and retain their retirement income. If a person retains medicare subsidized by their social security account as their carrier then their social security benefit would be reduced at the retirement age they choose, by the amount of the benefit used to subsidize their medicare premium. If a working person chooses to have medicare without a social security subsidy then their monthly premium would be deducted weekly from their paycheck and the employer would pay it to medicare as another deduction similar to the way it is done now for federal withholding tax, social security and the medicare trust fund contribution.<br />
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Everyone who chooses medicare as their primary insurance would still be responsible for all the deductibles and the co-insurances but at least this could help the system. Everyone would also be able to have a private insurance if they choose. I believe this could help those 40 million people and allow them to use a benefit that is rightfully theirs and in doing so help reduce the health care crisis our country is currently experiencing. <br />
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Thank you in advance for your time and consideration.<br />
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Respectfully,<br />
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<br />
Dominic P. Rotella <br />

Medicare for everyone is a monumentally stupid idea. Yeah, I wish I could buy the world a coke and teach it to sing in perfect harmony too, but this is the real world and it&#39;s comprised of a heck of a lot more than your wants and wishes. Medicare is broke. For every dollar paid in for a beneficiary over their life 3 dollars go out. That is why CMS is playing all these silly games to deny payment. They aren&#39;t evil. They don&#39;t hate providers. But they are broke and denying payment to us is less politically damaging than denying payment to a stage 4 wound patient in a LTAC. Think this through people.<br />
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Expanding Medicare coverage to everyone is just expanding a financially unsustainable situation. Not the smartest idea if you ask me.<br />
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And before you talk about taking the profit motive out of healthcare you need to ask yourself what sort of service is that going to buy you? What advances will be made by nonprofit drug companies? Who will give up 10 years of their life and go hundreds of thousands of dollars to become a doctor if they are making the same pay as an assistant principal at a high school?<br />
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The world is driven by scarcity of resources both natural and man made. Healthcare is no different and wishing so isn&#39;t going to help anybody.

And going back to the point of the article, small providers in these demo states are gonna drop like flies. You can&#39;t pay for liability insurance, rent, payroll and everything else on walkers and canes and hospital beds. If these guys can&#39;t get paid on 3-9 months of powerchair production for 6-30 months then it will be the end of small providers in these states. You will likely see defacto denial to access in some rural markets. And that will lead to more costly medicare payments for early nursing home admittances and home health utilization.

Bruce you raised some good point. But why do we have to suffer because they are group. If they would have called us on the table to try to negotiate rates this would have been a lot better. At least we know they respect us but to sit there and introduce unattainable rules every single day is just not feasible for most if not all. Maybe if they would cut nursing home stays from 500/day to 450 or even 400 they can save money and leave us alone. Maybe if a heart transplant didnt cost 758,000 there would be more money. I mean why the hell would a heart transplant cost 758,000. Its not like they have to buy the heart from a flee market or something, this stuff is donated by unfortunate people, why should someone make huge profit from it. <br />
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If Medicare is broke, they should send us letters and say so. But don&#39;t play games by trying to paint us as criminals. I mean these guys are there cutting reimbursement, introducing capped rental and then competitive bidding, all for the same item. Give me a break. One more thing, I also agree with you that they don&#39;t really see these power chairs as a real medical necessity and that is what this whole stuff is all about.

It&#39;s not rocket science.. Name any country that isn&#39;t in the top ten in healthcare that doesn&#39;t Hv a one payer system? I agree that Medicare should b available for everyone. Big insurance wud just contract with Medicare like they do now to provide the service. At least Medicare could mk money.. Anyone thinking they wudnt then why r prIvate insurance profiting billions? Private insurance use Medicare as a front to dump there liability on the tax payers while they&#39;re writing the laws that mk Medicare so unstable. If this industry is ever goin to survive the big players are going to Hv to air commercials bout our industry. Like every other industry out there that is trying to get there message out. It&#39;s easy we save Medicare money by keeping people at home were they wud rather b.

Chris, deadbeats never proclaim their poverty. They string people along as long as they are able to do it.

Jason, first please learn to spell correctly. Second, if you really want to save Medicare then please address the root of the problem. For every dollar contributed by you or your employer on your behalf, 3 dollars are spent on you by the end of your life. What do we do? Do we raise the eligibility age? Do we cut benefits? Do we raise your taxes? Do we raise the taxes of someone else for your benefit? Give me a practical solution Jason.

For what it&#39;s worth, I am not all negative about this. Anyone who can survive the cash hit will actually have a more stable environment going forward. If the doctors establish medical necessity with Medicare prior to our getting involved then all we have to do is fill the order and bill Medicare. That is an amazingly simple alternative to what we have now.<br />
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The trick is trying to figure out how you will survive such as a massive, long term deferment of income that always comes with prepayment audits. But whoever is left standing on the other end will actually have a better situation than the rest of us.

Also, if the whole point of a physician run PA system is to take medical necesity out of the hands of HME providers, then why do we have a phase one that involves the most massive prepayment audit in the history of power mobility? How is that a transition to the new system when the new system is so totally different?

prior authorization is great. I think is the way to do it.. If they would purchase the power wheelchair. Also during the prior authorization approval you could increase your cash flow with renting the power wheelchair to the patient. If they need a power wheelchair they would rent one until the get their approval. power wheelchair rental is okay too, but it takes a lot away from the technology of the power wheelchair business. Power wheelchairs are down 33 % that isn&#39;t good. Companies will be buying used power wheelchairs from people.. and they will make more money in the long run..

Buying used powerchairs is a tricky proposition. Do you only buy used chairs from one provider or multiple providers? Are you properly staffed to handle the higher rate of repair issues that come up with used chairs? On paper used chairs look like a good idea but there are a lot of ways this approach could work against you too.

Bruce, Medicare would not be broke if a) younger, healthier people who utilize benefits less were allowed to buy into it. Look at the huge profit private insurance companies rake in? Medicare would not be broke; and b) if Medicare did not pay private insurance payers a 15% premium above what they pay for FFS Medicare patients. Private insurance payers are a parasite on society and bring absolutely zero value to healthcare in this country. All you need to do to figure that out is look at what they pay their CEOs and executives and see the billions in profit they make each year (while paying at 50% of the Medicare fee schedule). Congress is bought and paid for by their lobbyists.

One thing that hasn't been mentioned here is the on-going fraud and abuse in the system-- that goes for both private and government funding sources.  Not only are insurance carriers paying fraudulent claims but they're also paying independent contractors to be their fraud-busters.  And the money exchange here is huge! All of this is another enormous wound in the healthcare industry because no one can change someone's moral compass, or lack thereof, whether on the consumer end or 'provider' end.  So where do the immoral predators factor in on the pie chart?  I'd love to know--