CMS sticks to script in final competitive bidding rule

YARMOUTH, Maine – With few changes between the proposed and final rule, attention now shifts to late spring or early summer, when the Centers for Medicare & Medicaid Services (CMS) plans to release more details on the next round of the competitive bidding program (CBP). 

CMS final rule confirms key competitive bidding policies 

CMS proposed new CBP policies on July 2, followed by a public comment period ending Aug. 29. The agency released its final rule on Nov. 28, largely sticking to its original plan. 

Industry stakeholders had urged CMS to make significant changes, including excluding urological, ostomy and tracheostomy supplies from the new remote item delivery (RID) CBP and preserving clearing prices as the methodology for calculating single payment amounts (SPAs). Instead, CMS kept those supplies in the RID CBP and adopted a new methodology for SPAs based on the 75th percentile of winning bids. 

“They pretty much finalized everything as proposed,” said Andrea Stark, a Medicare consultant and reimbursement specialist with MiraVista. “There was much room for improvement, but basically, the message from CMS and the tone throughout the rule is that two things are important to them: 1) compliance and 2) cost savings.” 

Will CMS add more product categories to CBP? 

CMS also published a tentative timeline on Nov. 28 indicating it will announce lead items for product categories in the next round. This has sparked speculation about whether CMS could add more categories at that time. 

Unnamed industry sources told HME News that CMS is expected to clarify that no additional categories will be added. At press time on Friday, however, uncertainty remained. 

During a Dec. 3 webcast, Ronda Buhrmester, senior director of payer relations and reimbursement for VGM & Associates, said: “We don’t know if there will be any additional products. It’s left to interpretation. We’ve heard it both ways – this could be it, or there could be more.” 

The product categories listed for the RID CBP:

• Class II Continuous Glucose Monitors (CGMs) and insulin pumps 
• Urological supplies 
• Ostomy supplies 
• Hydrophilic urinary catheters 
• Off-the-shelf (OTS) back braces 
• OTS knee braces 
• OTS upper extremity braces 

RID competitive bidding: National or regional scope? 

Another unanswered question: Will the RID CBP be national or regional? Based on the final rule, Stark believes CMS is aiming for one nationwide RID CBP per product category.

“The RID programming is not great,” she said. “It is definitely going to slash competition and that is my biggest concern for potential access issues and potential downstream effects.” 

Stark noted, however, that CMS does leave the door open for regional programs, stating in the final rule: “In determining which items may fall under a nationwide RID CBP, we will consider whether suppliers typically furnish the item around the country or if they are typically furnished on a regional basis." That data could compel a regional bid if supported in the claim data.” 

CMS to announce contract numbers for CBP in spring 

According to the timeline, CMS will also announce the number of contracts for each category in late spring or early summer. During the Dec. 3 webcast, Kelly Grahovac, general manager of The van Halem Group, explained that for the new RID CBP categories, the number of contracts will equal 125% of providers that filled at least 3% of total utilization of the lead item in the category and competitive bidding area (CBA) during the most recent calendar year prior to bidding. 

“What this does is reduce the number of required suppliers,” she said. “It gives CMS (the ability) to proceed with no less than two award winners per product category. In the past, there was a minimum of five per category. The least amount we could see is two nationally or more – it just depends on what the math maths out to.” 

Stark noted that CMS illustrated its methodology in the final rule using 2023 claims data and the 75th percentile approach. For example, CMS cited nine contracts for continuous glucose monitors (CGMs) compared to 11 contracts for the Round 2 recompete national mail order program for diabetes testing supplies. 

“This new methodology will likely reduce the number of contracts by 30% to 50%,” she said. 

Other provisions of note in the final rule 

• CMS has stuck to its original plan of requiring resurveys and re-accreditation every year instead of every three years. According to a document viewed by HME News, the agency plans to clarify that a provider’s resurvey and reaccreditation cycle will not begin until the expiration of their current reaccreditation three-year cycle (if issued prior to the final rule effective date). 
• CMS is revising provider enrollment provisions to expand retroactive PTAN revocation authority, expand stay of enrollment reasons and modify grounds for denial, revocation or deactivation. “They didn’t give us a lot of specifics around these changes, other than they’re allowing themselves to expand and modify,” said Melanie Ewald, vice president of payer relations and reimbursement for VGM & Associates. “There will be more to come.” 

Stay informed 

AAHomecare will host a webinar Dec. 15 at 2 pm ET to educate providers on the next round of Medicare’s competitive bidding program (CBP) and enlist them in the association’s fight for fair, sustainable policies. Register here.