Win for patients, challenges for suppliers in new vent policy

WASHINGTON – The final national coverage determination (NCD) for noninvasive home mechanical ventilators (HMV) and respiratory assist devices (RADs) will make it easier for patients to access therapy but impose some additional requirements on HME providers, say industry stakeholders. 

Released June 9, the final NCD provides coverage of RADs for the treatment of chronic respiratory failure that often accompanies COPD and establishes coverage for HMVs for the treatment of COPD.  

“This is a win,” said Dr. William Frazier, chief medical officer at Viemed. “It’s not perfect but it’s better and where the win is, is that the patients are going to get better and up-to-date care.” 

Doctor in driver’s seat 

Key among the provisions that will increase patient access: CMS will cover a RAD or HMV upon discharge from the hospital, and it will no longer require patients to “try and fail” on another device before qualifying for an HMV, say stakeholders. 

“CMS is no longer going to insinuate itself between the patients and the physician – they clearly state they want the doctor and the patient to decide what device is best suited,” said Frazier. “That’s what we all want.” 

However, stakeholders would like more clarity around which patients qualify for which devices and when, they say. 

“I would say it’s a lot clearer than it was, but there’s still not 100% clarity of, say, at what point I can go directly to a ventilator vs. to a BiPAP first,” said Zach Gantt, CEO of Encore Healthcare. “Our hope is that the DME MACs will provide more clarity in an LCD.” 

Higher bar for suppliers 

The NCD does place some more restrictive billing requirements on suppliers after the first six months of therapy. At that point, they must show the patient meets compliance each month up to month 13; after that, they must show compliance for any month they bill for resupplies. 

“There is some overhead burden for suppliers, because they have to make sure the patient is compliantly using it in order to get paid for each rental month,” said Ronda Buhrmester, senior director of payer relations and reimbursement for VGM.  

There’s always a “break-in period” when CMS implements new guidelines, says Frazier, but “it will be up to the industry to figure it out and the way to do that in an operationally efficient way.” 

Start planning now 

While the NCD is effective upon publication, stakeholders have asked for a delay in implementation. One thing’s for sure: Buhrmester says it’s time to start educating referral sources. VGM, for one, is hosting a webinar with leading industry experts on June 24. She also says it will be important to keep an eye on what other payers do in the wake of the new NCD. 

“They tend to follow what Medicare does, so if they don’t have a current policy, or even if they do, they can make adjustments and say, ‘Follow this,’” she said. 

• Related: Stakeholders see hurdles, burdens in proposed decision on vents 
• Sign up here for the VGM webinar.