Coverage:
Are You Headed For Disaster Under Doc Exam Requirement?
Published on Thu Aug 26, 2004
Scope of face-to-face exam rule shocks DME industry. Think you'd go unscathed by Operation Wheeler Dealer just because you don't furnish power wheelchairs? You'd better think again.
Watch out: A new proposal from the Centers for Medicare & Medicaid Services will place a staggering burden on suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). And you can trace the requirement straight back to the federal crackdown on power wheelchair fraud and abuse.
In its proposed 2005 physician fee schedule, CMS sets out a requirement for physicians to examine a patient face-to-face before ordering and renewing the orders for any DMEPOS items. CMS first floated the face-to-face exam requirement as one of its 10 points of Operation Wheeler Dealer last September (see Eli's HCW, Vol. XII, No. 32, p. 252).
In the Medicare Modernization Act passed last December, Congress expanded on the face-to-face exam mandate by decreeing that new DME clinical coverage standards "shall include the specification of types or classes of covered items that require, as a condition of payment ... a face-to-face examination of the individual by a physician." The law also specifically requires an exam for power wheelchairs.
And in the physician fee schedule proposal published in the Aug. 5 Federal Register, CMS runs with the ball. The agency carries the requirement even further than it appears Congress intended by declaring all, not just some "types or classes" of DME, require an exam for payment.
CMS used the regulation, with its host of requirements "to widen the net and make it much more complex than expected," charges Erik Sokol with the Power Mobility Coalition.
Suppliers were "shocked" by the exam requirement for every item of DMEPOS, says Mike Hamilton, executive director of the Alabama Durable Medical Equipment Association and Georgia Association of Medical Equipment Services. Suppliers "were jumping up and down screaming" because the widely held belief was that CMS would require the exams only for power wheelchairs, Hamilton tells Eli.
The rule is "a potential disaster," Hamilton predicts. If it is finalized "it won't be good for anybody" - physicians, patients or suppliers, he says.
"It's going to have a huge impact on all providers" of DME, expects Rose Schafhauser, executive director of the Midwest Association for Medical Equipment Services - the trade association for Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota and South Dakota.
The problem: Rural and homebound patients will have to undergo significant hardship to make it into a doctor's office every time they need a new DMEPOS item or prescription renewal, Sokol notes. Often, the patient or third parties such as home care nurses can easily identify a need for items such as walkers or hospital beds and tell the doctors, Hamilton explains.
"There is no useful purpose for that [...]
