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Home Health & Hospice Week

Industry Notes:

Expect Faster Coverage Decisions From Medicare

Published on Sun Oct 05, 2003

Beneficiaries receive separate process.

An overhauled method of issuing national coverage decisions could clear some of the murk from the process of securing Medicare coverage for new products and services.

The Centers for Medicare & Medicaid Services updates the process it will use to issue Medicare NCDs in a final rule published in the Sept. 26 Federal Register. Among the new policies is a separate process for beneficiaries who need an item or service that isn't currently covered. CMS says it will issue NCDs in such cases in 90 days.

The rule also clarifies what elements are required to make a formal request for an NCD and outlines what CMS will consider in making its determinations.

"Our goal is to make the latest advances in medical care available to Medicare beneficiaries more rapidly, while making evidence-based decisions that safeguard the health and safety of patients," says CMS Administrator Tom Scully.

The rule, which goes into effect Oct. 27, is available online at www.access.gpo.gov/su_docs/fedreg/a030926c.html.

  • Home health agencies will see some immediate survey changes thanks to the Home Health Compare Web site that will compares agencies' patient outcomes nationwide starting later this month. In a Sept. 11 letter to state survey agencies, CMS tells them to update HHAs' demographic data (name, address, phone number, services offered) upon request. Currently, that data is updated only during surveys.

    HHAs that want information changed must contact their state OSCAR/ASPEN coordinator, who can be located at www.medicare.gov/hhcompare/search/related/oscaraspen.asp, the letter says.

  • States could start paying for more home care services, if CMS gets its way. A Sept. 17 letter urges state Medicaid directors to adopt more "Money Follows the Person" programs, in which long-term care funding goes toward home- and community-based care, not just nursing home care.

    CMS praises Oregon, Indiana and Arizona for their programs that keep beneficiaries out of institutions. The letter, which also promotes self-directed care programs, is at http://cms.hhs.gov/states/letters/smd91703.pdf.

  • Durable medical equipment suppliers may see more enforcement of skilled nursing facility bundling in the New Year. CMS tells DME regional carriers to turn on their automated processing of the unsolicited response for SNF consolidated billing claims Jan. 1, 2004, according to Sept. 26 Trans. No. 1819.

    Remark code N121 tells suppliers "Medicare Part B does not pay for items or services provided by this type of practitioner for beneficiaries in a Medicare Part A covered skilled nursing facility stay."

  • Appeals for certain DME items are about to change. A written order prior to delivery is required for: pressure reducing pads, mattress overlays, mattresses, and beds; seat lift mechanisms; TENS units; and power operated vehicles, CMS notes in Sept. 12 Trans. No. 48. DMERCs may require a written order prior to delivery for additional items.

    Formerly, if a supplier billed for such an item without a written order, the item was denied as not meeting the benefit category. The new transmittal deletes the instruction "that an item denied as not meeting the benefit category is not appealable by the supplier," CMS notes.

  • The Community Health Accreditation Program has won the seal of approval from CMS to continue conducting deeming surveys of hospices, according to a notice in the Sept. 26 Federal Register. The reapproval, which allows CHAP to survey accredited providers in lieu of state survey agencies, lasts until November 2009.

  • CMS has issued a few new medical review instructions. DMERCs should review a beneficiary's claims history and medical documentation when processing Advance Determination of Medicare Coverage (ADMC) requests, CMS tells contractors in Sept. 26 Trans. No. 50.

    In another transmittal (No. 49), CMS says contractors don't have to use remittance advice N109 to indicate they've made a denial after review of medical records unless they wish to.

  • Five audits of states' drug rebate procedures brought five negative reviews from the HHS Office of Inspector General. The OIG found fault with Medicaid drug rebate processes for Florida, South Carolina, Georgia, Kentucky and Tennessee.

    Problems ranged from management weaknesses to missing audit trails. However, many of the states already have taken steps to correct identified problems, the OIG notes. The reports are at http://oig.hhs.gov/oas/oas/cms.html.

  • New Hampshire is delaying plans to institute a wait list for its Medicaid home care services, reports the Associated Press. After announcing its wait list plans (see pdf of Eli's HCW, Vol. XII, No. 34, p. 272), state lawmakers protested and the state agreed to try to find other ways to fund the care.

  • Two new managed care-related deals have been announced for home care providers. Option Care Inc. has become an in-network provider of home care and infusion services for members of Humana Inc.'s national PPO, the ChoiceCare Network. The Buffalo Grove, IL-based infusion company has 130 locations in 32 states.

    Matria Healthcare Inc. will furnish disease management services to customers of  Pfizer Health Solutions Inc., the Marietta, GA-based DM company says. Pfizer's customers include state Medicaid beneficiaries, health plans and employers who use the company's care management procedures.

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