Reimbursement:
Medicare Must Add Service To RADs Or Risk Harming Patients
Published on Fri Sep 05, 2003
Payment switch is 'a sledgehammer approach to killing a fly,' one expert says. The controversial issue of payment for services versus products has raised its ugly head again in Medicare reimbursement, and suppliers and patients stand to suffer as a result. The Centers for Medicare & Medicaid Services has proposed switching respiratory assist devices with bi-level capability and a backup rate from the frequent and substantial servicing payment category to the capped rental category. The Medicare category switch for the devices - formerly known as NPPVs (noninvasive positive pressure ventilators) - could mean $30,000 less in reimbursement over five years for just a single RAD, CMS notes (see Eli's HCW, Vol. XII, No. 30, p. 235). The problem is similar to the one surrounding Medicare reimbursement for drugs, notes Ron Richard, vice president of marketing for the Americas for San Diego, CA-based sleep disorder company ResMed. Durable medical equipment suppliers use the so-called extra margin included in payments for both RADs and drugs to pay for accompanying services, Richard notes. "RADs look easy and relatively inexpensive, but they require constant review and adjustment" to ensure the patient is using them appropriately, says Patrick Dunne, consultant with Fullerton, CA-based Healthcare Productions Inc. Capped rental items do include a modest service and maintenance fee after the 13- to 15-month rental period expires, "but that few bucks a month" won't cover the RT visits required to adjust and change settings on the RADs, Dunne protests. "It's a horrible mistake to go to capped rental," where the RAD is treated - and paid for - as "just another piece of equipment like a walker or a wheelchair" he argues. "There are no clinical services associated with the DME benefit," agrees Jill Eicher, government relations director for the American Association for Respiratory Care. AARC is concerned that if Medicare reimbursement doesn't cover RT services for patients using RADs, "it could result in harm to the patient," Eicher says. In fact, if Medicare refuses to provide enough reimbursement to cover RT services for RAD patients, "they are better off not covering the device at all," Dunne declares. Without the proper clinical visits accompanying RAD usage, the potential for harm to the patient is just too great, Dunne says. Payment System For High-Tech DME Flawed The Medicare reimbursement model for high-tech DME is "highly flawed, and has been for years," laments ResMed's Richard. DME payment rates are based on only equipment prices and upkeep, when many high-tech devices now require extensive clinical services accompanying them. To make up for Medicare's lack of official recognition for the services needed for items such as ventilators and oxygen concentrators, CMS puts them in the FSS category, where they continue to receive [...]
