Medicare Compliance & Reimbursement

DME suppliers should prepare for face-to-face requirement.

Suppliers have been suffering under Operation Wheeler Dealer for eight months, and the regulatory and reimbursement climate is only going to get worse.
 
The Centers for Medicare & Medicaid Services has proposed some welcome changes in the next phase of its wheelchair initiative. Top on the list is expanding HCPCS coding for wheelchairs currently in the catch-all K0011 category.

But that change will help only if it's "efficient," warns Erik Sokol with the Power Mobility Coalition. Seven new codes may be an improvement, while 70 would be going overboard, for example.

And rates for the new codes must take into account all the overhead required in the burdensome Medicare program, Sokol adds. The OIG admits in its report on wheelchair prices that it doesn't take administrative costs into account.

The industry also welcomes the clinician workgroup CMS announced, which will work on changes to the coverage policy for power wheelchairs. But it is eager to have a say in the policy guidance.

CMS is starting out by gathering an internal work group only, officials stressed in the April 28 Open Door Forum for home health. The agency will gather stakeholder input before issuing any sort of formal policy, a CMS official promised.

"We want to be included from the get-go," Sokol says. He worries another confusing policy change, such as the restriction that CMS pulled back, will come out of the internal work group if it fails to seek input from beneficiaries, clinicians and suppliers early enough.

In his testimony before the Senate Finance Committee April 28, CMS' Herbert Kuhn said the work group plans to complete its task by the end of the year.

Cause for concern: Not all the power wheelchair changes are helpful. Kuhn noted three reimbursement changes that will slash payment rates:

1) FEHBP rates. On Jan. 1, 2005, CMS will reduce K0011 rates by more than 3 percent to the reimbursement level of the Federal Employee Health Benefit Plan.

2) IR. Kuhn assured the committee that wheelchairs are at the top of the list for reduction by inherent reasonableness authority. CMS is conducting an IR review of the product already, he said.

CMS can't implement IR cuts until it publishes its guidelines on the process, the General Accounting Office's Leslie Arnovitz noted in the hearing. Those guidelines are expected by the end of 2004.

3) Competitive bidding. The GAO lauded the upcoming competitive bidding system for DME as a promising way to reduce payment rates. K0011 wheelchairs will be included in the bidding process, Kuhn promised. The system will begin in selected areas in 2007, and prices set by bidding can be applied nationwide by 2009, Kuhn noted.

By the time bidding is implemented, CMS expects the new K0011 HCPCS codes to be in effect, Kuhn added.

More Changes on the Horizon

In addition to the reimbursement changes, a number of regulatory changes are in the pipeline. Provisions in the Medicare Modernization Act passed last December call for a requirement for clinicians prescribing power wheelchairs to have a face-to-face meeting with patients first and for additional quality standards.

Both those requirements are in the regulatory process, CMS says.