Medicare Compliance & Reimbursement

Plus: HSAs, HDHPs may top new plan growth this year, survey predicts.

Congressional representatives are now hopping on the bandwagon to defeat the Deficit Reduction Act.

Rep. Henry Waxman (D-CA) is calling on fellow lawmakers to investigate "the White House's knowledge of the constitutional defects" of the DRA, which President Bush signed into law on Feb. 8--a move that could have big implications for DME suppliers.

The version of the DRA that the President signed (S. 1932) is not the same as the version passed in the House on Feb. 1. The House version requires Medicare to lease durable medical equipment to beneficiaries for up to 36 months, while the version the President signed limits such leases to 13 months. For DME suppliers, the shorter lease period could mean a cut in Medicare revenue of $2 billion over five years.

For an overview of Waxman's allegations, go to www.democrats.reform.house.gov/story.asp?ID=1033.

HSAs, HDHPs Likely To Show The Most Growth, Survey Says

Health savings accounts and high-deductible health plans recently beat out mini-med plans and Medicare Advantage plans as next year's "most likely to succeed."

More than 100 C-level health care executives--including health insurance carriers, reinsurance intermediaries, managing general underwriters and third-party administrators--participated in a climate survey at the seventh annual American Re Healthcare Symposium late last month. More than one-third of the survey participants agree that HSAs and HDHPs will see the most significant growth over the next year. In contrast, 13 percent believe that mini-med plans will be the frontrunners, while 12 percent have their highest expectations in MA plan growth.

In addition, the rising cost of health care is still a major concern. Among the survey participants, 44 percent agree that health care costs are becoming "too expensive for employers to provide at current levels."

"As many strengthen their belief that the U.S. healthcare system is in urgent need of a better balance, the debate for reform intensifies," says American Re HealthCare president Robert Trainer. "Our annual Symposium, which brings together leaders from throughout the health care field, facilitates this debate."

To view the symposium survey's results, visit www.americanrehealthcare.com.

In Other News...

• CMS reduces managed care system glitches. Providers may see a reduction in the number of patients whose switch to a Medicare managed care plan fails to show up in the Common Working File for months on end. CMS identified system problems with the beneficiary records for managed care plans and has corrected most of the problems, an agency staffer explained at a recent Open Door Forum.

Claims should process appropriately and inquiries should successfully give accurate information most of the time, the official promised. While "a smattering of issues" may persist, CMS will continue its efforts to make sure the managed care information is up-to-date and accurate, she pledged.

• CMS clarifies policy-making procedures for LCDs. CMS is offering more clarity on how it decides which local coverage determinations will become national policy. The agency has issued two guidance documents that detail steps in the national coverage determination process concerning CMS' determinations of whether an item or service is reasonable and necessary.

The guidance explains the factors CMS considers when initiating a Medicare NCD and determining whether to commission an external health technology assessment to evaluate a new health care technology, the agency says in a release. More information is at www.cms.hhs.gov/MedicareCoverageGuideDocs/.

 • Is OASIS data collection weighing providers down? Now's providers' chance to comment on the burden of OASIS. In the April 14 Federal Register, CMS requests comments on the burden of the Outcome and Assessment Information Set data collection and on OASIS electronic reporting. Comments are due within 30 days of the notice.

Instructions on submitting comments are in the notice at www.access.gpo.gov/su_docs/fedreg/a060414c.html --scroll down to the first CMS entry.

• High-tech PMDs don't warrant new benefit category. CMS shouldn't create a new benefit category to accommodate high-tech assistive devices, such as the Independence iBOT 4000 Mobility System.

At least that's the opinion of Elyria, OH-based Invacare Corp. and other major suppliers of power mobility devices. CMS invited stakeholders to comment recently on coverage of the high-tech PMD product from Independence Technology LLC, a subsidiary of Johnson & Johnson based in Endicott, NY.

"We do not believe ... that CMS has the legal authority to create a new benefit category for a particular manufacturer's device, especially when other manufacturers' products in the market provide similar function and performance," Invacare's Cara Bachenheimer noted in written comments to CMS.

• Unveil the secrets of E/M documentation, AV fistulas. If providers need a refresher course in evaluation and management documentation, help is at hand.

CMS has posted an electronic version of its E/M Services Guide. The guide includes a rundown of medical records documentation, ICD-9 diagnosis coding, CPT codes and the key elements of the E/M service. The guide is available online at www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf on the CMS Web site.

Also online is a new "training module" to creating AV fistulas in eligible hemodialysis patients for vascular access surgeons, interventional radiologists, nephrologists and other physicians. You can download it from www.cms.hhs.gov/MLNGenInfo on the CMS Web site.

• Physician groups gripe about MUEs. CMS should totally rethink the Medically Unbelievable Edits; it should also fully explain the reasoning behind the MUEs and allow physician groups to review and comment on the methodology and data it used to develop the MUEs, according to a recent letter from 16 specialty groups to CMS. After physicians have a chance to comment, CMS should move forward with only a "select, targeted number of MUEs," not 10,000 edits targeting every single CPT code, the groups proposed.

• MedPAC scrutinizes physicians' resource use. The Medicare Payments Advisory Commission is studying a sample of 5 percent of Medicare physician claims to figure out whether commercial episode groupers and clinical quality indicators can help indicate whether a physician is using resources efficiently.

• CMS is considering adding new diagnoses to the coverage criteria for some diagnostic tests. If a provider performs partial thromboplastin time tests for patients with primary hypercoagulable state (289.81) or prostate-specific antigen tests for patients with hypertrophy of prostate without urinary obstruction (600.00), then now's the provider's chance to comment by going to www.cms.hhs.gov/coverage. CMS is also considering adding 289.81 (Primary Hypercoagulable State) as a covered indication for prothombin time testing.