Medicare Compliance & Reimbursement

Plus:  MA Plans could earn a pay raise.

Federal regulators have spoken, but suppliers of power mobility devices say they need more specifics on what to document if they are to expect Medicare to reimburse them for their wares.

The Centers for Medicare & Medicaid Services' final rule on Medicare payment for PMDs--power wheelchairs and power operated vehicles, or scooters--recently appeared in the Federal Register with a June 5 effective date. The final rule fine-tunes provisions of the interim final rule regarding PMDs that has been in effect since Oct. 25, 2005 (70 FR 50940).

Most provisions of the interim final rule remain in the final rule, including these essentials:

• A physician or other practitioner (e.g., a physician assistant or clinical nurse specialist) must conduct a face-to-face examination before prescribing a PMD;

• The certificate of medical necessity for PMDs is a thing of the past; and

• The practitioner must provide a written prescription for the PMD and supporting medical documentation to the supplier to establish medical necessity.

The biggest shortcoming of the new rule carries over from the interim final rule, according to PMD suppliers: CMS' failure to clarify what constitutes "pertinent" medical record documentation for establishing medical necessity.

"The final rule fails to give clear guidance regarding what suppliers are expected to have in hand to support a prescription," says Eric Sokol of the Power Mobility Coalition. Without that objective guidance, Medicare's regional contractors are free to subjectively deny legitimate claims, Sokol contends.

Though suppliers must obtain prescription and supporting documentation prior to dispensing the PMD, they still face considerable risk, cautions Rita Hostak, vice president of government relations for Longmont, CO-based Sunrise Medical.

The DME regional carrier, after all, is free to deny a claim, and that's typically after the product has been delivered, Sokol points out. "We're not likely to be going back after a month or 60 days and asking a beneficiary to return the wheelchair when the claim is denied."

Industry representatives vow to keep up the fight for more specifics from CMS to bring some standardization to the required supporting medical documentation, even if that means enlisting Congress's help in pressuring the agency for clarification.

Meanwhile, the final rule does offer suppliers a concession. The rule's one substantive change gives suppliers 45 days from the time of the face-to-face exam to secure a prescription and appropriate supporting documentation. The interim final rule gave suppliers only 30 days to gather the information.

In addition, the final rule clarifies that a beneficiary discharged from the hospital does not need to have a separate face-to-face examination if the prescribing physician or treating practitioner performed the face-to-face exam during the hospital stay. That's as long as the practitioner meets the 45-day time limit.

Note: The final rule is at www.access.gpo.gov/su_docs/fedreg/a060405c.html --scroll down to CMS.

Medicare Advantage Plans Shine

In other news, Medicare Advantage plans are lowering costs and also saving beneficiaries money, including those benes who are prescription drug plan users, CMS announced recently. CMS announced it would increase payment rates for MA plans by 4 percent next year, at a time when physicians will be lucky to obtain another pay freeze next year.

Will 2007 Budget Include Medicare Cuts?

House lawmakers broke for a two-week Easter recess without voting on a fiscal year 2007 budget resolution. Disagreements between conservative and moderate Republicans over items including Medicare and Medicaid cuts stalled the legislation after it was passed without Medicare cuts by the House Budget Committee.

The Budget Committee's resolution did instruct the Ways and Means Committee to come up with $4 billion in savings over the next five years, but lawmakers insisted those cuts wouldn't come out of Medicare.

Whether the House will take up the budget resolution when it returns from recess is unclear. President Bush says he will veto any budget legislation that does not include cuts his Administration recommended earlier this year, including reductions to home health agency and hospice payment rates.