Page 18 - HME Business, Jan/Feb 2019

Setting a Smart Strategy for 2019
{ continued from page 15 }
Competitive Bidding Gap
For all of CMS’s commitment to competitive bidding, the program went dormant for 18 to 24 months starting Jan. 1. Per CMS’s recent Final Rule any Medicare accredited DMEPOS provider can offer items for which they didn’t have a bidding contract. For providers that were unable to successfully bid a contract for a competitive bidding area or a product category they might have previously served, this could represent a tremendous opportunity.
But it also begs a number of questions about whether or not they want to do that. For starters, many of those providers might have stepped away from those categories or CBAs and reshaped their business strategies after Rounds 1 and 2 of compet- itive bidding. In fact, they might have stepped
away from Medicare DMEPOS altogether, focusing instead on retail, private payer, Medicare Advantage or skilled nursing facilities, to name a few.
And if they decided to get back into those cate- gories, would they have to re-secure accredita- tion? They might have let their Medicare accredi-
tation for a particular category lapse and would have to undergo the process all over again.
Or, a provider might have entered a subcon- tracting relationship or 5 percent agreement with another provider that got a contract. Now they have to ask themselves if they want to leave those relationships?
And hanging over all these decisions is the fact that this competitive bidding gap is impermanent. The program will resume in the near future, and then what will those providers do? Re-bid? Do they stand a good chance of getting a contract? To be certain, the bidding gap is a good break from a bad program, but for many providers it will mean as many questions as it does opportunities in 2019.
The Remainder of CMS’s Final Rule
Let’s remember that the bidding gap is just one element of CMS’s Final ESRD/DMEPOS Rule, which it released in November. The Final Rule contains provisions that are clear wins for the industry, such as the aforementioned bidding gap; lead item pricing; additional rural relief; and a new method for calculating SPAs. In quantifying the upsides
to the Final Rule, the American Association for Homecare said it should bring at least $1 billion to the industry. That’s a welcome bit of business given how greatly the competitive bidding program has hurt providers revenues since it began. But there’s still a lot to sort out in 2019.
For starters, non-bid area providers that are not rural and in the contiguous United States still don’t have a break. Rural areas get a 50/50 blended rate, and Congress made it clear in the CURES Act and elsewhere that it wants those non-bid area providers to have those rates. The Final Rule also doesn’t retroactively apply Consumer Price Index (CPI) adjustments in CBAs based on the increases in the CPI from 2013 through 2018. The industry will have to work with Capitol Hill and CMS in 2019 to see what can be done to ensure all providers finally get those blended rates and adjustments, because the current situation is untenable for many HME businesses.
equipment) rate. Moreover, CMS has already taken public comments for plans to add ventilators to the next round of competitive bidding. Given the vital, life-sustaining nature of such equipment, this will likely be an advocacy fight during 2019.
TPE and Other Audit Challenges
TPE audits are an ongoing issue for providers that will continue to impact their business strategies in 2019. TPE stands for Targeted Probe and Educate and it aims to identify providers who are billing for certain codes and have higher error rates.
But the program is designed to help providers improve their documentation and billing. Rather just doing widespread prepayment reviews of claims, auditors will audit 20 to 40 initial claims, and if the provider’s error rate is under a certain amount, then auditors will notify the provider that it is essentially free to go about its business. But if the error rate is over a certain amount, then the provider has to go through a second round, starting with an education session in which the auditor details the issues and how to fix them. Afterward, the provider goes through another round of 20 to 40 audits.
After the third round, the error rate is still not where they anticipate it being, then that provider gets referred to CMS. CMS’s responses could include extrapolated overpayment, or referral to a RAC, or a ZPIC, for additional auditing, which is much more intensive.
And that’s just one audit challenge for 2019. For instance, CMS will likely emphasize patient privacy protection. HIPPA and Office of Civil Rights (OCR) reviews designed to protect patient healthcare information (PHI) performed more than 200 audits, and none of the providers passed all of the audit components, Moreover, 86 percent failed in certain categories either by making either minimal efforts to comply, negligible efforts, or no efforts whatsoever. Expect CMS to focus on protecting patient data as a result.
E-Prescription
Fortunately, we can see software vendors start to address the need to bring e-prescription to the HME industry in 2019, and providers should consider integrating it into their businesses.
E-prescription has been a regular component of U.S. healthcare IT systems for years — except
18 HMEBusiness | January/February 2019 | hme-business.com
Management Solutions | Technology | Products
Also, the Final Rule opens the door for CMS making changes to oxygen reimbursement.
CMS will create a new class for portable liquid oxygen equipment by splitting the existing class of portable gaseous and portable liquid oxygen. CMS would increase the payment amount for the new portable liquid oxygen class so that it is the same as the OGPE (oxygen generating portable
For most providers, the bidding gap that began on Jan. 1 will represent a double-edged sword: it’s an opportunity, but with a finite shelf-life. Do they want to be there when competitive bidding resumes?
Besides the bidding gap, there are a number of other provisions in CMS’s final rule that will shape HME for 2019. And some have yet to come into focus. Are providers ready?