Page 32 - HME Business, November/December 2022

Business Solutions
Tom Ryan, President and CEO,
The American Association for Homecare
“Essentially what they say to these plans is, ‘go do your thing.’”
And issues stemming from that lax over- sight are already cropping up.
“The key issues remain overzealous utili- zation management that is not consistent with Medicare FFS and as a recent OIG report pointed out, the prior authorization (PA) requirements are not consistent with Medicare FFS,” he says. “The report found inappropriate denials with as much as 13 percent meeting Medicare coverage rules but denied by the MAP.”
There is currently no regulation that requires the MAPs to only require authori- zation on what is required by Medicare FFS. However, the plans are not allowed to be more restrictive in medical policy coverage.
The PAs requirements are an important point, Ryan notes, because MAPs are not allowed to be more restrictive in medical policy coverage.
“This has caused inappropriate denials and over-utilization criteria that often require monthly Pas,” he explains. “A burden on the provider again not consistent with FFS.”
“These Medicare and Medicaid plans have
been pretty heavy-handed and have caused some problems for all providers and suppliers, including DME suppliers,” Baird agrees.
Fortunately, the industry is starting to be proactive via AAHomecare’s Payer Relations Council (which Baird sits on), which is trying to level the playing field for providers that serve beneficiaries of these plans. For instance, some states are starting to pass laws to control how Medicaid managed care plans work with providers and suppliers, and OIG and CMS have been studying MAPs, which prompted AAHomecare to submit a five-page letter itemizing key prob- lems with the current situation and solu- tions for them.
Notably, two of AAHomecare’s solu- tions re to establish a centralized national ombudsman for oversight of Medicare Advantage plans and centralized rate setting.
“We would certainly like to see CMS desig- nate a central contact or ombudsman with the authority and responsibility to oversee MAPs compliance with access to care and other requirements,” Ryan explains. “This CMS contact should ensure that adequate recourse is available to DMEPOS suppliers when a MAP is not in compliance and MAPs should not be allowed to simply terminate contracts with DMEPOS suppliers when suppliers seek such recourse.
“The payment rates need to ensure bene- ficiaries’ access to care,” he continues. “The MAPs should be required to demonstrate to CMS that they have completed access to care analysis for DMEPOS items and services. These analyses need to be done by DMEPOS-specific product category.”
Moreover, the Improving Seniors’ Timely Access to Care Act (H.R. 3173) recently passed in the House and has now moved into the Senate, where it has been receiving healthy debate at the subcommittee level. The bill would set up an electronic PA process for MAPs as well as establish a real-time PA process for routinely approved products and increase data transparency, Ryan notes.
So, what do providers do about this trend? For now, the key is to stay on top of developments related to these plans and join advocacy efforts when possible. Baird suggests reading whitepapers that have been produced by the Payer Relations Council at AAHomecare, attending event sessions
and reading industry articles on the topic, and staying in communication with groups like the Payer Relations Council. “The most important thing that DME suppliers can do is to become knowledgeable,” Baird says.
UPIC AUDITS
Wayne van Halem, president and founder of audit consulting firm The van Halem Group, says he is seeing an uptick in UPIC audit activity, particularly with respiratory equip- ment and claims with the CR modifier (i.e., Covid-related claims). He notes that his firm has started to see denials of claims with the CR modifier for items such as not having a reevaluation, which is surprising given that theindustrywasundertheimpressionthose requirements were waived. Fortunately, the UPICs have not been doing extrapolated
overpayments, and so far, have focused only on actual overpayments, he adds.
That said, his firm is appealing the find- ings to the DME MACs. “I have a feeling that the UPICs are going to get overruled on this,” he adds.
So why are the UPICs denying claims based on requirements that weren’t needed during Covid? Given the similarity in the types of claims the UPIC audits are reviewing (oxygen, ventilators, etc.) and that the letters are very standardized, perhaps this is a special project on the part of CMS’s program integrity group to study pandemic-related claims. That suspicion was further confirmed when, after he mentioned the audits to CMS’s provider compliance group — the part of CMS that oversees audits related to DME MACs and RACs — and that group wanted to see examples of the denials.
Ultimately, the UPIC denials speak to a question that has been on everyone’s minds
Wayne van Halem, President and Founder, The van Halem Group
Jeffrey S. Baird, Esq.,
Chairman of the Health Care Group of Brown & Fortunato, P.C.
20 HMEBusiness | November/December 2022 | hme-business.com Management Solutions | Technology | Products