Dan Fedor (left), Alexis Ward, and Jack Haire participate in the policy panel at HME Business FUTURE 2024 in Nashville.
As 2024 comes to a close, home medical equipment (HME) industry policy specialists continue to track a number of funding and regulatory topics expected to significantly impact HME providers in 2025.
While January will see a new administration in Washington, D.C., and new legislators on Capitol Hill, some policy topics remain consistently of concern for stakeholders.
(1) Medicare Advantage plans under scrutiny
The Centers of Medicare & Medicaid Services (CMS) put Medicare Advantage (MA) plans on notice regarding those plans’ prolific use of prior authorization, a process that can increase the time it takes for Medicare beneficiaries to receive their HME.
In announcing its intention to target inappropriate prior authorization use, Department of Health & Human Services (HHS) Secretary Xavier Becerra said in a Nov. 26 announcement, “Our loved ones with Medicare deserve care that puts their interests first. HHS is proposing to improve transparency, accountability and consumer protections in Medicare Advantage and Part D plans so that everyone receives high-quality care.”
In a panel discussion at the HME Business FUTURE conference in August, Dan Fedor, director of reimbursement and education for VGM & Associates, confirmed that the actions of MA plans are “a really big issue” that “seems to be getting worse.”
He added, “The Medicare Part C plans are required to follow the same coverage as traditional Medicare. But what we see and what I hear — I would say daily now from our members — is that they’re denying medically necessary equipment and services that traditional Medicare would approve. And it’s becoming very blatant. From what we’re seeing, many of our members are getting a prior auth from Medicare — traditional Medicare — for CRT [Complex Rehab Technology] for power mobility and then sending it to the Part C plan with the exact same documentation, and it’s getting denied. That’s widespread. So it’s challenging, and I think that one of the main issues is there seems to be no oversight.”
The structure of MA plans is also part of the problem, Fedor added. “Traditional Medicare was created to provide that safeguard for the elderly and disabled to have access with the intent of medical necessity,” he said. “Other motives are out there now in the Part C [Medicare Advantage] world, because Part C is for profit. So they have different goals.”
Alexis Ward, senior director of payer relations for the American Association for Homecare (AAHomecare), agreed with Fedor about MA-related challenges. Speaking as part of the policy panel, Ward said, “There’s a group of people in the industry requesting to meet regularly with CMS to talk to them from the oversight perspective of how to hold the Medicare Advantage plans accountable to those requirements that are put on them. But right now, it’s really fallen to the industry to do what we can to educate the Medicare Advantage plans as to what the requirements are and how that is not being felt by the people who are supposed to benefit from Medicare Advantage plans.
“Some of that has to do with the way that the requirements and the federal regulations are worded. They reference the existing medical necessity policies on the CMS side that have to be followed, but where there is a lack of a policy, [MA] plans are able to implement their own coverage guidelines.”
(2) CMS to focus on fraud and abuse
Regarding other CMS policy priorities, “There’s a true focus on their perception of fraud and abuse in the DME area,” said Jack Haire, director of DMEPOS/pharmacy for The Compliance Team. Also speaking on the HME Business policy panel in August, Haire added, “The personnel have changed at CMS, so right now, everyone at program integrity and oversight is very active.”
And how is that fraud-and-abuse priority playing out? From an accreditation perspective, Haire said, “What we’re seeing is guidance to all the [accrediting organizations] about how to conduct a site survey. You know, it’s an interpretation of the standards more consistently among all the accreditation organizations. That’s a new direction.
“An example would be that some of the accrediting organizations would require or allow mock patient files for a new provider. And the idea of accreditation, from our point of view, is that we’re accrediting an active business, somebody that’s in business — because otherwise, how can we really evaluate and see that they understand the quality standards? And that was always CMS’s intent. So they have made that now an official regulation, that mock files wouldn’t be accepted.”
Another challenge this year has been validation surveys, Haire added. “They have always used CMS contractors, and once you’re accredited, every three years they would send in some sort of validation contractor to look at the 30 supplier standards. And right now, there’s a huge problem.
“Every day, I’m getting calls from providers from across the country — not just us at The Compliance Team, but other accrediting organizations are also reporting the same thing, where these contractors are of limited knowledge. Most of them are coming in, really not even identifying themselves, and then not understanding the business model. Because every site that I do, it’s a different business model. We have mail order. It could be chiropractic, it could be a pharmacy doing CGMs [continuous glucose monitors].
“They all have to meet the quality standards, but these contractors don’t understand it. So when they interpret a supplier standard, they’re just crossing it off, and then they’re leaving and not doing an exit interview. You as a provider have no idea what happened or transpired during that visit, and then two weeks later, you get a letter of revocation, and your cash flow stops. This is a problem that we’re seeing right now.”
(3) Educating newly elected members of Congress, Senate
With the new year come new members of Congress and the Senate — many of whom won’t know much about home medical equipment policies or the crucial roles that HME providers play in the health-care continuum.
Ward suggested that educating legislators about HME is key to industry advocacy.
“Something I’ve always found helpful is hosting visits at your location, having the legislator or their aide or their office staff come to your location to walk through how that works on a daily basis,” she said. “A lot of people outside of our very small, unique industry do not understand it. They’ll see a wheelchair, but they’re not understanding all of the pieces that go into that.”
As the industry continues to press for more appropriate funding rates, it will be crucial to have House and Senate allies who understand reimbursement policy from a provider’s and from a Medicare beneficiary’s perspective.
“I would say the 75/25 blended rate, as we heard mentioned earlier, is a very important topic right now,” Ward said, referring to industry efforts to reinstate the Medicare rate that expired in January 2024. “And continuing to educate, educate, educate the legislators and their staffs on the rising costs and the not-anywhere-near matching reimbursement rates that are continuing to be challenges in the HME space.”
Editor’s Note: At the time of the panel and at the time this story was originally published, Alexis Ward was senior director of payer relations for AAHomecare. Ward has since announced she’s joined Cubby Beds as head of funding and advocacy.