Observation Deck

The Buck Stops Where?

CMS continues to place providers in an unfair position with referring physicians.

The past year contained as many or more challenges for the HME provider than any other year. Those challenges included mandatory accreditation, surety bonds, the ramp up of audits conducted by the Recovery Audit Contractors (RAC) and Zone Program Integrity (ZPIC’s) programs. We encountered our first full year of managing process’s for capitated payment of oxygen, and new PAPpolicy guidelines.

Added to that, the last quarter of 2009, brought the full realization of the impact PECOS could mean in regards to cash flow to our businesses, as well as learning of the direction given by CMS to the DME/MAC Medical Directors to ‘tighten up” claims processing. A decision based on data gleaned from the contractors for the Comprehensive Error Rate Testing Service, (CERTS) program. (While there certainly were other challenges, this column is limited to one page.)

Misplaced Responsibility

My current position enables me to travel and work with HME providers of various sizes throughout the country. There is by far one issue that causes the most frustration and emotional fatigue to providers and patients alike: being held responsible for the physician-to-patient visit component.

To clarify what that means, it is important to note that this past year we have seen an increasing direction of CMS for the HME provider to communicate to the physician:

  • How to initially evaluate patients.
  • When to evaluate patients.
  • How to re-evaluate patients.
  • When to evaluate patients.
  • Where to evaluate patients (lab vs. PCP’s office).

A quote taken directly from the current PAP LCD states, “Suppliers are encouraged to help educate physicians on the type of information that is needed to document a patient’s need for PAP therapy.”

Most suppliers would agree that “educating” a community of physicians is not something they should be charged with responsibility for completing.

While I am not going to argue that CMS may have policy based on good medicine, the mandated process is in fact bad. The argument made by CMS is that the HME is being paid for the equipment; it is their responsibility to obtain “qualifying” documentation. Reflect on the process from the position of the patient’s physician:

He or she attended four years of undergraduate education, then had to compete ( often intensely) for the opportunity to complete another 3-5 years of medical school, then minimally another 2 years for residency.

To have anyone who is not a “peer” direct inquires that can be perceived as questioning medical judgment, documentation practices, or office performance, is generally not accepted graciously, ( to say the least) .

Peer Review has been around now for over two decades, in response the Health Care Quality Improvement Act of 1987, (HCQIA) (P.L. 99-660).

It was recognized that physicians and other professionals are more likely to regard the advice and inquiries of peers than of those perceived as subordinates or those with lesser education. The goal of course is to drive improved clinical outcomes.

Good Gates Make for Good Referrals

Providers who do try to obtain notes and documentation to meet the preciseness of each LCD are often faced with scenarios such as one provider that laments the following:

“Our company tries very hard to comply with the PAP policy to the letter. We have had patients that have not been compliant at the end of the 91 days. When presented with the available options at the end of the trial period we have had a local pulmonologist tell us that if we picked up the patient's equipment (they were unwilling to order a new sleep study, DC or change the patient to bilevel) that we were conflicting with their standing orders and the long and short of it is we would never receive another referral from them again and become ‘blacklisted.’

“They did not care what the Medicare rules were; we were refusing care to their patient,” the provider continued. “Keep in mind that the patient is unwilling to sign an ABN and refused to voluntarily return the equipment because she says the Dr wants her to have it. This is putting the dealer in a Catch 22 situation which is completely unfair. I believe there needs to be some recourse to the physician in a case like this. I am very frustrated about this somewhat subjective policy and the lack of documentation that the physicians make.

“Additionally, have we heard anything more about moving the gate to the sleep lab regarding evidence of the face-to-face visit prior to the sleep study?”

I like the provider’s choice of the word “gate.” In the dictionary, a gate is defined in part as, “Gates may prevent or control entry or exit, or they may be merely decorative” While we all know of stories of providers for whom the gate is merely decorative, many are working vehemently to obtain the necessary components to meet requirements stated in the LCD, and are preventing patient entry into the system based on policy requirements.

The gate is simply in the wrong place. In the case of sleep diagnostics and PAP therapy, placing the gate at entry to the lab versus at the point of obtaining equipment makes more sense. That would create physician to physician communication as opposed to what we have now.

While the DME/MAC Medical Directors have crafted informative letters to physicians, they have not been enough to create understanding of policy.

If CMS is going to dictate the how, when, and where of the patient’s care, then it should be accomplished by peer-to-peer communication. Put the gate in a more effective place, the wrong candidates are getting through while too many right ones don’t gain access at all.

This article originally appeared in the January 2010 issue of HME Business.

About the Author

Kelly Riley, CRT, is director of The MED Group's National Respiratory Network and has more than 25 years of experience in the respiratory arena.

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