Power Mobility Preview: Coming Into Focus
Power mobility providers have been through a lot. Not only have standard power mobility providers had to suffer through industry-wide funding cuts such as the 9.5 percent funding cut from the Medicare Improvements for Patients and Providers Act, but they also had their business model turned completely upside down when the first-month purchase option was removed, and they had to convert to a rental business model that now sees their funding trickle in over 13 months.
Fortunately complex rehab providers were spared from the ravages of competitive bidding and the removal of the first-month purchase option, but that isn’t to say that providers of higher-end mobility solutions aren’t dealing with their own challenges. That segment of the industry has been working overtime to get a handle documentation issues, and has been striving to try and separate itself from the Medicare DMEPOS benefit in a way similar to how orthotics and prosthetics are a separate benefit.
But 2013 will be a watershed for mobility providers of all stripes. They face a number of challenges that could yet again completely rearrange their businesses, and perhaps truly threaten their livelihoods in a worst-case scenario. That said, there are some opportunities for mobility providers, as well.
So what are providers going to face in 2013 and how should they prepare? Perhaps instead of whipping out a crystal ball, it might be better to use a microscope to get specific about the coming year for power mobility. HMEB talked to some power mobility public policy and funding experts to get their insights into the trends and issues that will impact mobility providers’ businesses over the next 12 months.
Competitive Bidding & The MPP
The industry faces a tough timeline when it comes to competitive bidding. The Round Two bid amounts still have yet to be announced (that was supposed to happen by the end of fall). Then in spring, CMS will announce the list of providers that have been offered contracts for the various categories and competitive bidding areas in Round Two. Then later in summer, CMS will implement the program. Whether the tardy bid amounts will throw that off remains to be seen.
Meanwhile the industry is trying to create a revised version of H.R. 6490 (a.k.a., the Medicare DMEPOS Market Pricing Program Act of 2012), a bill launched into the House by Rep. Tom Price’s (R-Ga.) that calls for the replacement of CMS’s bidding program with the industry’s market pricing program (MPP). Unfortunately the bill did not get passed in the Lame Duck session of the 112th session and now Rep. Price is looking to create a new version for the 113th Congress.The MPP outlines various fixes to a Medicare bid program for DMEPOS that actually makes it a competitive system that would not in result in the shuttering businesses and diminishment care of care that the industry and its partners and patients has witnessed in Round One of competitive bidding.
The industry's strategy for H.R. 6490 was a long shot, but it had some solid reasoning behind it: The industry had hoped to attach the MPP legislation to a larger piece of legislation that Congress hopes to pass during the lame duck session that ended Jan. 1, 2013. As Congress approaches the fiscal cliff, that doesn’t leave much time for Congress to pass sweeping legislation, but it will try to pass what it can. What it can pass might be the so-called Doc Fix, which aims to prevent physicians from taking a 30 percent pay cut when serving Medicare patients.
“Our issue is a teeny issue in the grand scheme of Washington, but the dynamics of Obama being re-elected is actually the better dynamic for us than had Romney been elected," says Cara Bachenheimer, senior vice president of Government Relations for Invacare Corp. “If Romney had been elected, no Republican (i.e. Boehner and Republicans in the House) would feel like there was any need to negotiate with the President and come up with a package before all these expiring provisions by the end of the year. … So now that Obama is going to be President for 2013, there is nothing to be gained by punting into next year for either party. Both parties have an incentive to do something before the end of the year so that we mitigate the fiscal cliff before the end of the year.”
That line of thinking was especially astute, because if CMS had released its bid amounts after the Congressional Budget Office scores the bill, there is a possibility H.R. 6490’s “pay for” could be thrown off, and it might cease being budget neutral. In a cost-conscious Congress approaching the fiscal cliff, it is imperative the bill leave the books balanced, and lawmakers would be much more amenable to work with the industry to tweak the bill if it had an overwhelming number of backers.
But now the industry is worrying that it will have to seek passage passage of the MPP before contracts are award and implementation rolls forward. Well, that’s not a scenario anyone wants to consider, but it is looking increasingly likely.
“Assuming the worst scenario, and the current CMS bid program continues and we have 91 new bid areas — and actually with subdividing between Los Angeles, Chicago and New York, it’s closer to 100 — we’re going to see an incredible exacerbation of what happened in Round One," Bachenheimer says.
And what happened wasn't good for patients.
“In power mobility, we had problems with beneficiaries getting their power wheelchairs’ replacement batteries and getting repairs,” she describes. “Going into Round Two, it’s more than 10 times the volume that Round One was. And I think we will see the impacts become apparent more quickly. … I think it’s going to be extraordinarily challenging for providers.”
Another issue that could arise, Bachenheimer says, is, if Round Two is like Round One, a number of new providers could surface that don’t have much experience in the power mobility game. That would obviously create more problems for beneficiaries.
Certainly this sounds like a terrible scenario for providers, but perhaps being able to use Round One to visualize exactly how bad competitive bidding could be for power mobility businesses and patients could wind up being beneficial for providers lobbying efforts for whatever bill Rep. Price ultimately launches into the House. Mobility patients are a very visible and in some respects, vulnerablepatient group that can help make the industry’s case. It’s a point of paint that could resonate with lawmakers.
“It should,” Bachenheimer says. “There are a lot of national consumer organizations that have signed on to replace the current bidding program with the market pricing program. [Bachenheimer refers to a recent letter from 31 consumer and patient groups thanking Rep. Price for launching H.R. 6490 and pledging their support of the bill.] The individual consumers are concerned with getting what they need. The last thing on their minds is calling their members of Congress. But given the volume of impact, we might see more direct, grassroots outcry as a result. It’s tough to say. A lot depends on what the bid rates end up being and who the winners end up being.”
A Separate Complex Rehab Benefit
The next big issue facing mobility providers is the fate of Medicare’s complex rehab benefit. There has always been an effort to break off competitive bidding from the rest of the power mobility benefit. Its patients are far more varied, have extremely complex needs, and the equipment and services that help them are highly specialized. This is why the industry successfully sought to get complex rehab removed, for the most part, from competitive bidding.
However the industry was working to permanently make complex rehab a separate benefit by way of H.R. 4378, the Ensuring Access to Quality Complex Rehabilitation Technology Act of 2012, which was introduced in the House by Rep. Joseph Crowley (D-N.Y.). Currently the bill has 35 co-sponsors, but according to Seth Johnson, vice president of Government Affairs for Pride Mobility Products, the legislation will need to be reintroduced in 2013, and he says there have been preliminary discussions to that end.
“We’re really focused, from a complex rehab technology perspective, on advancing that legislation in the next Congress and doing everything we can build the support necessary to see that passed into law,” he said.
Of course complex rehab providers and other stakeholders will be working on that effort at the same time as the industry as a whole is trying to stop competitive bidding and get Rep. Price’s MPP bill passed. Will complex rehab providers be able to multi-task or will they need to prioritize?
“I really view these as two separate issues, and it really depends on the companies you talk to as to whether they would have to make a decision as to which one they supported, and which one was the bigger priority,” Johnson says. “Since complex rehab technology is exempt from the current competitive bidding program those truly complex rehab companies that just do complex rehab don’t have much of a stake in competitive bidding or the MPP.
“Most of the companies that do complex rehab today, don’t provide the other categories that would be covered by competitive bidding,” he adds.
Johnson added that was especially true since the complex manual wheelchair code was added to the complex rehab exemption, as well. So there might be enough bandwidth available for the industry to work on both issues at the same time: replace competitive bidding with the MPP and advance the separate benefit for complex rehab.
That said, Bachenheimer says that those complex rehab-focal companies shouldn’t ignore the MPP, as it does a better job of full insulating them from competitive bidding. It includes not only manual complex rehab but also custom seating and cushions, as well.
Regardless, our experts agree that complex rehab needs to be a separate benefit.
“The separate benefit issue is critical,” Bachenheimer says. “A lot of these patients aren’t just Medicare. They’re Medicaid, or worker’s comp or some other insurance. It’s a younger population.”
Both Bachenheimer and Johnson see the separate benefit effort as something that will be handled in 2013 as opposed to this year. Right now the industry’s efforts will be fixed on advancing the MPP, given the unique opportunity the aforementioned lame duck session offers the industry to get H.R. 6490 wrapped into a larger piece of legislation.
In terms of the prospects of actually pulling off making complex rehab a separate benefit, Johnson says that lawmakers are becoming amenable to the idea.
“I think it’s gaining more traction every day,” he says. “Congress back in 2008, when we secured the first delay of competitive bidding, made a decision to carve out complex rehab power from competitive bidding. So there was that recognition that complex rehab was different.
“So we’ve been building on those efforts within Congress to make the case for the separate benefit, and the support is building and the message seems to be resonating with lawmakers,” he continues. “Clearly we have a lot more work to do, and like I said the bill will be reintroduced next year, so we have to begin educating lawmakers again to get their support on the bill as we look forward to the advancement of that in the next Congress.”
And in terms of any possible opposition, Johnson says he’s not aware of any specific group of legislators or other people that are against the idea. So essentially, the industry is looking at not fighting a battle against something so much as making lawmakers be for something.
“The people we’ve talked to say it makes perfect sense,” he says. “Largely what we’re trying to do is what orthotics and prosthetics did, as far as separating from the DME benefit.”
Currently, CMS is operating a prior authorization demonstration project for power wheelchairs and scooters in seven states: California, Illinois, Michigan, New York, North Caroline, Florida and Texas. CMS has been positioning this project as an anti-fraud effort, but if anything if could be doing exactly what providers want. For years, providers have been trying to get specific documentation requirements and instructions for power mobility claims that they can ensure documentation snags won’t hold up the approval and funding for power mobility claims.
So, CMS implemented a prior authorization plan, that, once the industry got involved with, started becoming something that providers could actually happy about, assuming they have some level of control in steering its direction. The key is leveraging the demonstration project, which started Sept. 1, 2012 and runs for three years, to work to the industry’s benefit.
The demonstration project impacts the following categories in the seven states:
- All Power operated vehicles (K0800-K0805 and K0809-K0812).
- All standard power wheelchairs (K0813 thru K0829).
- All Group 2 complex rehabilitative power wheelchairs (K0835 thru K0843).
- All Group 3 complex rehabilitative power wheelchairs without power options (K0848 thru K0855).
- All pediatric and Group 4 power wheelchairs (K0887 thru K0891).
- Miscellaneous power wheelchairs (K0898).
- Group 3 complex rehabilitative power wheelchairs with power options (K0856 thru K0864) are excluded.
If a system can be worked out that is error free and truly gains prior authorization, this might be something for mobility providers to crow about. So far, the results of the project have been generally positive, but there have been hitches. For instance, CMS has acknowledged that there have been claims that were denied even though affirmed under prior authorization that were later denied.
“It seems to be doing pretty good, generally,” says Peggy Walker, RN, Billing and Reimbursement Advisor for the U.S. Rehab division of VGM Group Inc. Corp. “In all four jurisdictions, there’s about 50 percent non-affirmed rate for claims. But the non-affirmed claims are becoming easier to turn around because what we’re seeing is that because the non-affirmed status goes back to the provider and the physicians, the physician can write an addendum, send it in, and it overturns.
“And they’re getting that in less than 30 days,” she adds. “Some of them turn it around in 10 to 12 days, and some people have gotten it in eight days.”
There are slight differences between the four jurisdictions, and of course the fallout from Hurricane Sandy has impacted Jurisdiction A, but generally claims are making it through with a 50-50 chance of getting affirmed on the first pass.
Ultimately, the problems that are happening are somewhat procedural and definitely preventable, which means that the demo is off to a positive start, Walker says, adding, “Honestly, I am enthused.” Many of the denials, as mentioned, are simple issues, such as providers in Jurisdiction C were getting non-affirmed claims for either billing for claims before Sept. 1 (the start of the demonstration project), or for claims that were outside the seven states, Walker says.
“The other big non-affirmations that the providers could control were that they simply did not have their detailed product description right, or one part of the seven-element order was missing, or they did not do a date stamp on the detailed product description,” she catalogs.
The upshot is that if done right, prior authorization will mean big things for providers of power mobility both large and small, and might attract some providers who would otherwise have trepidation about providing power mobility devices because of the complex documentation and possible claims hold-ups.
“This is going to be huge for providers that are not doing 500 claims a month,” she says. “Maybe they only want to do one a month. Now they have a chance. They don’t have to go buy that chair and put it out and then bill it and then take a chance of getting it denied. It’s not going to work that way.”
If the demo works then after three years the program would most likely be taken nationally, so providers that are not in the seven states should be taking notes.
“What providers not in the prior authorization demonstration should be doing is, no. 1, looking at the updates that each of the Jurisdictions are putting out,” Walker says, “and looking at what the non-affirms were, and what happened, and why they were non-affirmed. They’re also putting out quarterly denial updates on the K0823s that they have on pre-pay, because they’re staying on pre-pay in the other states.”
And if the demonstration project does work out and is taken nationally, this will have other benefits, such as further insulation from the ever-looming threat of post-payment claims audits.
“If you think about it, instead of a ‘pay and chase’ mentality for the government, the provider would be assured of having all the medical records and medical necessity substantiation up front,” Invacare’s Bachenheimer says. “So, three, five, six years later, when you get an audit, it’s a non-issue because that medical necessity will have already been met. It could be a better world, and to get there we need to take baby steps.”
Hopefully, for mobility providers, those baby steps will become confident strides as the project proceeds.
Early Warning, Hidden Opportunity
In any case, the change of the year will be pivotal to mobility providers, because they, like the rest of the industry, will be facing a much larger problem, that really the entire country is facing: the fiscal cliff.
“Everybody is assuming there will be a massive deficit reduction package passed into law in ,” Bachenheimer says. “The problem for that is that [lawmakers] are always looking at the Medicare program. People are talking about out-of-the-box things they would never have talked about before, such as changing the eligibility age or changing the co-payment requirement; things that would actually affect patients directly.
“But in terms of providers payments and provider payment cuts, those things are on the table,” she warns. “Next year is going to be a big year with Congress looking at ‘how are we going to get this deficit under control?’ And when that happens, Medicare is always no. 1 on the chopping block there. So we have to be very vigilant.”
While the industry considers that “global” threat there are also some hidden opportunities. A key one for mobility providers is a little-known element in the healthcare reform bill: Going back to 2009 there are a large number of home- and community-based programs and demonstrations that the government is rolling out that, overall, focus on getting patients out of nursing homes since doing so saves a considerable amount of government funding, Bachenheimer explains.
Now much of this is Medicaid-based, and states such as California are lining up to get such programs approved so that they can give nursing home residents care in the home setting.
“The whole objective is to save money while providing at least the same level of care,” she explains. “So I think we’re sort of beyond that discussion of ‘homecare is not just patient preferred but infinitely more cost effective than institutional care.’ The question is how do you get there? And that’s what the states are going to be struggling with for the next several years.”
But for providers this means now is the time to beef up their Medicaid expertise and involvement in 2013 so that they can get in on the ground floor of this nascent agenda.
“There are seven to 12 states that have given indications that they will be moving forward with this,” Bachenheimer says. “I think we’re going to be seeing more of that at the state level and it should be good news for our industry overall.”
David Kopf is the Publisher and Executive Editor of HME Business and DME Pharmacy magazines. Follow him on Twitter at @postacutenews.