AAHomecare Triple Play

CMS's Competitive Bidding and Audits Change Up

In this new department of HME Business, we interview The American Association for Homecare's experts to get their insights on important legislative, policy, regulatory and industry advocacy developments.

Competitive Bidding and AuditsVarious developments have recently cropped up that could influence the industry’s strategy for stopping competitive bidding, including: the proposal in the Senate doc fix to expand competitive bidding rates to Medicaid; the President following up with a similar proposal in his 2015 budget; and CMS’s call for comments on nationwide expansion per the Affordable Care Act.

Q: Given these recent developments, how should HME professionals view the state of competitive bidding and the MPP?

Kim Brummett, vice president of regulatory affairs — I think HME professionals need to be concerned with the recently released ANPRM asking for input on how to use CB pricing in non-CB areas. This could have a huge impact on many areas of the country. Similarly, the use of CB pricing as a basis for Medicaid pricing is simply bad policy. This population of patients is very different and many of the states employ very different strategies on coverage and pricing. Simply forcing this pricing does not necessarily fit into the current state systems.

Jay Witter, senior vice president of public policy — AAHomecare continues to work to build support for H.R. 1717, as well as include key components of the market pricing program (MPP) into the Medicare “doc fix” bill that is moving through the House and Senate. At the same time, we continue to fight efforts to apply competitive bidding rates to Medicaid. AAHomecare strongly opposes this effort and is telling key members of the House and Senate that this is just bad policy. Congress has rejected this proposal for the last four years and should do so again.

Tom Ryan, president and chief executive officer — The ANPRM and the President’s budget are clear indicators that the push to expand an unproven and in my opinion unsustainable program will continue to be a challenge.

We have responded with very well thought out comments noting our concerns for the expansion in the ANPRM that is a statutory requirement of the Affordable Care Act. This has been followed up with a request for a sit down meeting with key leadership in CMS. I am confident that meeting will happen.

The fight to keep the pay for in SGR with dollars from an unproven program to now be used for a completely different population with different needs is just outrageous and not well thought out.

I argue this in all of my lobbying meetings and we have been successful in keeping this at bay. The current final SGR fix did not have that in it. That did not happen without work and building consensus on the hill that it is what AAHomecare continues to do. We are in DC daily working the Hill and winning some of those arguments.

Q: What should providers be doing from an industry advocacy standpoint?

Brummett — Everyone can continue to update members of Congress on the issues related to CB and patient concerns, we cannot ever let this one go. Complacency is the biggest fear. Follow-up with members of Congress on the response to CMS on the ANPRM, the concern for what this can mean for our industry is widespread. Be vocal now! Engage Medicare beneficiaries and local media on current stories on the difficulties in receiving service under the current Medicare structure.

Witter — Homecare providers should continue to tell lawmakers about problems with competitive bidding, as well as encourage patients to voice concerns with the flawed Medicare program. The more Congress hears from about the issue, the better the chances are that changes will be made to protect Medicare beneficiaries’ access to HME. Providers should tell their Senators and Representative that the time for Congress to act is now!

Ryan — In this world of increasing audits and overly burdensome regulations exacerbated by price compression and competitive bidding, providers are the key to our grassroots. Providers need to tell their story, and help their patients and referrals tell theirs to the government.

This is our democratic right and we all need to work together and join the fight. I’m on Capitol Hill on a daily basis, and I can’t tell you how important it is that lawmakers hear directly from their constituents. When lawmakers hear directly from providers, they will mention their names in meetings, and it helps build a constructive dialogue.

This is a national fight and as the national association, we are working collaboratively with our providers across the country, but we always need more providers in the ranks. So as the slogan goes, “We need a few good men/women,” now please join up!

Another key issue is audits. In order to content with a backlog of appeals, CMS’s Office of Medicare Hearings and Appeals (OMHA) recently decided to delay assignment of administrative law judges to appeals by two years.

Q: What is the true peril of the OMHA decision to delay ALJ assignment?

Brummett — The true peril is the apparent ‘stall’. While we are making many suggestions to the Senate Finance Committee staff and CMS, this issue is today and right now nothing is happening. Providers need to continue to challenge prior levels of appeals as best they can until there is some relief.

Ryan — The peril is that this delay are putting providers in a crisis mode and costing them money that could very well be recovered at the ALJ level. I told this to Judge Nancy Griswold at the open forum. We are working on that follow up meeting as well. The delay has created awareness with recent round table discussions happening in the Senate Finance Committee that Kim and AAHomecare were invited to. We are coming to that table with viable solutions and lawmakers are listening.

Q: What kind of resolution might the industry reach with OMHA, and what kind of timetable are we looking at?

Brummett — Recommendations have been made to Senate Finance Committee such as; find in favor of providers when ALJ cannot get to the appeal in the required time frame, settle as a percentage on these claims, stop auditing until backlog is caught up, only audit what can be anticipated to be appealed all the way to ALJ, stop recoupments until all level of appeal are exhausted and stop interest accrual until all level of appeal are exhausted.

Ryan — The resolution needed with OMHA is fund them to meet the demand! The problem is not in OMHA, they do their job well with the 67 or so judges that they have. ALJ has stated that their workload has increased by 184 percent, which should require a root cause analysis and the dollars to fund.

When technical denials need to get to an ALJ because the system does not work for an earlier resolution, we need to fix what is broken before we stress the system and our legitimate providers anymore. We have solutions and Kim is the industry go-to person on that. Committees of jurisdiction with key legislators are listening. The timetable is now, really it was actually months ago.

Q: What do providers need to do to help move things in a positive direction?

Brummet — Providers can contact members of Congress and push the message that no action is not acceptable. If they are not already, providers can start keeping of their own audits using the AAH audit tracking tool.

Ryan — Providers need to be advocates. All should understand that when entitlements pay for our products and federal and state dollars are in use, it is a complicated business.

You need protections and regulatory expertise and good relationships on the Hill. You need a national association on the front lines in D.C., working the myriad of issues such as proposed rules, OIG reports, budgets and legislation that affect the industry.

Don’t sit on the sidelines while someone else is going to bat for the industry. Join the team and help shape the solutions, I need you!

This article originally appeared in the May 2014 issue of HME Business.

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