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Headline News
Final Power Mobility Rule Published; Providers Still Waiting for Documentation Clarification
BALTIMORE--While stakeholders applauded CMS for remedying one major point of contention in the final rule on power mobility, the industry is still awaiting further clarification on exactly what documentation is required for reimbursement of power mobility claims.

In the final power mobility rule, published in Wednesday's Federal Register, CMS said physicians and treating practitioners will have 45 days, rather than 30 days, after the date of a face-to-face patient examination to supply medical records to HME providers. Providers also must receive a prescription for the equipment within 45 days of the exam or 45 days after the patient has been discharged from the hospital. The final rule takes effect June 5.

Even though many in the industry were pushing for a 60-day timeframe, "45 days is certainly an improvement over 30 days, and something that we welcome. I really think that's going to take care of most of the claims that were an issue," said Seth Johnson, director of government affairs for Exeter, Pa.-based Pride Mobility.

Following the release of the interim final rule in August (see HomeCare Monday, Aug. 29, 2005), many stakeholders argued that 30 days was not enough time to obtain all of the necessary documentation, especially if the patient has a complex condition and requires an additional evaluation for fitting.

Other major elements of the interim final rule--which eliminated the power mobility certificate of medical necessity and replaced it with a doctor's prescription, face-to-face exam and patient records documenting medical necessity--remain intact. But providers hoping for further instructions on exactly what documentation should be included with reimbursement claims came up empty-handed. In a fact sheet issued last week (see HomeCare Monday, April 3), CMS stated that prescribing physicians should include documentation of the beneficiary's need for the device in the home, including the face-to-face exam, information such as the history, physical examination, diagnostic tests, summary of findings, diagnoses and treatment plans.

But the Washington, D.C.-based Power Mobility Coalition said it was disappointed that CMS did not include objective criteria or a clear documentation requirement.

"By eliminating any objectivity in the PMD claims process, CMS contractors now have the discretionary authority to deny any and all claims," said PMC Director Eric Sokol. "Our goal is to achieve some balance and work toward a system that has some objective criteria in which lawful suppliers can comply and have a reasonable expectation of reimbursement."

The PMC said it is also concerned that many physicians and health practitioners still are unaware of the rule changes. "Despite its intent, this rule will ultimately place suppliers, not physicians, in the role of determining what documentation supports the claim and if the physician's prescription is valid," said PMC Counsel Stephen Azia. "This would be like allowing your pharmacist to determine whether you really need a prescribed medication."

CMS stated in the final rule that it "cannot develop an all-inclusive list of documents or information that Medicare contractors may request during audits." The agency added that "there is no type of document that, taken alone without regard to substantive content, will guarantee that the beneficiary's clinical condition meets the conditions for payment. It would be misleading to suggest otherwise."

Cara Bachenheimer, vice president, government relations, for Elyria, Ohio-based Invacare Corp., said she was not expecting clarification in the final rule because the agency had indicated earlier that the document was not the appropriate place for that information. But, she said she remains hopeful that further details will be published soon. "[The release of the final rule] opens the door to CMS putting out documentation clarification," she said. "Our No. 1 objective is clarity, and we're hoping that's what CMS and the DMERCs will provide."

CMS said it received approximately 65 comments on the interim final rule, adding that "the industry response has been very positive. As a result of the educational outreach to physicians and treating practitioners, suppliers have noted a significant improvement in the timeliness, completeness and substantive content of medical record documentation submitted in support of PMD prescriptions."

This statement, which was published in the final rule, puzzled Bachenheimer. "It's 100 percent contrary to the comments we hear every single day from our customers," she said. "I am wondering who they were talking to."

To view the final power mobility rule, click here.

AHRQ: Too Many Patients with Chronic Illness Enter ER
ROCKVILLE, Md.--A large portion of emergency room admissions include patients with chronic conditions that should have been managed outside of the hospital, according to a new statistical brief from the Agency for Healthcare Research and Quality.

According to the report, 72 percent of hospital admission cases with congestive heart failure, chronic obstructive lung disease and asthma were admitted through the ER. AHRQ said these were "chronic conditions that should be controlled on an outpatient basis with good primary care."

The report said "there is also concern that emergency departments care for patients with chronic conditions who may not be receiving adequate outpatient follow-up to control their conditions."

In 2003, more than 16 million patients entered the hospital through ERs, about 55 percent of hospital stays excluding pregnancy and childbirth. The average hospital stay for a patient admitted through the ER cost $7,400, according to the AHRQ, with Medicare and Medicaid covering 66 percent of all admissions.

Circulatory disorders were the most frequent reason for admission to the hospital through emergency rooms, accounting for 26.3 percent of ER admissions. Respiratory and digestive disorders were the next most common at 15.1 and 14.1 percent, and injuries made up 11.4 percent of admissions through the ER.

The report was issued as health care professionals voice concern about the overuse and inappropriate use of emergency rooms. Home care advocates have recently predicted that emergency room visits by home-based oxygen patients will increase because of a provision in the Deficit Reduction Act that caps oxygen rental at 36 months and transfers equipment ownership to the beneficiary (see HomeCare Monday, Feb. 27).

To view the AHRQ report, click here.

U.S. Sees $15 to 24 Billion in Medicaid Fraud and Abuse Each Year
WASHINGTON--Some 5 to 8 percent of state and federal Medicaid funding is generally believed to be lost to fraud and abuse, a CMS official said.

That range--which was quoted to senators at a March 28 Homeland Security and Governmental Affairs subcommittee hearing--translates to $15 billion to $24 billion each year from the $300 billion program, according to a BNA report.

CMS Center for Medicaid Services Director Dennis Smith said fraud "comes in a variety of shapes and sizes," with the greatest area of concern involving health care providers who have an incentive to overbill Medicaid.

The Subcommittee on Federal Financial Management, Government Information and International Security examined recent attempts to fight Medicaid fraud--including provisions in the recently passed Deficit Reduction Act, such as improved enrollment documentation requirements, incentives for states to enact false claim acts and additional funding for the OIG to control fraud and abuse.

Smith said the DRA also mandates the creation of a new Medicaid Integrity Program, requiring CMS to develop a comprehensive plan to audit, identify and recover overpayments as well as provide education.

Aggressive prosecution is a necessary component of any fraud control program, according to Subcommittee Chairman Sen. Tom Coburn, R-Okla.--he said more physicians and providers need to go to jail as an example of what happens when people steal from Medicaid, BNA reported.

"I'm hot after this [fraud] because this is where the money is," Coburn said. "We've got to get better."

According to HHS Inspector General Daniel Levinson, the federal share of each state's Medicaid costs is anticipated to total more than $192 billion this year.

For more information on the subcommittee hearing, click here.

Newsmakers
Apria Healthcare, Lake Forest, Calif., has appointed Terry P. Bayer to the company's board of directors. Bayer is COO of Molina Healthcare. Previous positions include president of AccentCare West, president and CEO of Praxis (Sechrist) Clinical Services and executive vice president of Matria Healthcare.

William Hewlett has been named vice president of pharmacy services for Southfield, Mich.-based Arcadia Resources. Hewlett previously served as national director of pharmacy products for Orlando, Fla.-based Rotech Healthcare.

Little Rock, Ark.-based breast form maker ContourMed has named Mike Thurman as vice president of manufacturing. Thurman has more than 18 years of experience in the manufacturing field, working for companies such as Mercury and Yamaha.

Dave Campbell has been named vice president of sales for Columbus, Ind.-based Cosco Home & Office Products, including the company's Adepta line of home medical equipment. Campbell was previously vice president of retail sales for Springs Window Fashions, Middletown, Wis.

Diabco-HIPAA Billing Systems, which offers HME billing and management software, has hired Duane Ridenour as its national sales manager. Ridenour will be responsible for nationwide sales activities, including support and product innovation.

Heather Fesko, a senior associate in Epstein Becker & Green's health care and life sciences practice, has been promoted to a member of the law firm in its Chicago office. The law firm represents health care organizations in litigation, transactional, regulatory and compliance issues.

Marietta, Ga.-based Matria Healthcare has named Jeffrey Hinton as CFO. Hinton replaces Stephen Mengert, who resigned to become CFO at Franklin, Tenn.-based MedSolutions.

Stoughton, Mass.-based Medical Specialties Distributors has appointed Peter J. Huie to the position of vice president, operations, and Jay Monaghan to senior marketing manager. Huie was previously vice president of operations at RedcatsUSA, an e-commerce distributor of apparel and home products. Monaghan has more than 30 years of health care experience, holding senior management positions at Medline Industries, Wexford Labs, First Source Medical and Crown Health Management.

David Little has been hired as the new director of national accounts for Tampa, Fla.-based Orthotic Rehabilitation Products. Little was previously director of sales/marketing for Bledsoe Brace Systems.

Secaucus, N.J.-based Panasonic Consumer Electronics Company has named Deborah Anderson as national marketing manager, health care products.

San Dimas, Calif.-based PaperPak has appointed Michael Fagan as CEO, Terry Jordan as senior vice president of sales and Rick Finlayson as vice president of marketing for the company, which markets disposable incontinence products.

William Boone, Pride Mobility Products team leader for Kentucky, Tennessee and Mississippi, has been elected to a two-year term as the Kentucky Medical Equipment Supplier Association (KMESA) trustee manufacturer representative. In this position, William will meet with providers statewide about industry issues and work with state government officials on DME affairs.

John Miclot, president and CEO of Murrysville, Pa.-based Respironics, has received the 2005 Manufacturer of the Year Award given by the Pittsburgh Business Times. The award recognizes excellence in 11 categories including product innovations, sales and marketing strategies, customer relations, and economic and global impact.

Belleville, Ill.-based The Roho Group has promoted Chris Ritter to national sales manager, support surface division. Ritter was formerly the company's southeast regional manager. The company also named Gregg Garland senior vice president, full support surface sales. Garland was formerly vice president of wound care sales.

Vernon Pertelle, former corporate director of respiratory and HME services at Apria Healthcare, Lake Forest, Calif., has been appointed to the board of directors of SeQual Technologies, San Diego. Pertelle left Apria in January to join Tri-City Hospital District in north San Diego County as vice president of outpatient services. Alex "Pete" Hart, former CEO of Advanta and former president and CEO of MasterCard International, has also joined SeQual's board. Jeffery T. Kerven has been named regional sales manager for SeQual's western region.

Cathrine Säf Sternberg has been named sales manager for lower extremity products at North Branch, Minn.-based Swede-O. She has previously held positions in medical sales, including product management with Johnson & Johnson.

Irvine, Calif.-based VQ OrthoCare has promoted Leslie Sorrells to director of reimbursement. Sorrells has held a number of management and directorial positions since joining the company in 1999.

Toni Ann Esposito has joined Northampton, Pa.-based Webb Medical Systems as corporate director of sales. Esposito previously worked with Young Medical for 21 years and most recently with Rotech Healthcare, Orlando, Fla.

Coming Up
CMS will hold a DME, Home Health and Hospice Open Door Forum Wednesday at 2 p.m. To participate, call (800) 837-1935 and reference conference ID 5245410.

VGM will hold Sales Training University April 17-18 in Phoenix. For more information, call (866) 227-8171 or visit www.vgmeducation.com.

The Pacific Association for Medical Equipment Services (PAMES) will hold its annual convention in Seattle April 18-19. For more information, call (503) 253-9691 or visit www.pames.org.

The American Association for Homecare will hold a teleconference on "Finding the Role for DME in Home Telehealth" April 19 from noon to 1:30 p.m. EST. The deadline for registration is April 17. For more information, click here or call (703) 535-1887.

The Illinois Association for Medical Equipment Suppliers (IAMES) will hold its annual conference and exhibition April 20-21 in Liles, Ill. For more information, call (630) 369-7782 or visit www.iames.org.

The Midwest Association for Medical Equipment Services (MAMES) will hold its annual spring convention and exhibition April 20-21 in Omaha, Neb. For more information, call (651) 351-5395 or visit www.mames.com.

The 18th Annual National Managed Health Care Congress (NMHCC) will be held April 24-26 in Washington, D.C. For more information, call (212) 661-3500 or visit www.nmhcc.com.

Essentially Women Group Purchasing Organization will hold Focus on the Future, its annual conference and trade show, April 24-26 in North Charleston, S.C. For more information, call (800) 988-4484 or visit www.essentiallywomen.com.

CMS will hold a HCPCS meeting for DME and accessories April 25 from 9 a.m. to 5 p.m. in Baltimore. A HCPCS meeting on orthotics and prosthetics will be held April 26 from 9 a.m. to 5 p.m. and April 27 from 9 a.m. to 5 p.m. A HCPCS meeting on supplies and other will be held May 4 from 9 a.m. to 5 p.m. and May 5 from 9 a.m. to 5 p.m. For more information, visit www.cms.hhs.gov/medhcpcsgeninfo.

The New York Medical Equipment Providers Association (NYMEP) will hold its annual meeting and exhibition April 25-26 in White Plains, N.Y. For more information, call (518) 436-9637 or visit www.nymep.org.

The American Occupational Therapy Association (AOTA) will hold its annual conference and exposition April 27-30 in Charlotte, N.C. For more information, call (800) 729-2682 or visit www.aota.org.