“HME in 2016 and Beyond: Predictions and Commentary Relative to

“HME in 2016 and Beyond:
Predictions and Commentary Relative
to Reimbursement, Bundled
Payments, and other Hot Topics ”
June 17-18, 2015
Holiday Inn Resort - Wrightsville Beach, NC
My Contact Information:
• Mark Higley, Vice President - Regulatory Affairs
[email protected] O: 888.224.1631 C: 319.504.9515
Let’s get started today with
“how many of us are still out there?...
Supplier
Type
Supplier Type Code Description
Code
Count of Suppliers
with Active Med ID
(11/01/2010)
Count of Suppliers
with Active Med ID
(11/01/2011)
Count of Suppliers
with Active Med ID
(11/01/2012)
Count of Suppliers
with Active Med ID
(11/01/2013)
Count of Suppliers
with Active Med ID
(11/01/2014)
54
MED SUPPLY COMPANY
9,438
9,503
8,880
8,222
7,881
A6
MEDICAL SUPPLY COMPANY WITH RESPIRATORY THERAPIST
2,109
1,972
1,941
1,876
1,793
53
MEDICAL SUPPLY COMPANY WITH ORTHOTIC-PROSTHETIC
701
698
704
679
764
51
MEDICAL SUPPLY COMPANY WITH ORTHOTIC PERSONNEL
416
403
391
361
358
52
MEDICAL SUPPLY COMPANY WITH PROSTHETIC PERSONNEL
313
287
269
248
242
B3
MEDICAL SUPPLY COMPANY WITH PEDORTHIC PERSONNEL
61
74
99
113
104
B1
OXYGEN & EQUIPMENT
66
81
96
93
93
58
MEDICAL SUPPLY COMPANY WITH REGISTERED PHARMACIST
59
70
74
87
91
13,163
13,088
12,454
11,679
11,326
TOTAL
Those are locations (NPIs)
(and NOT “Companies”!)
• So how do we find “where they are and
who they are?”
Start Here!
Click here!
This is what you’ll see!
• This file is updated weekly! Hence you can access it
“real-time” on the Internet or…
• You can download and save as an alternative.
• It is BIG! 60MB…
• I have the North Carolina state file available for
download upon request!
• There are more than 2700 North Carolina locations with
supplier numbers. BUT…many are chain pharmacy, big
box, physicians and opticians.
• YES, you can sort and filter by supplier type (via product
line) to determine “real” HMEs.
But it’s simply Excel; you can widen
columns, freeze the top frames…
This spreadsheet may be copied/edited and is easily
manipulated via the Data/Sort function.
• For example, you may wish to copy a certain state or region
and obtain a listing of all suppliers in the area by city to
determine competitor locations, alternate referral needs (e.g.
you are out of stock or are considering subcontracting for
bidding purposes), prospecting (e.g. for your Florida state
association), advocacy issues, and many other potential
reasons.
• You can also sort these locations as to which suppliers offer
certain products…for example CPAP.
• There are 80 product categories in which the NSC recognizes
and updates via the 855S format.
• Any location with a current NCB contract is identified
in the first column (by product category).
• There are 13 competitive bid product categories.
This is because Round 1 Recompete had several
revisions (new categories or combinations of
categories) from Round 2.
• Many full line suppliers offer dozens of products.
Some niche suppliers (think opticians who offer
cataract sunglasses) may only be in one or two
categories. You will be able to sort these out by a tool I
will demonstrate shortly. But let’s start first with the
NCB data…
• The first 20 columns of this database (A to W) identify
the supplier by location/contact detail and to whether
the supplier has any competitive bid contracts. It also
includes a column (X) as to whether the entity is a
participating Medicare supplier. See next slides...
EXCEL ROW
A
Competitive Bid Service Area
B
Company Name
C
DBA Name
D
Address
E
Address 2
F
City
G
State
H
Zip
I
Zip Plus 4
J
Phone
K
Oxygen Supplies and Equipment
L
Mail-Order Diabetic Supplies
M
Enteral Nutrients, Equipment and Supplies
N
CPAP Devices, Respiratory Assist Devices, and Related Supplies and Accessories
O
Hospital Beds and Related Accessories
P
Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories
Q
Walkers and Related Accessories
R
Support Surfaces (Group 2 mattresses and overlays)
S
Standard (Power & Manual) Wheelchairs, Scooters, and Related Accessories
T
External Infusion Pumps and Supplies
U
General Home Equipment and Related Supplies and Accessories
V
Respiratory Equipment and Related Supplies and Accessories
W
Standard Mobility Equipment and Related Accessories
X
Is Supplier Participating?
Example: Suppliers in Charlotte, NC;
associated CBAs and to which contracts
(YES or NO) these suppliers have:
• Beginning with Column K (this is Oxygen Supplies and Equipment)
the data option is either NO or YES.
• If NO this supplier has no competitive bid contract.
• If YES then the supplier (in this location) has a competitive bid
contract for that product category.
• Both Round 1 recompete and Round 2 product categories follow
in columns K through W.
• Again…Remember there were differences in categories between
these two rounds and hence the 13 categories.
• At column X the competitive bid data set ends and, as noted,
column X is a YES or NO as to whether the supplier is
participating.
The next series of columns include all
80 product categories included within
the 855S enrollment data.
• If the supplier location is
accredited/credentialed to bill Medicare for the
category, the indication is YES.
• If not NO.
Starting with Column Y and ending at
Column DA the products are as follows:
Automatic External Defibrillators (AEDS)
Commodes, Urinals, & Bedpans
Continuous Passive Motion (CPM) Devices
Dynamic Splints
Blood Glucose Monitors & Supplies: Non-Mail Order
Blood Glucose Monitors & Supplies: Mail Order
Blood Glucose Monitors: Mail Order
Gastric Suction Pumps
Heat & Cold Applications
Hospital Beds: Electric
Hospital Beds: Total Electric & Pediatric
Hospital Beds: Manual
Hospital Beds: Manual & Pediatric
Infrared Heating Pad Systems
Infusion Pumps & Supplies: External Infusion
Infusion Pumps: Implantable & Uninterrupted
Infusion Pumps & Supplies: Insulin Infusion
Infusion Pumps & Supplies: Implanted Infusion
Negative Pressure Wound Therapy Pumps & Supplies
Neuromuscular Electrical Stimulators (NMES)
Osteogenesis Stimulators
Pneumatic Compression Devices
Speech Generating Devices
Support Surfaces: Pressure Reducing Beds, Mattresses, Overlays, & Pads
Support Surfaces (e.g. Air Fluidized bed)
Traction Equipment
Transcutaneous Electrical Nerve Stimulators (TENS) Units
Ultraviolet Light Devices
Home Dialysis Equipment & Supplies
Hemodialysis Equipment & Supplies
Canes & Crutches
Patient Lifts
Power Operated Vehicles (Scooters)
Seat Lift Mechanisms
Walkers
Wheelchairs & Accessories: Standard Manual
Wheelchairs & Accessories: Standard Manual (e.g. Pediatrics)
Wheelchairs & Accessories: Standard Power
Wheelchairs & Accessories: Standard Power (e.g. Pediatrics and custom cushions )
Wheelchairs & Accessories: Complex Rehabilitative Manual
Wheelchair Seating/Cushions
Wheelchair Seating/Cushions (e.g. skin protecting seat cushions)
Orthoses: Custom Fabricated
Orthoses: Prefabricated
Orthoses: Off-the-Shelf
Breast Prostheses & Accessories
Cochlear Implants
Facial Prostheses
Neurostimulators
Ocular Prostheses
Ostomy Supplies
Somatic Prostheses
Tracheostomy Supplies
Urological Supplies
Voice Prosthetics
Prosthetic Lenses: Conventional Eyeglasses
Prosthetic Lenses: Conventional Contact Lenses
Prosthetic Lenses: Prosthetic Cataract Lenses
Enteral Nutrients, Equipment, & Supplies
Enteral Nutrients & Supplies for Special Metabolic Needs and Pediatrics
Parenteral Nutrients, Equipment & Supplies
Limb Prostheses
Eye Prostheses
CPAP, RADs, & Related Supplies & Accessories
CPAP and RADs Supplies (e.g. combination masks)
High Frequency Chest Wall Oscillation (HFCWO) Devices
Invasive Mechanical Ventilation
Intermittent Positive Pressure Breathing (IPPB) Devices
Intrapulmonary Percussive Ventilation Devices
Mechanical In-Exsufflation Devices
Nebulizer Equipment & Supplies
Nebulizer Equipment: Ultrasonic and Controlled Dose
Oxygen Equipment & Supplies
Respiratory Suction Pumps
Ventilators, Accessories & Supplies
Surgical Dressings
Diabetic Shoes & Inserts: Prefabricated
Diabetic Shoes & Inserts: Custom Fabricated
Now, I recognize that much data may
be difficult to comprehend (!!!)
• What you could do is select just a state or
region, and copy it into another blank
spreadsheet.
• Then, using the “Filter” function (a very simple
maneuver) select by product category or
competitive bid contract.
• As an example, I copied all of the
North Carolina suppliers from the
master spreadsheet.
• There are 2765 NPI locations!!
• Again – you can copy my file today,
or, if you want the most current
version, download it per the
previous instructions.
Now Let’s Use the Filter
Function!
Click Filter and Select a Column
(Category)
Drop down menu
Choose “Yes” Only & Click “OK”
Of 2765 North Carolina Locations,
476 offer Oxygen
Let’s add CPAP to the Filter!
The new “count” is 465
Let’s add Walkers & Standard
Wheelchairs:
And finally let’s add semi-electric
hospital beds
If you add additional products, the number
dwindles quickly. So, we could state with
some reasonable certainly, that North
Carolina has about 200 “real” DME
locations that offer a reasonable full line of
home equipment.
If you sort by company name (not by
location) the number is 106.
• If you add additional products, the number
dwindles quickly. So, we could state with
some reasonable certainly, that North Carolina
has about 200 “real” DME locations that offer
a reasonable full line of home equipment.
• If you sort by company name (not by location)
the number is 106.
• That is the “population” of real HME
companies in your state.
The Round Two Recompete:
My predictions…
Factors:
1. Respiratory Equipment and Related Supplies and
Accessories (includes oxygen, oxygen equipment, and
supplies; continuous positive airway pressure (CPAP)
devices and respiratory assist devices (RADs) and related
supplies and accessories)
2. Standard Mobility Equipment and Related Accessories
(includes walkers, standard power and manual wheelchairs,
scooters, and related accessories)
3. General Home Equipment and Related Supplies and
Accessories (includes hospital beds and related accessories,
group 1 and 2 support surfaces, commode chairs, patient
lifts, and seat lifts)
• For many Round 2 recompete bidding
companies, these product categories
combine products not typically furnished
by the supplier in the today’s marketplace.
• For example, HMEs furnishing oxygen and
oxygen equipment do not necessarily
furnish CPAP devices and RADs.
• The combining of product categories (e.g., oxygen and CPAP)
might result in a reduction in the amount of out-of-area bidders,
who, in previous rounds, bid CPAP in virtually all areas of the
country.
• Delivery of CPAP supplies have seen, arguably, an increase in
drop-shipments. Now that the bidding supplier must also offer
oxygen and oxygen equipment in the same CBAs (requiring
comparably more in-home service), I anticipate a decrease in the
number of out-of-area contracts offered (with a resulting
increase in reimbursement/single payment amounts).
• There are also about 17% less “traditional HME” supplier
locations in the marketplace. You saw the previous summary via
my FOIA report:
CMS is conducting the Round 1 2017 competition in the
same nine metropolitan statistical areas (MSAs) as the
Round 1 Recompete. Competitive bidding areas (CBAs)
in multi-state MSAs have been defined so that there are
no multi-state CBAs. As a result, 13 CBAs are in the
Round 1 2017 competition.
Summer 2015
• CMS announces bidding schedule
• CMS begins bidder education program
• Bidder registration period to obtain user ID
and passwords begins
Fall 2015
• Bidding begins
CBIC Removes Ventilators from Round 1 2017
• E0464 Noninvasive ventilation (NIV) was included as a
one item product category for the Round 1 2017
program.
• The category was to be bid in eight of the 13 CBAs
(including Charlotte, NC).
• But, on June 5, CMS removed the product category:
“For Medicare program purposes, this change is
needed in order to correctly apply national Medicare
coverage rules and statutorily mandated payment rules
for ventilators, and to prevent abuse of the program.”
CMS plans to consolidate current ventilator codes into two
codes effective December 31, 2015
• CMS will replace the current codes E0450, E0460, E0461,
E0463, and E0464 with two new codes that have yet to be
assigned, but will be effective January 1, 2016:
• Exxx1 - Home ventilator, any type, used with invasive interface
(e.g., tracheostomy tube)
• Exxx2 - Home ventilator, any type, used with non-invasive
interface (e.g., mask, chest shell)
• CMS: “Program abuse is occurring when code E0464 is
used inappropriately to bill for pressure support
ventilators that can also function as and are used as
positive airway pressure devices for treatment of OSA
rather than treatment of respiratory failure. In these
instances, the devices are paid using the wrong fee
schedule amounts and payment rules.
• Some products classified under code E0464 are
capable of being used in multiple modes, either to
ventilate patients using a noninvasive interface to treat
respiratory failure or to provide continuous positive
airway pressure using a non-invasive interface to treat
OSA.”
Bottom line…
• Pressure Support Ventilator will be paid at the
Volume Ventilator rate ( $1,019 versus $1,567)
which is about a 35% decrease in
reimbursement.
Update on CMS-1614-F
• The Affordable Care Act amended the Medicare Modernization Act
statute to mandate use of information from the DMEPOS
competitive bidding program to adjust the fee schedule amounts
for DME in areas where competitive bidding programs are not
implemented by no later than January 1, 2016.
• CMS estimates that by applying bid rates throughout the entire
United States it would save over $7 billion over FY 2016 through
2020.
• This obviously affects the many non-metro regions of North
Carolina!
“National” Pricing
• How? Adjust fee schedule amounts for states in different regions of
the country based on previous competitive bidding round pricing in
these “regions”.
• The regional prices would be limited by a national ceiling (110% of the
average of regional prices) and floor (90% of the average of regional
prices)
• There were three possible “Regions” (see next)
• Most NC attendees here today service the “Southeast” BEA region.
• CMS determines a regional price for each state equal
to the average of the single payment amount for an
item or service from the CBAs that are fully or
partially located in the same region where the state
is located.
• CMS determines a national average price equal to
the average of the regional prices.
• Adjust fee schedules annually using CPI-U
• Revise the SPA each time there is a new round
of bidding.
• BUT…to be clear, the current RSPAs have
already been determined using Round 2 (e.g.,
Raleigh) and Round 1 recompete (e.g.,
Charlotte) single payment amounts. The
recent Round 2 recompete SPAs will not affect
the 2016 roll-out of RSPAs!
• “Although we believe that the costs of furnishing items
and services in rural areas are different than the costs of
furnishing items and services in urban areas, there is no
evidence to support a statement that the difference in
costs is significant.
• However, in order to proceed cautiously on this matter in
the interest of ensuring access to covered DMEPOS items
and services, we are proposing to phase in the price
adjustments, as explained below, so that we can monitor
the impact of the adjustments as they are gradually
phased in.”
• What this means: One half the reductions take effect
January 1, 2016; the remainder on July 1, 2016.
While not released…
• We have the current SPAs in all markets from
the current programs.
• As CMS has provided us the methodology to
determine the regional payment amounts
(RSPAs), and has confirmed that the “BEA”
regional array will be utilized, we can hence
determine the RSPAs for North Carolina and the
other regions now.
Summary of Provisions
• As noted, the new adjusted pricing for DMEPOS CBP items will
begin on January 1, 2016. This will be a phase-in process over 6
months, allowables will be reduced by 50% on 1/1/16 and 100%
on 7/1/16.
• CMS finalized a pricing methodology for non-competitive bidding
areas.
• A rural area will be defined as a postal zip code that has more than
50 percent of its geographic area outside of a metropolitan area
(MSA) or a zip code that has a low population density area that
was excluded from a competitive bidding area. The payment
amount will be 110 percent of the average of the SPAs of all the
areas where CBPs are implemented.
• Let’s look at North Carolina:
• NC counties in an “orange” metropolitan area but not
included in the CBA (bid area) are paid at the RSPA.
• North Carolina is in the Southeast region.
• Using the averages of the oxygen single payment
amounts in the of all CBAs in this region, the
reimbursement would be $136.57 on January 1, 2016,
and then $94.89 on July 1, 2016.
• The yellow rural areas, however, will be reimbursed
at the adjusted fee schedule amounts based on 110
percent of the national average RSPA.
• As noted earlier, CMS has adopted an expanded
definition of rural areas eligible for this provision.
• The array of ZIP codes defined as rural will be
released sometime in late 2015.
• Thus, the RSPA in rural NC areas for E1390 is
$103.38.
• Lastly, how about a state that has NO CBAs?? CMS
dubs these states as “rural” or “frontier”
• In this case the SPA would again be 110% of the
national average.
Can we see (now) the actual RSPAs?
• Yes! AAH Regulatory Council has created a document
which includes the high utilization codes. Go to:
http://www.vgmncbservices.com/Documents/AAHomecareFinalRulePricing.pdf
Summary…
This issue is especially troubling…
(Source:)
Frequently Asked Questions on Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) 2015 Medicare Payment Final Rules
(CMS-1614-F)
Adjusting DMEPOS Payment Amounts Using Competitive Bidding
Information– 42 CFR 414.210(g)
•
2Q. When CMS uses competitive bidding information to adjust the
DMEPOS fee schedule amounts in accordance with the
methodologies established under this rule, would the bid limits for
competitions under the competitive bidding program(s) that begin
after the adjusted fee schedule amounts are implemented be based
on the adjusted fee schedule amounts?
• 2A.Yes. This issue is discussed in the November 6, 2014,
Federal Register at 79 FR 66232.
• The payment amounts that would be adjusted in
accordance with sections 1834(a)(1)(F)(ii) and (iii) of
the Act for DME, section 1834(h)(2)(H)(ii) of the Act for
orthotics, and section 1842(s)(2)(B) of the Act for
enteral nutrients, supplies, and equipment shall be
used to limit bids submitted under future competitions
and DMEPOS competitive bidding programs (CBPs) in
accordance with regulations at § 414.414(f).
• Section 1847(b)(2)(A)(iii) of the Act prohibits the awarding of contracts under a
CBP unless total payments made to contract suppliers in the competitive
bidding area (CBA) are expected to be less than the payment amounts that
would otherwise be made. In order to assure savings under a CBP, the fee
schedule amount that would otherwise be paid is used to limit the amount a
supplier may submit as their bid for furnishing the item in the CBA.
• The payment amounts that would be adjusted in accordance with sections
1834(a)(1)(F)(ii) and (iii) of the Act for DME, section 1834(h)(2)(H)(ii) of the Act
for orthotics, and section 1842(s)(2)(B) of the Act for enteral nutrients,
supplies, and equipment would be the payment amounts that would
otherwise be made if payments for the items and services were not made
through implementation of a CBP.
• Therefore, the adjusted fee schedule amounts would
become the new bid limits.
Next: “Bundling”…
• Also within CMS-1614-F, CMS is adopting – with
revisions – its proposal to test a limited phase-in of
bundled payments for certain types of DME subject
to competitive bidding, under the auspices of the
CMS Center for Medicare and Medicaid Innovation's
demonstration authority.
• This is a limited phase in (12 areas) of bundled monthly
payment amounts for the equipment, supplies,
accessories, maintenance and repairs for (then proposed)
enteral nutrition, oxygen, standard wheelchairs, hospital
beds, CPAP/RAD in place of capped rental policies.
• CMS will move forward with a bundling for power
wheelchairs and CPAP in up to 12 markets.
• CMS did not move forward with bundling for: oxygen,
standard manual wheelchairs, enteral nutrition, RADs, and
hospital beds.
• CMS will initially test this payment model in no more than
12 CBAs in conjunction with competitions that begin on or
after January 1, 2015; any expansion of the program would
follow program evaluation and future notice and comment
rulemaking.
• Under this policy, the SPA for the monthly rental of DME
will be based on bids for the monthly rental of DME and all
item and service associated with the rental equipment,
including all related supplies, accessories, maintenance,
and servicing.
• The SPA is based on bids submitted and accepted
on a monthly basis for each month of medical
need during the contract period.
• Separate payment for replacement of equipment,
repair or maintenance and servicing of
equipment, or for replacement of accessories and
supplies necessary for the effective use of the
equipment would not be allowed.
Thank you!
Mark Higley, Vice President Regulatory Affairs, VGM Group Inc.
[email protected]
(888) 224-1631 office
(319) 504-9515 cell