MiraVista: Medicare News Blog

MiraVista Seeking Associates

April 16th, 2014

 

“Do or do not.  There is no try.” – Yoda

 

MiraVista LLC, a medical billing and consulting company, is searching for candidates for full and part-time associate positions in our Statesboro, GA office.

 

Do you qualify?

 

If you just need a job, you will hate working with us.  We are perpetually trying to figure things out and get better; not just better than our competition, but better than ourselves.

 

While not a bad thing, we do not typically look for prior medical billing experience.  Quite frankly, it takes longer to break bad habits than to teach qualified people with no direct experience.  So the “better-than-$2.10 per hour plus tips” question is:  Do you qualify?

 

We require:

  • Strong communication skills.  To contribute to our staff, you have to initiate discussion and participate in debate.  You cannot do that without strong communication skills.  Twitter only counts if you are truly compelling in 140 characters or less.
  • Decent desktop computer skills.  We use Microsoft Excel…heavily.  Most other applications we use pivot on the general knowledge necessary to get around Microsoft Office products and popular browser-based web tools.  There are no wildly specialized applications that we use, but you have to know your way around a desktop computer.
  • Good research skills.  If you don’t know the answer to a question, you should be able to Google it…and get it…and then share it with us.
  • Hustle.  Period.

 

We admire the following:

  • Work experience.  4.0 grade point averages are great, but that is not how we operate.  We don’t have 3 weeks to do something perfect; we have 3 weeks to do lots of things pretty damn well.  If you have worked while putting yourself through school, mastered a craft of any kind, or even participated in meaningful extracurricular activities while paying the rent, we think that’s cool.
  • Other experience.  People who have seen and done things are awesome.  Some of the greatest innovations in our work come from ideas that are relatively boring in some other industry, culture, or environment.
  • College degree or certification.  To be clear, we are less interested in the specific degree than that it represents you push yourself to learn and you finish what you started.

 

If you are an experienced problem solver, call us.  If you are an experienced researcher that can develop and test hypotheses, call us.  If you are not afraid to push yourself to be better, call us.  Otherwise, it probably won’t work out.

 

If we have not convinced you to steer clear, we cannot wait to meet you.  Send your resume and cover letter to resume@miravistallc.com  

 

Comment Period Closing for CMS Competitive Bidding Proposal

March 25th, 2014

Andrea Stark

 

On February 26, 2014, CMS released a proposal to solicit public comment on how to apply the pricing and methodologies of the current competitive bidding programs to the remainder of the country. The proposal, located on the federal registry website, outlines the techniques being considered by CMS to adjust fee schedule payment amounts for DMEPOS items and services furnished in areas that are not included in the current competitive bidding programs. Among the considerations, CMS has explored the possible testing of a bundled payment system for certain items of DME which would completely transform the capped rental category as it is currently known.  The proposal puts a few ideas on the table and reiterates CMS’s intent to move forward with its expansion of the competitive bidding program by 2016. Providers have a unique opportunity to affect the outcome of this dialogue by submitting comments electronically via regulations.gov. As of 11:59 PM on March 24th, only 13 comments have been documented as received by CMS. It is vital that providers understand what is being proposed, contemplate the impact and provide feedback to CMS.

 

The electronic comment period for this proposal closes March 28th, 2014 at 11:59 PM ET.

 

Much to the dismay of the DME industry, the Competitive Bidding initiative is pushing forward with no signs of slowing down. To protect reimbursement as this moves forward, CMS must hear from the DME suppliers that will ultimately be impacted by these proposed changes.

 

Not sure what this proposal means for your business? 

Join the discussion as DME Consultant and Reimbursement Expert Andrea Stark dives into this proposal and discusses the major components during our March 27th webinar “CMS Sparks Conversation with DME – FTF, RAC Transition and Nationwide Competitive Bidding” at 3 PM ET. Register on  our website at http://www.miravistallc.com.

Newest FTF Development – Audits Begin for WOPD

March 7th, 2014

 

On December 3, 2013 CMS posted a clarification on the Face-to-Face rule that rattled the DME community.  The F2F rule, has effectively been divided into two major directives: 1) the requirement for a documented F2F within the six months prior to the written order, and 2) the requirement to secure a Written Order Prior to Delivery. CMS intends to enforce the Written Order Prior to Delivery for claims processed in January 2014.

 

Prior to the December announcement, enforcement of the Rule was delayed on two separate occasions.  The first was a three month delay in the enforcement from the original July 1, 2013 start date, and the second offered an unspecified delay of enforcement through an unspecified date in 2014.  However, on December 3rd, CMS came forward to indicate that only the F2F provisions were intended for delay and they never intended a delay for the WOPD requirement.  Amid several remaining unanswered questions, CMS and the MACs continue to move this portion of the directive forward.

 

As of February 18, 2014, we are beginning to see the first of what we except to be many audits as a result of this announcement.  The Jurisdiction C DME MAC posted a notice of a service-specific prepayment review of a number of HCPCS affected by the F2F rule:

 

  • E0607 – Home Blood Glucose Monitor
  • K0001 – Standard Manual Wheelchair
  • K0002 – Standard Hemi Manual Wheelchair
  • K0003 – Lightweight Manual Wheelchair
  • E0748 – Osteogenesis Stimulator
  • E2510 – Speech Generating Device
  • E2402 – Negative Pressure Wound Therapy Electrical Pump

 

This pre-payment review is an effort to verify compliance with the Face-to-Face provisions concerning the detailed written order prior to delivery (DWOPD) requirements.  Claims subjected to this audit will be developed for additional documentation including:

 

  • Written Order Prior to Delivery
  • Delivery Documentation
  • Pertinent patient records
  • Copy of the ABN if used

 

While this audit was announced by the Jurisdiction C DME MAC, we expect that the other MACs will be following suit in the days ahead.

 

Face-to-Face Clarifications Rattle DME Community

December 9th, 2013

Andrea Stark and Angela Hayden

 

A ground breaking clarification posted by the Centers for Medicaid and Medicare Services to the Face-to-Face Encounter home page on December 3rd, 2013, has sent providers reeling.  The clarification states “The delay of enforcement only applies to the face-to-face requirements in CFR §410.38(g)(3). CMS expects full compliance with the remaining portions of the regulation.” Earlier this year the final rule mandating Face-to-Face Encounters for select items of DME, affecting 166 HCPCS, indicated an effective date of July 1, 2013.  However, CMS issued a delay to October 1, 2013, and then further delayed enforcement until a date yet to be announced in 2014.  This rule not only requires that a face-to-face encounter with a physician, nurse practitioner, physician’s assistant or clinical nurse specialist take place and be documented within six months prior to the detailed written order, but an additional requirement also establishes the necessity to collect a Detailed Written Order prior to delivery (even in cases where a verbal or dispensing order had previously been sufficient).

 

CMS begun instructing contractors to educate providers on a few key expectations, notably that they are expecting DME providers to follow all of the written order prior to delivery requirements set forth in the rule (dating back to July 1, 2013).

 

We have discovered that behind the scenes, the Program Integrity Manual has already been updated in several key sections through Revision 468.  This revision cites it was: Issued: 05-31-13; was Effective 07-01-13; and has an Implementation of 07-01-13.  The Program Integrity Manual (PIM) is the instruction manual used by the auditing contractors to enforce Medicare policy.  These citations clearly state they are in effect and implemented as of July 1, 2013 which is quite troubling from a retroactive audit standpoint.  The following are brand new sections that detail CMS expectations about procurement of a written order prior to delivery for items subject to the face-to-face rule:  Section 5.2.3.2 Detailed Written Orders for Face-to-Face Encounter, 5.2.3.2.1 – Face-to-Face Encounter Conducted by the Physician, 5.2.3.2.2 – Face-to-Face Encounter Conducted by a Nurse Practitioner, and 5.2.3.2.3 – Detailed Written Order for Covered Items.

 

Another curveball popping up in education sessions from some of the DME MACs includes instructions that they expect providers to have signed medical record notes in hand before delivering equipment to comply with the rule (after the delay expires).  If CMS maintains this course, this interpretation will be particularly burdensome to physician practices that send all their documentation out for transcription prior to making the documents available.  The interpretation is also counter intuitive to several critical need products such as oxygen and other items on the list.

 

Providers and advocate agencies have been reaching out to specifically discuss the impossibility of a retroactive enforcement of these additional provisions due to the inextricable connected nature to the Face-to-Face provisions.  The industry has been told that a Med Learn Matters article is forthcoming, but we are hopeful we can come to a mutual understanding of the key issues prior to the release of formal education on these issues.  Uncertainty still remains regarding several key issues, however, as more information on this topic develops, MiraVista will continue to disseminate key updates.  Please see additional education on this topic on our blog and via our Products menu.

 

PECOS Edits Officially Coming in January – Will Your Claims Deny?

November 7th, 2013

Anglea Hayden

 

After nearly four years of operating under Phase I of the PECOS project, CMS has officially released the implementation date for Phase II edits via MLN Matters Article SE1305. Phase II was originally set to go into effect on May 1st of this year, however an eleventh hour delay published on April 29th pushed the implementation to an unspecified future date.  Medicare Contractors have now been officially instructed to deny claims that are linked to an ordering or referring physician that is not PECOS enrolled as of January 6, 2014.

 

DME providers have seen PECOS Phase I warning messages dating back to October 1, 2009, when the project was first initiated.   Providers initially received warning messages via claim status reports. Those warning messages were then migrated to the Medicare Remittances in the form of remark code N544 after the 5010 conversion, where they are currently still reported.  The N544 remark code is an indicator that future claims tied to the same non-PECOS enrolled ordering or referring physician will deny.  Once the edits take effect in January, these claims cannot be reprocessed until that physician is officially enrolled, and providers risk an unnecessary hold on reimbursement for these claims.

 

With the PECOS surrogate program now underway, providers have a better chance at getting busy physicians properly enrolled with PECOS to mitigate claim denials.  The surrogate program allows physicians to delegate the enrollment process to employees or third parties.  When working with overwhelmed referral sources, DME providers certainly understand just how valuable this tool can be.

 

While getting non-enrolled physicians to enroll in PECOS is an important part of the compliance process, most denials will be a result of non-matching records.  The PECOS Phase II edits require that the physician’s record match exactly to what is being submitted on the claim, which means that any typographical errors  in the spelling of the physician’s name, or transpositions of the NPI number within your records will cause the claim to deny.  Providers that have not already begun to scrub their files for these errors should do so immediately to ensure all records are clean prior to January 6, 2014.

 

The key to this process is to be proactive.  The majority of the denials that will result from the implementation of Phase II can be avoided by taking action now to scrub your physician records. Providers have enough uncertainty in the current market; don’t let the implementation of Phase II be another barrier between you and your Medicare reimbursement.

 

For more information on the steps to take to avoid claims denials and to better understand how the PECOS project will impact your business join us for our special webinar PECOS Revisited conducted by Reimbursement Consultant Andrea Stark on December 12, 2013 at 3pm (see details on registration here) or contact our office to schedule a consult with Andrea at 803-462-9959 ext. 246

 

CMS Releases SPAs for Round 1 Recompete

October 1st, 2013

Angela Hayden

 

The CBIC posted the newly released single payment amounts for the Round 1 Recompete on October 1st. As a part of the Competitive Bidding program CMS is required to “recompete” contracts at least once every three years. Round 1 of Competitive Bidding affects nine metropolitan areas. While it initially began with a false start, it was re-launched as the Round 1 Rebid program which officially took effect on January 1, 2011. The existing contracts under Round 1 Rebid will expire on December 31, 2013. With the announcement of payment rates for the next round of competition, CMS will take the next three months to establish contracts and educate providers before the Round 1 Recompete launches on January 1, 2014. A total of 16 products are affected by Round 1 Recompete which CMS has broken into six categories. Those products are:

  • Respiratory Equipment & Related Supplies & Accessories
    • Oxygen Equipment & Supplies
    • CPAP Equipment, Supplies & Accessories
    • Respiratory Assist Devices, Supplies & Accessories
    • Standard Nebulizers
  • Standard Mobility Equipment & Related Accessories
    • Walkers & Accessories
    • Standard Power Wheelchairs, Scooters & Accessories
    • Manual Wheelchairs & Accessories
  • General Home Equipment & Related Supplies & Accessories
    • Hospital Beds & Accessories
    • Group 1 & Group 2 Support Surfaces
    • TENS Units
    • Commode Chairs
    • Patient Lifts
    • Seat Lift Mechanisms
  • Enteral Nutrients, Equipment & Supplies
  • Negative Pressure Wound Therapy Pumps, Related Supplies & Accessories
  • External Infusion Pumps & Supplies

According to the release, single payment amounts for the Round 1 Recompete show an average reduction of 37% off of the traditional fee schedule amounts. However, specific product categories are seeing cuts as deep as 47% off of fee schedule amounts. The steepest reimbursement reduction appears to be in the general DME category for the Riverside-San Bernardino-Ontario CA Competitive Bidding Areas (CBA), where rates were cut by 56%. CMS did issue a breakdown of the number of contract offers they expect to award by CBA and product category which can be accessed here. Until the contract offers are formally accepted and fulfilled, we will not know who the contracted providers will be, the final number of awarded contracts and/or locations serving beneficiaries in these nine areas. If a provider declines a contract, CMS will extend offers to other eligible providers that did not make the initial cut.

 

MiraVista will continue to keep you posted as updates are announced. Be sure to sign up for our mailing list to catch breaking news updates!

 

Are You Prepared for the Final HIPAA “Omnibus” Rule Compliance Deadline?

September 12th, 2013

Maureen Bacon & Angela Hayden

 

Note:  This editorial is designed to give you an overview of several changes in the Final Rule which is 138 pages in its final form.  Information in this article should not be construed as legal advice.  For specific questions about how to interpret or implement official requirements within your organization, please consult the source document or contact a knowledgeable healthcare attorney.  For a more in-depth editorial on this ruling, see our most recent edition of VistaNotes available for purchase on our products page at: http://www.miravistallc.com/products.php.

 

The term “HIPAA Compliance” is very commonplace in our industry.  HIPAA, is the acronym for the Health Insurance Portability and Accountability Act of 1996.  This rule included provisions that require the Department of Health and Human Services (HHS) to improve the efficiency and effectiveness of the health care system and to set national standards for the security and privacy of individually identifiable Protected Health Information (PHI). On January 25, 2013 HHS issued a new Final Rule that modifies previous rules1.  The Final Rule wraps all of the previous rules into one, and provides reference to all the parts of the original rules that providers must continue to follow.  The final rule, appropriately deemed the Final “Omnibus” Rule, became effective on March 26, 2013 and established a compliance period of 180 days, making September 23, 2013, the ultimate deadline for compliance.

 

If this is the first time you are hearing about this new “Omnibus” Rule, you are not alone. The Competitive Bidding and National Mail Order initiatives have taken center stage in our industry, and this updated ruling has flown largely under the radar.  In the Final Rule, any entity that is involved in the transmission of any PHI in electronic form is considered to be either a (1) Covered Entity (CE), (2) business associate (BA) of a covered entity, or (3) subcontractor of a business associate (SubBA). This classification system breaks down the relationship of businesses involved in the transmission of PHI and how PHI should be handled between entities.  Companies that create, receive, maintain or transmit protected health information on behalf of a covered entity are now considered business associates under the new federal regulations and are now subject to business associate agreements regardless of their status as a CE, BA or SubBA. Additionally, all business associate agreements must meet the compliance regulations described within the rule.  Providers that have business associate agreements executed prior to January 25, 2013, will need to amend those agreements before September 22, 2014 in order to become compliant.  Any new business associate agreements executed on or after January 25, 2013, should be replaced with new compliant agreements on or before September 23, 2013

 

Two of the most significant changes to the rule that providers should take note of relate to the definition of what constitutes a “breach” and an update to the breach notification process.  Previously, an “incident” was considered a breach that required written notification only if the PHI disclosed was unsecured or identifiable and the risk of “harm” was great.  The new final rule mandates that providers must perform a risk assessment that now more objectively determines a breach’s risk of “compromise”. The four factors of the risk assessment are: (1) To whom the disclosure was impermissibly made, (2) Whether the PHI was actually accessed or viewed, (3) Whether or not the recipient could identify the subjects of the data, and (4) Whether the recipient took appropriate mitigating action.  As a result, we will likely see many more instances of breach that require written notifications.  

 

Providers are also faced with changes regarding the Marketing, Fundraising and Sale of PHI.  Through this final rule, new limits have been set on how information can be used and disclosed for marketing and fundraising purposes. Additionally, the final rule states that the sale of an individual’s PHI is now prohibited without their express permission. 

 

One of the more labor intensive burdens placed by the final rule requires providers to revise their internal training and procedures to reflect compliance with the modifications.   This involves updating existing HIPAA Authorizations and Forms to adhere to these new requirements.

 

Providers should note that this article only scratches the surface of the complexities within this Final “Omnibus” Rule. We encourage readers to seek additional information on the Health and Human Services website https://www.hhs.gov for the details of this rule and how it will impact their business.

 

1Security (Security and Electronic Signature Standards) Proposed Rule – published in 1998

HIPAA Privacy Rule – proposed 1999

Final Privacy Rule – released 2000

Final HIPAA Security Rule – published 2003

Genetic Information Nondiscrimination Act (GINA) – signed into law 05/21/2008

Breach Notification Final Rule – published 2009

Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as a part of the American Recovery and Reinvestment Act of 2009 – signed into law 02/17/2009

Final HITECH Rule – became effective 11/30/2009

Using Competitive Bidding Modifiers

July 26th, 2013

Angela Hayden

 

Competitive Bidding Round 2 is now in full swing and many providers are struggling with the transition. A question that has cropped up repeatedly relates to the use of competitive bidding modifiers. As providers juggle two fee schedules (the traditional fee schedule and Round 2 Single Payment Amounts), understanding when to use the appropriate modifier for claim submission can be a challenge. Below we have pulled an excerpt from our most recent issue of our signature publication Vista Notes that provides a brief overview of the most commonly used competitive bidding modifiers. For comprehensive updates, we recommend that you consider a one-time or annual subscription.

 

“The KG modifier is used to distinguish between HCPCS codes that can be used with both competitively bid items and non-competitively bid items. Specifically if the item can be billed in multiple categories and it is SUBJECT to competitive bidding and therefore should be priced at the single payment amount (SPA), providers should append the KG modifier. The example used by Medicare is an IV Pole which can be used with both Enteral Nutrition (competitively bid) and Parenteral Nutrition (non-competitively bid). When using an IV pole (E0776) with enteral nutrition (subject to competitive bidding), providers should utilize the KG modifier to signify that it is for use with a competitively bid product. Similarly if a leg rest is used with a standard power wheelchair (subject to competitive bidding), the KG modifier should also be used.

 

The KK modifier is the anti-KG modifier. It is also used for supplies and accessories that are used across both competitively bid categories and non-competitively bid categories. Specifically if the item can be billed in multiple categories and it is NOT SUBJECT to competitive bidding and should be priced at the standard fee schedule amount, providers should affix the KK modifier. Therefore, in the above example, the E0776 billed with parenteral nutrition would be billed with the KK modifier to signify that the item is NOT SUBJECT to competitive bidding and is being used with a non-competitively bid product and therefore should be paid at the higher rate. Similarly the leg rests billed with a complex rehab chair should also be submitted with the KK modifier as complex chairs are not subject to competitive bidding.

 

The KL modifier is used with diabetic supplies to indicate that supplies are furnished via mail order. Effective July 1st mail order is redefined to include “all diabetic supply codes delivered to the beneficiary via any means.” Essentially, any diabetic supply that is not picked up in person at a retail location will be considered mail order. Under National Mail Order, only contracted suppliers will be eligible for reimbursement for mail order supplies. These suppliers must use the KL modifier to denote that supplies were delivered to the beneficiary unless the customer walks in to pick up the supply. (Note: Effective July 1, 2013 due to provisions in the American Taxpayer Relief Act, all diabetic supplies are reimbursed at the same rates/allowables regardless of delivery method. Therefore this modifier does not affect reimbursement rates, but is used to enforce mail order contracts.)

 

The KV modifier is used by physicians and treating practitioners that are not contracted providers, but will furnish exempt walkers and walker accessories to beneficiaries residing in a Competitive Bid Area (CBA). The KV modifier can only be used with the following list of HCPCS in order to be reimbursed: A4536, A4637, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0154, E0155, E0156, E0157, E0158 and E0159. Again this is used only for physician and treating practitioners providing this equipment to their own patients. They must have a DME supplier number and bill the walker with the corresponding office visit on the same day for proper processing.

 

The KT modifier is used for traveling beneficiaries. When a beneficiary resides in a CBA but travels outside of that CBA into a non-competitively bid area where they are provided a competitively bid item, that claim must have the KT modifier. Likewise if a beneficiary resides in a CBA and travels to a different CBA, they must be serviced by a contracted provider for that CBA, and the KT modifier must be affixed to competitively bid items. This modifier also applies to Skilled Nursing Facilities and Nursing Facilities that are not located in a CBA but provide competitively bid items, such as enteral nutrition, to a beneficiary that has a permanent residence in a CBA. The KT modifier essentially tells the claims processing system to bypass the expected contracted provider for the home CBA. Claims that are not submitted with the KT modifier in these cases will be denied.”

 

Competitive Bidding modifiers may in some cases cause modifier overflow, where the claim line limit of four modifiers is exceeded. In these cases, providers are advised to utilize the 99 modifier in the fourth position to indicate that the number of modifiers exceeds the limit. Additional modifiers should then be reported in the narrative or NTE section of the claim. When working with claims that exceed the four modifier limit, providers should prioritize pricing (including competitive bidding) and medical necessity modifiers (such as the KX). Informational modifiers such as LT and RT can then be reserved for the narrative or NTE section of the claim.

 

Understanding the proper usage of these and other claim components will assist providers in processing claims more efficiently, which will in turn ensure more expedient payment. For additional questions on claims processing or other reimbursement questions please contact our office to schedule an appointment with Andrea Stark for consulting at 803-462-9959 ext.246.

 

Face-to-Face Enforcement Delayed by CMS Amid Readiness Concerns

June 28th, 2013

Angela Hayden

 

(07/31/2013: Updated to correct broken link in the last paragraph and to reflect updates to MLN Matters article 8304)

 

CMS made some big announcements this week for the DME industry.  Most notable is the delay in enforcement of the Face-to-Face (FTF) regulations set forth in the Affordable Care Act. Originally set to go into effect for new orders on or after July 1st, the enforcement of these regulations is now delayed until October 1, 2013.  FTF affects a total of 166 HCPCS and requires that a physician (with an MD or DO credentials) document the face-to-face encounter with the beneficiary and sign off on evaluations performed by nurse practitioners, physician assistants or clinical nurse specialists. The evaluation of the beneficiary must have taken place within the six months prior to the detailed written order. Additional requirements handed down for those 166 codes disqualify the use of verbal orders to dispense equipment and instead subject these HCPCS to the detailed written order prior to delivery (WOPD) requirements. 

 

Official education on these requirements has been scarce until recently when CMS issued MLN Matters article 8304 which speaks directly to the necessity of documenting the FTF encounter, but did not speak to the requirement of the WOPD in its original release (it was later updated to clarify those requirements).  CMS cites the concern that some providers are unprepared for implementation and will need additional time to implement the proper protocols for compliance. However, in our opinion, lack of sufficient education on the entirety of the rule for suppliers and physician referral sources is the most compelling reason for the delay.   

 

It is important for providers to understand that the program itself is not delayed; Face-to-Face regulations will still exist starting July 1st. It is the enforcement of those regulations that is to be delayed until October 1st.  For providers, this means that auditing contractors will not deny claims for compliance with FTF requirements when identifying overpayments for new orders prior to October 1st, 2013.  Providers that are already in compliance with the FTF rule should continue that protocol. Those who have not yet established procedures should work diligently to become compliant by the deadline of October 1st. CMS will expect full compliance of all providers by the October 1st deadline.  

 

CMS has indicated that it will continue to update information concerning the face-to-face rule via their website at www.cms.gov/medical-review MiraVista will keep you informed as updates are released.  More detailed coverage of the Face-to-Face ruling can be found in our signature VistaNotes publication or in select digital recordings (specifically “New Face-to-Face Requirements Get Finalized for DME: Are you Ready for Implementation” recorded on 02/07/2013)  that can be found on our products page.

 

Licensing Challenges, Lawsuits and Prospects for Delay as Bidding Implementation Approaches

June 20th, 2013

Andrea Stark

 

MiraVista continues to monitor the situation with contracted providers under Round 2 of competitive bidding.  We have been able to confirm, based on a letter from Marilyn Tavenner to Congressman David Roe from Tennessee, that approximately 30 Tennessee contracts were voided out of 98 awards.  CMS indicates they do not intend on immediately awarding replacement contracts (relying on in-state suppliers and grandfathered suppliers), but will “closely monitor the situation in the state”.

 

With voided contracts in Tennessee, these providers will not jeopardize the entirety of their CBIC contracts by not having everything in place on the start date of July 1, 2013. While disruptive, MiraVista maintains this is a welcome reprieve.  Most of these providers relied on the licensure database housed on the National Supplier Clearinghouse website when submitting their bids back in January 2012.  The database did not accurately reflect all of the states licensure requirements (specifically for Tennessee).   Most of the providers who received voided contracts were unaware of the additional licensing requirements that also mandate a brick-and-mortar location approved by the state to dispense any medical equipment in that state. These providers were notified by the CBIC on or about April 15, 2013 that contracts had been awarded based on the same, incomplete licensure information contained in the database (and not according to actual state licensure requirements in place at the time of bid submission, as was required by law).  The April letter directed the suppliers to submit a complete 855-S form to enroll a new TN location for their organization.  Submission of the application requires prior licensure approval, accreditation, and surety bonds for the new location. The Medicare application process to enroll a new location takes at a minimum 45-60 days.  All combined, it was an insurmountable feat to get all of this finalized with approximately 75 days’ notice start-to-finish.  Having these “problematic” contracts voided, takes the pressure off the risk of non-compliance and subsequent breach and loss of all other contracts in unaffected states.

 

We know other states have cited that the CBIC has awarded contracts to providers that do not meet licensure requirements in their state.  What remains to be seen is how CMS will address these other concerns.  MiraVista maintains that this is an increasingly complex issue CMS must contend with.

 

We believe other contracts will eventually be voided if the licensure requirements were in effect at the time of bid submission where licensure had not been procured by the supplier by the original, May 1, 2012 extension date. This precedent is now established with the Tennessee nullifications.  Yet we do not know how CMS will handle changing licensure requirements where rules change mid-stream.  Will they offer grace periods to allow contracted providers to come into compliance? We have learned that Mississippi now has a regulation similar to Tennessee in that a physical location is required to procure licensure, but the requirement was changed AFTER bid submission closed.

 

AAHomecare announced yesterday, June 19th that it has filed a lawsuit against the Health and Human Services in conjunction with a Maryland provider.  The lawsuit seeks to stop the program citing the licensing irregularities in other states to include: Colorado, Ohio, Maryland, North Carolina, Tennessee, Virginia and Washington.  We will continue to monitor the progress of this initiative.

 

We are most hopeful for the prospects of new legislation introduced just last week on June 14th, HR 2375 The Transparency & Accountability In Medicare Bidding Act of 2013.  The bill will mandate a minimum delay of six months for all bidding programs to include Round 2, National Mail Order and Round 1 Recompete.  Round 1 could not proceed until six months after Round 2 resumes.  It would obligate CMS to meet with three auction experts, an economist and an econometrician (collectively an “auction expert team”) for the purpose of an independent review and assessment of the program. The goal will be to address the design, development, adequacy of support for beneficiaries, market fairness, sustainability and functioning of the program.  It disqualifies any current or former CMS employee, contractor or individuals that were involved in the original creation or design of the program from being selected for the auction expert team. CMS will have to cooperate fully and disclose all confidential information related to the program to the auction expert team.  A report to include recommendations for changes must then be submitted to Congress within four months of engaging the auction expert team.

 

The bill gives us a real opportunity to elicit fundamental change which is desperately needed.  A Dear Colleague letter contained the foundation for the bill’s text.  The letter was signed by 226 Representatives and delivered to CMS on June 13th.  The letter relies on CMS to make the call to delay, but to date, CMS shows no sign that they will consider a delay.  However, if we convert the co-signers on the letter to co-sponsors of the bill, we have a strong chance of getting passage in the house and can begin work in the Senate.  Passage of the bill will mandate CMS to suspend the program.  This could move quickly, but will not be complete in the two weeks before the program start date of July 1, 2013.

 

We cannot accept minor band-aid fixes that do nothing to address the unintended consequences of conducting a flawed auction program.  The current program has forced unnatural market trends.    This has produced so many shifts in geographical presence, product offerings, state licensing complexities, and unsustainable rates all in the interest of “survival” and not “true competition”.  Auctions like the Market Pricing Program can work for DME as set forth in HR1717, but competitive bidding in its current form will fall far short.

 

 


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