In the last year Andrea Stark, on behalf of MiraVista LLC and the AAHomecare HME RT Council, has been working to connect with the right leaders within CMS to remove restrictions on upgrades within a single HCPCS code. Stark believes it is of critical importance to restore this benefit of consumer choice in the market place. This most recent meeting included CMS leaders from multiple departments that oversee the ABN form, beneficiary protections, and claims processing; just to name a few. The meeting also included industry leaders Cara Bachenheimer of Invacare, Healthcare Attorney Asela Cuervo, and Kim Brummet of AAHomecare.
During this meeting, Stark presented tangible examples of products that have been excluded from upgrades as a result of CMS directives dating back to 2006. A variety of mastectomy bras and walkers with various discretionary features were presented to demonstrate the nuances that each product can offer within a single HCPCS. The CMS language contained in chapter 20 section 120 of the Medicare Claims Processing Manual has directed the MACs to disallow upgrades for products where the features of the upgrade do not exceed the official code descriptor. The nature of the code set to be very generic to prevent code "bloat" is counter intuitive and unnecessarily restricts these products from upgrades. The end result is that beneficiaries are having to expend more money out of pocket or are being denied choices of product, which is counter to what Congress intended when they carved out the upgrade benefit.
The message brought by Stark and her industry counterparts seemed to resonate with many of the CMS representatives in attendance at the meeting. However, additional work will be required to completely resolve remaining concerns held by select CMS representatives.
The open line of communication and CMS’s willingness to meet on this issue are essential components to moving this initiative forward. Stark will continue to fervently advocate on behalf of our industry to strike this restriction from the processing manual and restore this benefit. Stay connected with MiraVista to get additional updates on this important issue.
The message brought by Stark and her industry counterparts seemed to resonate with many of the CMS representatives in attendance at the meeting. However, additional work will be required to completely resolve remaining concerns held by select CMS representatives.
The open line of communication and CMS’s willingness to meet on this issue are essential components to moving this initiative forward. Stark will continue to fervently advocate on behalf of our industry to strike this restriction from the processing manual and restore this benefit. Stay connected with MiraVista to get additional updates on this important issue.
(From left) Kim Brummet, Cara Bachenheimer, and Andrea Stark in Baltimore MD on November 3, 2015
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