CRT Alert: CMS Change to Competitive Bid Accessories Reimbursement Violates Exemption

Posted on in HME Government Issues

Competitive Bid (CB) accessories used on a non-bid base (complex rehab) were to be reimbursed at the fee schedule and NOT the single payment amount (SPA). Unfortunately, due to an internal Medicare processing system error, those accessories were in most cases not paid correctly until Jan. 5, 2015, when a system fix was implemented. Effective Jan. 5, 2015, CB accessories used on non-bid bases should be paying at the fee schedule and providers were asked to submit a reopening to have those claims that paid at the SPA (which is less than the fee schedule) adjusted. In the End Stage Renal Disease Prospective Payment System, Quality Incentive Program and Durable Medical Equipment, Prosthetics, Orthotics and Supplies final rule released by CMS on Oct 31, 2014, Medicare plans to calculate a weighted SPA and use that amount for all CB accessories regardless of the type of base it is used on (group 2 K0823, group 3 K0861). This "clarification" of the Final Rule is in violation of Congressional legislation (the Medicare Improvements for Patients and Providers Act of 2008) that exempted CR power wheelchairs and accessories from CB. It is also contrary to Medicare policies that CMS itself created after this legislation that established that accessories used on both non-bid manual and power wheelchairs be paid according to the fee schedule and not the single payment amount. Many providers and industry experts are concerned with this upcoming change as group 2 single power options and above require an ATP whereas a group 2 standard does not. And even though many accessories have the same HCPCS code, they vary substantially in design, materials and overall costs, therefore, reimbursing the same amount for an accessory used on a bid base compared to a non-bid base (complex rehab) is not practical. It is possible that one of the driving factors behind CMS' decision to not have two different reimbursement rates for the same accessory has more to do with maintaining the logic in the processing system to properly adjudicate these claims. CMS has stated in the final rule that, "It would be unnecessarily burdensome to have different fee schedule amounts for the same item, when it is used with similar but different type of base equipment." Burdensome to whom? The DME MAC contractors or the provider losing money on the accessory or the patient that will no longer be able to obtain the accessory on their complex (NON BID) rehab base because the costs incurred to provide the item exceed the reimbursement rate (SPA)? As an industry, we are first reaching out to CMS to ask them to change this but if this doesn't work that the next step is working with Congress for a legislative change. NCART is preparing a letter that will be sent to representatives outlining these issues. Greg Packer, president of U.S. Rehab, is on the subcommittee that developed the response to CMS for the industry. Our team at VGM and U.S. Rehab is working to keep this issue as it currently is. If pushed, we will be going to Congress to stop this madness. If it comes to that, we hope we will have your support. Greg Packer and I are here to make a stand for complex rehab along with NCART and CRMC. We cannot take additional cuts and be able to maintain access for our patient population. Dan Fedor The VGM Group and U.S. Rehab Employee Owned P: 844-794-8459 F: 844-307-5729