CMS Update MedTrade Fall Atlanta, Georgia Tuesday, October 28, 2008 3:00 PM

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CMS UpdateMedTrade FallAtlanta,
GeorgiaTuesday, October 28, 2008300 PM

• Mary Ellen Conway
• President

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Overview

• What is the Accreditation Requirement?
• New Deadlines to Know
• Update on Important Legislation
• Your Options for Accreditation
• Tips on Choosing Your Accreditor
• Issues with fees/costs

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Overview Continued

• How Do You Get Started?
• Must Haves
• Video Examples
• Main Reasons Organizations Fail
• How Long Does It Take?
• Ten Things You Can Do Now to be Ready

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Common Acronyms

• CMS Center for Medicare Medicaid Services
• DME Durable Medical Equipment
• DMEPOS Durable Medical Equipment, Prosthetics,
  Orthotics and Supplies
• ESRD End Stage Renal Disease
• HME Home Medical Equipment
• MMA 03 Medicare Modernization Act of 03

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Download the presentation

• www.medtrade.com/mt/1500/conference/
• Conference_handouts_info.jsp
• www.capitalhealthcaregroup.com/media

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What is the Accreditation Requirement?

• The Medicare Modernization Act of 2003 (MMA 03)
  states that ALL DME Providers billing Medicare
  for identified Part B products must be
  accredited--- this will be enforced initially
  through the Competitive Bidding Requirement
• There were between 117,000 and 150,000 Medicare
  Part B supplier numbers at the start in 2005
• This applied to DMEs as well as pharmacies
  billing for identified items as well as PTs,
  MDs and all others

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The BIG Announcement

• ALL providers who expect to receive reimbursement
  for identified Part B products and supplies must
  be accredited by
• September 30, 2009

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Other Recently Announced Deadlines

• New DMEPOS suppliers who applied by March 1, 2008
  -accreditation by January 1, 2009
• New DMEPOS suppliers submitting enrollment
  applications on or after March 1, 2008-
  accreditation prior to submitting the application
  (exempt if more than 25 locations)

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Newest Deadline

• If you contract for DME services to a Medicare
  Certified Hospice, you must be accredited by
  December 2, 2009
• Medicare Certified Hospices had new Conditions of
  Participations released on June 5, 2008 requiring
  that they contract only with accredited DMEs.
  These regulations so into effect on December 2,
  2008.

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Update on Legislative ActivityHR 3331 Medicare
Improvements forPatients and Providers Act of
2008
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Medicare Improvements forPatients and Providers
Act of 2008 Passed July 15, 2009

• Key Items
• Delays Competitive Bidding 18 to 24 months
• Scheduled to restart Round 1 in 2009, improves
  the bidding process and establishes quality
  measures for DME
• Repeals title transfer of oxygen concentrators
• Now stays with dealer, although at 36 months
  equipment rental is no longer paid and issues of
  maintenance and service and payment for those is
  still to be defined

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Medicare Improvements forPatients and Providers
Act of 2008

• To offset the cost savings that were to be
  accomplished in competitive bidding, all items
  that were to be included are reduced 9.5,
  starting January 1, 2009
• Oxygen Supplies and Equipment
• Standard Power Wheelchairs, Scooters and Related
  Accessories
• Complex Rehab Power Chairs and Related
  Accessories
• Enteral Nutrients, Equipment and Supplies
• CPAP, RADs and Related Supplies and Accessories
• Hospital Beds and Related Accessories
• Mail Order Diabetic Supplies
• Negative Pressure Wound Therapy Pumps and Related
  Supplies and Accessories (excluded from Round
  One)
• Walkers and Related Accessories

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Medicare Improvements forPatients and Providers
Act of 2008

• Quality measures
• Requires contracting suppliers to disclose all
  subcontracting relationships
• Now excludes physicians and other practitioners
  from DMEPOS accreditation requirements until CMS
  develops provider specific standards (clarified
  9-2-08)
• Establishes a separate ombudsman program within
  CMS to handle supplier and beneficiary issues
  related to the competitive bidding program

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Medicare Improvements forPatients and Providers
Act of 2008

• Excludes Puerto Rico from Round One re-bidding
• Allows physician and other treating providers to
  supply off the shelf orthotics without being
  awarded competitive bidding contracts and
  hospitals to provide those items without
  contracts
• Uses a broader definition of physician to cover
  podiatrist

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Medicare Improvements forPatients and Providers
Act of 2008

• Provides Medicare mental health parity
• Gradually reduces 50 co-pay to 20
• Offer new preventive benefits to Medicare
  beneficiaries
• Makes it easier to add preventive services to the
  list of Medicare-covered services
• Extends the exceptions process for therapy caps
• Allows for specific diagnosis and procedures to
  receive coverage after beneficiary has met their
  therapy cap for the year

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Medicare Improvements forPatients and Providers
Act of 2008

• Modifies the Medigap program
• Directs HHS to work with the states to establish
  new requirements for Medigap plans
• Provides better care for patients with ESRD
• Bundles all of the costs of ESRD care into a
  single payment beginning January 1, 2010
• Establishes a new benefit to allow those with
  advanced disease, but before failure, to learn
  more about options for dialysis and transplants
• Provides additional coverage under Part D
• Requires Part D to cover benzodiazepines and
  barbiturates

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Medicare Improvements forPatients and Providers
Act of 2008

• Codifies a Part D plan requirement to cover most
  drugs in certain important classes
• Requires coverage of all or substantially all
  drugs in classes for which lack of timely access
  to medication can result in serious consequences
• Blocks a scheduled 10.6 cut to physician fees
• Averts the cut and increases fees by 1.1 in 2009
• Incentivizes adoption of electronic prescribing
  by physicians
• Creates new incentives for MDs to adopt
  technology for electronic prescriptions
• Increases incentives for physician quality
  reporting
• Extends the Medicare Physician Quality Reporting
  Initiative for services delivered in 2009 and 2010

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When Do You Need to Be Ready?

• All others are required to be accredited (whether
  or not there is Competitive Bidding in your
  service area when/if it resurfaces in 2009) by
  September 30, 2009
• Other payer, state and regional requirements
  could be an issue

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Items Identified by CMS for Accreditation

• Mobility Assist Equipment
• Canes and Crutches, Patient Lifts, Walkers,
  Scooters, Wheelchairs (Standard, Power, Complex,
  Related Accessories, Seating/Cushions)
• Respiratory Equipment
• CPAP, IPPB, RADs, High Frequency Chest Wall
  Oscillation Devices, Invasive Mechanical
  Ventilation Devices, Invasive Mechanical
  Ventilation Devices, Ventilators Accessories and
  Supplies, Intrapulmonary Percussive Ventilation
  Devices, Intrapulmonary Percussive Ventilation
  Devices
• Tracheostomy Care Supplies
• Oxygen Equipment and Supplies
• Nebulizer Equipment and Supplies
• Suction Pumps

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• Durable Medical Equipment
• Automatic External Defibrillators,
  Commodes/Urinals/Bedpans,
• Continuous Passive Motion (CPM) Devices
• Contracture Treatment Devices Dynamic Splint
• Blood Glucose Monitors and Supplies (mail order
  and non-mail order),
• Gastric Suction Pumps, Heat and Cold
  Applications, Hospital Beds (all),
• Infrared Heating Pad Systems, External Infusion
  Pumps and Supplies,
• Insulin Infusion Pumps and Supplies, Implanted
  Infusion Pumps,
• Negative Pressure Wound Therapy Pumps and
  Supplies,
• Neuromuscular Electrical Stimulators,
  Osteogenesis Stimulators,
• Pneumatic Compression Devices, Speech Generating
  Devices,
• Support Surfaces/Overlays/Pads, Traction
  Equipment,
• Transcutaneous Electrical Nerve Stimulators (TENS
  Units)
• Ultraviolet Light Devices, Urologicals, Ostomy
  Supplies,
• Wound Care/Surgical Dressings

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More Items

• Enteral Nutrients, Equipment and Supplies
• Parenteral Nutrients, Equipment and Supplies
• Home Dialysis Equipment and Supplies
• Diabetic Shoes and Inserts
• Orthotics
• Custom Fabricated
• Prefabricated (non-custom fabricated)
• Off-the Shelf
• Prosthetics
• Breast Prostheses and Supplies
• Limb Prostheses
• Eye Prostheses
• Many more items under prosthetics

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Update October 2008

• Revisions were released last week.
• www.cms.hhs.gov/MedicareProviderSupEnroll
• Left side of page DMEPOS Accreditation
• Updates (found in red) are as follows

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Administrative

• 1. Obtains and supplies appropriate quality
  equipment, items and services
• 2. Have a physical location and display all
  licenses, certificates and permits
• 3. FDA approved items and obtain copies of
  features, warranties and instructions
• 4. Comply with Medicare policies (coverage,
  claims processing, payment policies and
  disclosure of ownership) Example Disbarment List
  www.oig.hhs.gov/fraud/exclusions.html
• 5. The supplier shall comply with all Medicare
  statutes, regulations (including the disclosure
  of ownership and control information requirements
  at 42 CFR 420.201 through 420.206), manuals,
  program instructions, and contractor policies and
  articles.

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Administrative, continued

• 6. Implement business practices to prevent and
  control fraud, waste and abuse by
• Using procedures that articulate standards of
  conduct that ensure compliance with applicable
  laws and regulations.
• Designate leader(s) responsible for compliance
  issues

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Financial Management

• 1. Implement financial management practices that
  ensure accurate accounting and billing.
• 2. Accurate, complete and current financial
  records
• 3. Cash or accrual based accounting
• 4. Link equipment to client
• 5. Manage revenues and expenses on an ongoing
  basis
• Reconcile charges with invoices, receipts and
  deposits
• Operating budget
• Mechanism to track actual revenues and expenses

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Human Resource Management

• Implement policies on
• Specific qualifications
• Training
• Experience
• Continuing education requirements
• Technical personnel
• Competent
• Licensed, certified or registered (and current
  copies on file)
• Implement policies and issue job descriptions
  that specify personnel qualifications, training,
  certifications/licensures where applicable,
  experience, and continuing education requirements
  consistent with the specialized equipment, items,
  and services it provides to beneficiaries
• Provide copies of such policies and job
  descriptions, upon request, to accreditation
  organizations and government officials or their
  authorized agents
• Verify and maintain copies of licenses,
  registrations, certifications and competencies
  for personnel who provide beneficiary services

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Consumer Services

• Provide clear written or pictorial, and oral
  instructions on use, maintenance infection
  control practices and potential hazards of
  item(s) as appropriate
• Provide expected time frame for receipt of
  delivered item(s)
• Verify item/service was received
• Document in the beneficiarys record the make and
  model number of any non-custom equipment and/or
  item(s) provided
• Provide contact information and options for
  rental or purchase
• Provide information and telephone numbers for
  customer assistance
• Regular business hours, after hours, repair,
  emergencies
• If the supplier cannot or will not provide the
  equipment, item(s) or service(s) that are
  prescribed for a beneficiary, the supplier shall
  notify the prescribing physician, practitioner or
  other healthcare team member promptly, within
  five calendar days.

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Consumer Services

• 3. Within 5 calendar days of receiving a
  beneficiarys complaint, the supplier shall
  notify the beneficiary, using either oral,
  telephone, e-mail, fax or letter format, that it
  has received the complaint and is investigating.
  Within 14 calendar days, the supplier shall
  provide written notification to the beneficiary
  of the results of the investigation. The supplier
  shall maintain documentation of all complaints
  received, copies of the investigations and
  responses to the beneficiaries.

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Performance Management

• Implement performance management plan that
  measures outcomes of customer service, billing
  practices and adverse events. At a minimum,
  measure
• Beneficiary satisfaction and complaints
• Timeliness of response to questions, problems and
  concerns
• Impact of business practices on adequacy of
  beneficiary access to items, services,
  information
• Frequency of billing/coding errors
• Adverse events to beneficiaries due to inadequate
  service(s) or malfunctioning equipment and/or
  item(s) (e.g injuries, accidents, signs and
  symptoms of infection, hospitalization)
• The supplier shall seek input from
  employees, customers, and referral sources when
  assessing the quality of its operations and
  services.

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Product Safety

• The supplier shall
• Implement a program that promotes the safe use of
  equipment and items and minimizes safety risks,
  infections and hazards both for its staff and for
  beneficiaries.
• Implement and maintain a plan for identifying,
  monitoring, and reporting (where indicated)
  equipment and item failure, repair, and
  preventive maintenance provided to beneficiaries.
  
• Investigate any incident, injury or infection in
  which DMEPOS may have contributed to the injury
  or incident or infection, when the supplier
  becomes aware. The investigation should be
  initiated within 24 hours after a supplier
  becomes aware of an injury, incident or infection
  resulting in a beneficiarys hospitalization or
  death. For other occurrences, the supplier shall
  investigate within 72 hours after being made
  aware of the incident, injury or infection. The
  investigation includes all necessary information,
  pertinent conclusions about what happened, and
  whether changes in systems or processes are
  needed. The supplier should consider possible
  links between the items and services furnished
  and the adverse event.
• Have a contingency plan that enables it to
  respond to emergencies and disasters or to have
  arrangements with alternative suppliers in the
  event that the supplier cannot service its own
  customers as the result of an emergency or
  disaster

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Product Safety

• Verify, authenticate, and document the following
  prior to distributing, dispensing, or delivering
  products to an end-user
• The products are not adulterated, counterfeit,
  suspected of being counterfeit, and have not been
  obtained by fraud or deceit
• The products are not misbranded and are
  appropriately labeled for their intended
  distribution channels and
• The products were obtained from a distributor or
  wholesaler approved and authorized by the
  manufacturer of the products.

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Appendix B Complex Rehab

• Employ (W-2 employee) at least one qualified
  individual as a Rehabilitation Technology
  Supplier (RTS) per location. A qualified RTS is
  an individual that has one of the following
  credentials
• Certified Rehabilitation Supplier (CRTS)
  (discontinued 12/31/08)
• Assistive Technology Supplier (ATS) (discontinued
  12/31/08)
• Assistive Technology Practitioner (ATP)
  (discontinued 12/31/08)
• Assistive Technology Professional (AT) (effective
  1/1/09)
• Completed at least 10 hours annually of
  continuing education specific to Rehabilitation
  Technology

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Not to CONFUSE anyone

• Additional Supplier Standards

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• DMEPOS suppliers are not required to disclose the
  25 supplier standards to Medicare beneficiaries
  until the full implementation date - September
  30, 2009.
• Suppliers are encouraged however, to release the
  updated list of standards as existing reserves
  are depleted. (Supplier Standard 16 requires
  DMEPOS suppliers to disclose all supplier
  standards to each beneficiary to whom it provides
  a Medicare-covered item.)

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• 22. All suppliers must be accredited by a
  CMS-approved accreditation organization in order
  to receive and retain a supplier billing number.
  The accreditation must indicate the specific
  products and services, for which the supplier is
  accredited in order for the supplier to receive
  payment of those specific products and services
  (except for certain exempt pharmaceuticals).
• 23. All suppliers must notify their
  accreditation organization when a new DMEPOS
  location is opened.

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• 24. All supplier locations, whether owned or
  subcontracted, must meet the DMEPOS quality
  standards and be separately accredited in order
  to bill Medicare.
• 25. All suppliers must disclose upon enrollment
  all products and services, including the addition
  of new product lines for which they are seeking
  accreditation

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CMS-6036-P

• This is a 2008 proposed rule to amend DMEPOS
  enrollment requirements and revise the current
  supplier standards. Comments were submitted by
  many stakeholders the comment period ended March
  25, 2008.
• CMS-6036-P also proposes to add new standards
  (26 - 31).
• A final rule is expected later this year.

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• The proposed Additional
• Supplier Standards

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• (26) Reserved
• (27) Must obtain oxygen from a State-licensed
  oxygen supplier (applicable only to those
  suppliers in States that require oxygen
  licensure.) Thus if a supplier is located in
  oxygen license state it must obtain its oxygen
  from a state licensed oxygen supplier regardless
  of which state the oxygen supplier obtained its
  licensure. CMS contends this standard would
  promote quality in the furnishing of oxygen.
  Effectively, this will prevent suppliers from
  purchasing oxygen from an outside vendor in a
  state where a license is required.

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• (28) Is required to maintain ordering and
  referring documentation, including the NPI,
  received from a physician, nurse practitioner,
  physician assistant, clinical social worker, or
  certified nurse midwife, for 7 years after the
  claim has been paid. Few comments were submitted
  on this issue.
• (29) Is prohibited from sharing a practice
  location with any other Medicare supplier. This
  would include physician or physician groups or
  other DMEPOS suppliers. CMS proposed this
  requirement because it believed that allowing
  suppliers to commingle locations, staff,
  inventory and other supplier operations
  constitutes a significant risk to the Medicare
  program.

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• In addition CMS does not believe that legitimate
  DMEPOS suppliers routinely share practice
  locations with other Medicare suppliers. However,
  CMS noted that it is aware that physicians and
  other practitioners may supply DMEPOS from their
  office. CMS solicited comments on whether an
  exception for physicians and nonphysician
  practitioners and the circumstances which
  warrant an exception should be established. We
  await the final standard.

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• (30) Is open to the public a minimum of 30 hours
  per week, except for those DMEPOS suppliers who
  are working with custom made or fitted orthotics
  and prosthetics. CMS proposed this standard
  because the NSC had found a number of suppliers
  with posted business hours that were so limited
  it is nearly impossible to conduct an onsite
  visit or for a beneficiary to obtain services..

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• In addition, CMS contended that most legitimate
  DMEPOS suppliers are open to the public at least
  30 hours per week (either six hours a day, five
  days a week or five hours a day, six days a
  week).
• "We believe that ... all legitimate DMEPOS would
  need to be open at least 30 hours a week in order
  to attract, retain and serve Medicare
  beneficiaries," according to the proposal.
• Industry commenters suggested this could be a
  significant issue for small providers who must
  handle both the office activities and deliveries.
  We would have to be in the office a significant
  amount of time, which could limit routine
  delivery times," one stated.

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• (31) Does not have an Internal Revenue Service
  (IRS) or a State taxing authority tax
  delinquency. This is defined as money owed, a
  conviction for or a charge of tax evasion, or a
  tax lien. CMS also proposed to revise the
  enrollment application to require that suppliers
  certify that it does not have delinquencies and
  consent to having CMS or a contractor verify that
  the information. Providers who do not comply with
  this standard will have billing privileges
  revoked. In its reasoning, the agency noted a
  report from the Government Accountability Office
  that found more than 21,000 providers reimbursed
  under Part B owed taxes totaling more than 1
  billion in 2005.

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Back to Accreditation!
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First Steps

• Choosing Your Accreditor

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The Recognized Accreditors

• JCAHO
• CHAP
• HQAA
• ACHC
• NABP
• The Compliance Team
• NB of A for Orthotic Suppliers
• ABC of OP
• BOC
• CARF

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Tips to Use in Choosing Your Accreditor

• CMS is not your only payer! (How about
  hospice???)
• Payer or state licensure requirements to be
  accredited ex Anthem BC, State of Florida,
  Oklahoma Medicaid
• What is the accreditors schedule and what are
  the requirements for in-between?
• ex Triennial and or annual updates
• Fees paid vs. administrative costs
• Other services (infusion, home health)
• Process (electronic vs. paper)
• Interview/discussions with accrediting
  organizationyour perceptions--- Whos downstairs
  in Accreditation Central?
• Your peers experience

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One Main Area to Concentrate

• Performance Improvement

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• Performance Management
• Beneficiary satisfaction surveys
• Patient complaint log
• After hours (on call) log to prove timeliness of
  response to questions, problems and concerns
• Log that documents frequency of billing and/or
  coding errors
• Log documenting adverse events (as defined by
  your P P manual)
• Log documenting staff and patient infections
• Many accrediting organizations require at least
  three months of surveys collected and summarized
  with plans for improvement or you will have to
  provide written follow-up and possible a re-visit

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Performance Improvement Examples are Everywhere

• Where do you see them?

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Main Reasons Organization Fail

• Lack of Preparedness
• Few Staff Aware of Process/Requirements
• Lack of Focus and Follow-through

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Is this your future if youre not accredited?
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• Stay Tuned!
• Watch for updates on a weekly basis
• AAHC Wednesday in Washington
• (www.aahomecare.org)
• Homecare Monday (www.homecaremonday.com)
• HME News (www.hmenews.com)
• The Friday Report (www.hmetoday.com)

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Your Questions ???
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Thank You!

• Mary Ellen Conway
• President
• Capital Healthcare Group, LLC
• Bethesda, MD
• 301-896-0193
• www.capitalhealthcaregroup.com