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


... of the costs of ESRD care into a single payment beginning January ... Capital Healthcare Group, LLC. Bethesda, MD. 301-896-0193. ... – PowerPoint PPT presentation

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

CMS UpdateMedTrade FallAtlanta,
GeorgiaTuesday, October 28, 2008300 PM
  • Mary Ellen Conway
  • President

  • 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

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

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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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

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

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)

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,

Update on Legislative ActivityHR 3331 Medicare
Improvements forPatients and Providers Act of
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

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
  • Complex Rehab Power Chairs and Related
  • 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
  • Walkers and Related Accessories

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
  • Establishes a separate ombudsman program within
    CMS to handle supplier and beneficiary issues
    related to the competitive bidding program

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
  • Uses a broader definition of physician to cover

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
  • 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

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

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
  • Extends the Medicare Physician Quality Reporting
    Initiative for services delivered in 2009 and 2010

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

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
  • Tracheostomy Care Supplies
  • Oxygen Equipment and Supplies
  • Nebulizer Equipment and Supplies
  • Suction Pumps

  • Durable Medical Equipment
  • Automatic External Defibrillators,
  • 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
  • Neuromuscular Electrical Stimulators,
    Osteogenesis Stimulators,
  • Pneumatic Compression Devices, Speech Generating
  • Support Surfaces/Overlays/Pads, Traction
  • Transcutaneous Electrical Nerve Stimulators (TENS
  • Ultraviolet Light Devices, Urologicals, Ostomy
  • Wound Care/Surgical Dressings

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

Update October 2008
  • Revisions were released last week.
  • Left side of page DMEPOS Accreditation
  • Updates (found in red) are as follows

  • 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
  • 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

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

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

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

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,
  • 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.

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.

Performance Management
  • Implement performance management plan that
    measures outcomes of customer service, billing
    practices and adverse events. At a minimum,
  • Beneficiary satisfaction and complaints
  • Timeliness of response to questions, problems and
  • Impact of business practices on adequacy of
    beneficiary access to items, services,
  • 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

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
  • 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

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.

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
  • Certified Rehabilitation Supplier (CRTS)
    (discontinued 12/31/08)
  • Assistive Technology Supplier (ATS) (discontinued
  • Assistive Technology Practitioner (ATP)
    (discontinued 12/31/08)
  • Assistive Technology Professional (AT) (effective
  • Completed at least 10 hours annually of
    continuing education specific to Rehabilitation

Not to CONFUSE anyone
  • Additional Supplier Standards

  • 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.)

  • 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.

  • 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

  • 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.

  • The proposed Additional
  • Supplier Standards

  • (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.

  • (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

  • 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.

  • (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..

  • 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
  • "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.

  • (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.

Back to Accreditation!
First Steps
  • Choosing Your Accreditor

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

Tips to Use in Choosing Your Accreditor
  • CMS is not your only payer! (How about
  • 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

One Main Area to Concentrate
  • Performance Improvement

  • 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

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?
  • Stay Tuned!
  • Watch for updates on a weekly basis
  • AAHC Wednesday in Washington
  • (
  • Homecare Monday (
  • HME News (
  • The Friday Report (

Your Questions ???
Thank You!
  • Mary Ellen Conway
  • President
  • Capital Healthcare Group, LLC
  • Bethesda, MD
  • 301-896-0193
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