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Medicare Settlement Plan Could Relieve Appeal Backlog

• New CMS Medicare appeals settlement initiatives aim at curtailing nearly three-year backlog of cases
• Forthcoming details could decide amount of dent in backlog

(Bloomberg Law) — A pair of initiatives announced recently by the Centers for Medicare & Medicaid Services could allow the agency to resolve a portion of its gargantuan Medicare administrative appeals backlog.

But although health-care attorneys hope the initiatives will help close some of the cases contributing to the $6.6 billion in disputed Medicare reimbursements, their success will depend largely on how the CMS implements them, they told Bloomberg Law. “The CMS hasn’t really given many details on how they will be applying these, so I will be curious to know what limits, if any, they will place on them,” R. Ross Burris III, a health-care attorney with Polsinelli PC in Atlanta, told Bloomberg Law.

The Medicare appeals backlog has grown so much in recent years that a health-care provider challenging a reimbursement decision may have to wait as long as three years before its reimbursement appeal is finally adjudicated. The backlog has been the subject of multiple lawsuits, including one brought by the American Hospital Association that led a federal court to order the CMS to come up with ways to reduce the backlog.

In the face of this judicial pressure, the CMS Nov. 3 announced two new settlement initiatives aimed at reducing the number of pending appeals. The low-volume appeals settlement option allows providers with fewer than 500 pending appeals and a total billed amount of less than $9,000 per appeal to settle their claims for 62 percent of the net allowed amount. Additionally, the CMS has said it will expand the use of settlement conference facilitation, which is a type of mediation between the health-care providers and the CMS, to arrive at an acceptable settlement value for resolving claims.

Provider Buy-In Required

According to Burris, the settlement initiatives could put a sizable dent in the Medicare backlog if health-care providers determine that it is worth it give up a portion of their claim in return for quicker payment.

“I know that some parties have gone through the process the CMS offered before and came away very pleased with the process, saying it was worth the reduced payment to not have to wait two years,” he said.

However, Burris said, some parties that have participated in settlement conferences with the CMS have come away disappointed with the amounts they were offered.

“It depends on how likely you think you are to get more of your claim repaid by going through the appeals process and how able you are to wait out that process,” he said.

In particular, some attorneys say, the low-volume appeals settlement option will require the most buy-in from health-care providers.

“Any effort to resolve the appeals through an expanded settlement program is always good news for at least some providers, the questions is how many,” Joseph Glazer of the Law Office of Joseph D. Glazer PC in Princeton, N.J., told Bloomberg Law. “As the new settlement option is targeted at certain providers with ‘low-volume appeals,’ HHS will need significant buy-in from those providers to reduce the backlog in any meaningful way through this initiative,” he said.

Denial or Approval of Claims?

Burris said the decision by a health-care provider to seek a settlement will rest prominently on how those settlements are treated by Medicare. “A lot rides on whether Medicare deems the settlement an approval of the charges or a denial of the charges,” he said.

Burris also said health-care providers have to know what kind of precedent they are setting by accepting the settlements. “If you settle your claims and Medicare deems it as a denial of the claim, what kind of precedent are you setting for any future claims that you may have that are of the same type,” he asked.

Further, “If the charges are deemed denied by Medicare, a provider is going to have a much harder time collecting in a secondary payer situation,” he added.

The CMS website that announces the new initiatives urges potential participants to check back for details about the initiatives in coming months. As the CMS answers the questions posed by these attorneys with more detailed information, there should be a clearer view of how much a dent they will put in the backlog.

To contact the reporter on this story: Matthew Loughran in Washington at mloughran@bna.com

To contact the editor responsible for this story: Peyton M. Sturges at PSturges@bna.com

For More Information

The CMS announcement is at http://src.bna.com/ugn.

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Congressional letter to HHS Secretary Price Gaining Support

The reported number of signers to the congressional letter to HHS Secretary Tom Price and CMS Administrator Verma from Rep. Cathy McMorris-Rodgers (R-Wash.) and others is nearing 50 and will likely climb this week.

Click here to view the current list of cosigners.

It is very important to get your member of Congress on this letter! We are hoping to get 150-200 cosigners by the end of the week. The deadline to sign is this Friday, June 9. Strong support of this letter will speak volumes to the leadership at HHS/CMS about the importance of DME policy reform. This needs to be a priority this summer.

The map below indicates the congressional districts that have signed on to the letter. We have 100 percent support from North Dakota and Iowa! Can your state get 100 percent support? If your congressional representative says they have signed on, please let us know!

If you haven’t already done so, please take a few minutes today to reach out to your member of Congress. Call and/or send them a message. Ask your co-workers and friends to do the same. We have made it easy for you!

Click here to message your member of Congress.

A Recap of 2017 Legislative Efforts and Continuing the Fight

There have been several key developments in the past several weeks, which our grassroots coalition must continue to push forward to gain their legislators support.

Congressional Letter to HHS Secretary Price

The letter being led by Reps. Cathy McMorris Rodgers (R-Wash.), Dave Loebsack (D-Iowa), Lee Zeldin (R-N.Y.), and Diana Degette (D-Colo.) is calling for reforms to policies and regulations involving durable medical equipment and complex rehab technology. The letter is being sent to HHS Secretary Tom Price of and CMS Administrator Seema Verma. The congressional offices are looking to get broad bipartisan support from their fellow representatives, which is where your colleagues and patients can play a huge role! Call your member of Congress, and visit our VGM Action Center today!

Currently there are 41 cosponsors of this letter. Click here to view the most recent list of sponsors. If your legislative member is not on this letter, we ask that you call the Washington, D.C., switchboard at 202-224-3121 and ask for your representative. Remember, this letter is coming from the U.S. House, so remember to ask for the legislator who represents your district. Additionally, you can visit the VGM Action Center and send a message to your representative with just a few clicks!

Small Business Committee Letter

In an effort spearheaded by Patrick Naeger, president of MAMES (Midwest Association for Medical Equipment Services), independent DME suppliers have gained the attention of the House Small Business Committee. Much like the concerns prompting the letter by Rep. McMorris Rodgers and others, the Small Business Committee is gravely concerned about the 40 percent reduction in providers in such a short period. Many of these independent HME locations are in metropolitan and rural areas, something that Congress does not like to see diminished. This reduction has a large snowball effect that impacts jobs, local economies, and patient access to care.

Click here to see a list of the Small Business Committee member,s and contact them to support the letter focused on keeping the small businesses open and prosperous.

Keeping Complex Rehab Technology Accessories Out of Competitive Bidding

In 2008 Congress intentionally exempted CRT from the competitive bidding program, but in November 2014, CMS issued a final rule explaining that competitive bidding would be used to adjust CRT wheelchair accessories. There have been multiple delays in this program, and now the clock is ticking because on July 1, 2017, without action, the most recent delay will expire.

U.S. Rehab is at the forefront working to solidify a permanent solution for complex rehab providers. H.R. 1361 and S. 486 will extend the needed protection to complex rehab chairs and keep patients out of the hospital. There will be an extreme gap in access to complex rehab equipment if this is not fixed. We must keep up the pressure on Congress to solve this!

To play a role in supporting this long-term solution, please visit U.S. Rehab’s page to send a message to your members of Congress to support this legislation and use the phone look up function to call their offices.

Prior Authorization Bill Introduced H.R. 2445

Rep. Marsha Blackburn (R-Tenn.) has introduced a new bill that would require a prior authorization for high-dollar durable medical equipment. At its core, this legislation seeks to reduce the amount of burdensome audits against which providers continue to fight. This legislation would create a more secure outlook into the future for independent medical suppliers. VGM will provide further analysis, calls for action, and updates as we follow this legislation.

You can also contact your members of Congress to support this bill by becoming a cosponsor. The bill was just recently introduced, so a strong showing of broad bipartisan support will be key for this.
State Licensure Efforts Continuing into the Next Session

Earlier this month the state of Georgia was the latest to sign DME state licensure into law. State licensure is one of the most effective ways to keep health care local. As many providers know all too well, the flawed competitive bidding program has opened the door for providers – who are hundreds, if not thousands of miles away – to win contracts. This does not bode well for patient outcomes.

Coordinating state licensure efforts does not happen overnight. Now is the time to start planning and preparing to pursue state licensure in your state. It takes a strong coalition of providers and state associations on the ground to garner the support needed to pass state licensure. Please reach out to VGM Government Relations to see what things you can do as a provider to support state licensure efforts.

CMS, SBA Reps to Attend Heartland Conference

VGM’s annual Heartland Conference will be the site of a panel discussion with officials from the Centers for Medicare and Medicaid Services (CMS) and the Small Business Administration (SBA).

During the session, held June 13, CMS and SBA will discuss the future of the competitive bidding program, as well as promote government resources available for small businesses to utilize. The open forum will also provide an opportunity for audience members to interact with the panelists.

“We are thrilled for Heartland attendees to have the opportunity to ask questions and share feedback directly with officials from CMS and the SBA on impacts to their business from regulations,” said John Gallagher, VGM’s vice president of Government Relations. “Providing platforms to share their concerns and connecting VGM members with resources to navigate the regulatory environment helps strengthen and protect their businesses.”

Attending on behalf of the two agencies are CMS Competitive Acquisition Ombudsman Tangita Daramola and Deputy Ombudsman for Regulatory Enforcement Fairness of the SBA, Yolanda Swift. In addition to the agencies, Medicare contractors have also been invited to participate. Gallagher will moderate the session, and along with Daramola, Swift, and the contractors, will be available to answer questions asked by attendees.

Compliance and regulatory is one of nine tracks of education held during Heartland Conference. Visit www.vgmheartland.com to view the complete schedule of courses, speakers, exhibitors and social events.

Mark Your Calendars for Friday, June 2. VGM Lunch Bucket with John Gallagher, Mark Higley, Tom Powers, and Ronda Buhrmester

During this Webcast, John, Mark, Tom, and Ronda will discuss topics related to the current state of the DME industry, including the competitive bidding program, Medicare’s audit process, and reimbursement issues. Similar to previous “Lunch Buckets,” viewers will have the opportunity submit questions about the current issues.

Click here to register.

For more information, please contact Emily Harken at 866-512-8465 or emily.harken@vgm.com.

Seeking support for the Prior-authorization Bill at AAHomecare conference

Last week, H.R. 2445 – Prior Authorization bill was introduced by Rep. Marsha Blackburn (R-Tenn.). At the core, this legislation seeks to reduce the amount of burdensome audits against which providers continue to fight.

Vice President of VGM Government Relations John Gallagher said, “The prior authorization bill introduced by Congresswoman Blackburn is a strong step to reign in the excessive amount of audits that providers are buried in. Providers are losing crucial cash flow for years while they go through the appeals process, and this bill will play a big role in reducing those audits.”

Gallagher, Clint Geffert, and Tom Powers will be attending over 30 congressional meetings during the AAHomecare Legislative Conference this week. They will be seeking support for the prior authorization bill in addition to the letter to HHS/CMS from Rep. McMorris-Rodgers.

Actions Needed This Week! Ask Your Representative to Sign the Letter to HHS/CMS

Thank you to the many advocates of the DMEiIndustry who are attending AAHomecare’s Legislative Conference next week. If you are not attending, we need your help back home. We need you, your co-workers, family members, and friends to reach out to your congressional representative asking them to sign on to the letter to HHS Secretary Tom Price and CMS Administrator Seema Verma. This letter asks Price and Verma to make DME policy reform a priority!

Click here to view the letter.

Please do these two things:

  1. Send a message to your member of Congress. We have made this a simple process that only takes a minute. Visit the VGM Action Center to send a message to your representative urging them to support the letter!
  2. Follow up with a phone call to your member of Congress. Pick up the phone and call your congressional representative’s office. Tell them why it is important to the patients you serve and your business that reforming DME policies become a priority.

Grassroots efforts for the past few years have led to these developments. Recent awareness to our issues has stirred up congressional champions such as Reps. Marsha Blackburn (R-Tenn.), Cathy McMorris Rodgers (R-Wash.), Dave Loebsack (D-Iowa), Lee Zeldin (R-N.Y.), and Diana Degette (D-Colo.). Please continue to the fight for DME!

U.S. House Small Business Committee Members Preparing Letter to HHS

U.S. House Small Business Committee Members Preparing Letter to HHS
In an effort spearheaded by MAMES (Midwest Association for Medical Equipment Services) and its president, Patrick Naeger, independent HME suppliers have gained the attention of the House Small Business Committee. Much like the concerns prompting a letter being circulated by Rep. Cathy McMorris Rodgers (R-Wash.) and others, the Small Business Committee is gravely concerned by the 38 percent reduction in providers in such a short period.

Rep. Blaine Luetkemeyer (R-Mo.), who authored the letter, says, “These small businesses and their owners serve the individuals in our communities, and often times they have known their clients for years. However, the policies of the previous administration have put durable medical equipment stores in jeopardy with poor regulations and steep cuts.”

Click here to view letter.

Vice President of VGM Government Relations, John Gallagher, said, “Thanks to a highly engaged grassroots coalition, Congress is making it clear that these CMS policies are not helping small businesses in America. It is increasingly difficult for small businesses to sustain these deep reimbursement cuts while managing to navigate through the endless red tape of doing business.”

“I am grateful to my friend, Congressman Blaine Luetkemeyer, for recognizing the destruction small businesses like mine and thousands of others across the country are facing as a result of Medicare competitive bidding rural fee schedule cuts,” said Naeger, exective vice president of Healthcare Equipoment & Supply in Perryville, Missouri. “Because DMEPOS providers are mostly small businesses, it is imperative to have the support of those in Congress who fight for small business. I appreciate Congressman Luetkemeyer, his staff, and other members of the Small Business Ccommittee for their support.”

After this letter is circulated to the Small Business Committee, it will be passed on to HHS Secretary Tom Price and CMS Administrator Seema Verma.

If your representative is on the Small Business committee, please reach out to them and ask them to support this letter.

The RAC Giveth?

The RAC is well known for audits and recovery of overpayments (they taketh away). But, does the RAC ever giveth? As far back as I can remember, I’ve never heard of any Medicare contractor reviewing claims for UNDERPAYMENTS then giving money, which is due, back to the providers. You may not be aware of this, but the RAC is funded to find underpayments. And, on May 17, 2017, Performant Recovery, the National DMEPOS RAC, announced that it will begin to recover underpayments or incorrect reductions owed to suppliers for wheelchair accessories and cushions for Group 3 complex power rehab wheelchairs. This underpayment review was suggested by the van Halem Group’s Wayne van Halem!

What this means to you.

The RAC has been given approval from CMS to begin reviewing underpayment for accessories used on Group 3 power wheelchair bases for dates of service Jan. 1, 2016 – June 30, 2016. This timeframe is when the DME MACs’ processing system was not able to accept the KU modifier, which would allow the claims to pay at the unadjusted fee schedule (the one NOT affected by competitive bid pricing). Providers were able to submit a written reopening for these underpayments after July 5, 2016, once the DME MACs’ processing system was updated to accept the KU modifier and pay at the unadjusted fee schedule. U.S. Rehab issued many articles/webinars on this situation with details of how to recover these funds via written reopening; however, some providers have not submitted the reopening to request the additional money owed to them.

Fortunately, thanks to Wayne van Halem’s suggestion, the RAC has announced that for Group 3 power wheelchair claims with these dates of service that have not yet been adjusted at the providers request, they will reprocess and issue additional reimbursement. The average amount of these adjustments for a Group 3 multiple power base (K0861) is approximately $1,000 per claim. Click here to for the list of affected accessories.

Read the original announcement from The van Halem Group.

If you have any question regarding this information, please contact me:

Dan Fedor
Reimbursement Specialist, U.S. Rehab
VGM Group, Inc.
Proud Employee Owner
O: 844-794-8459
C: 570-499-8459
E: dan.fedor@vgm.com
F: 844-307-5729

Not Attending the AAHomecare Conference? Your Actions are Needed!

Next week many advocates of the DME industry will trek to Washington, D.C., to attend the AAHomecare Legislative Conference. Many of these attendees struggle to find the time and the funding to travel, but they all understand that making changes to DME policies requires educating and informing leaders in Washington. Thank you to the many advocates of the DME industry who are attending.

Many of these attendees will attend back-to-back congressional meetings across Capitol Hill, asking for support for reform to DME policies. Their feet will be sore at the end of the day.

If you are unable to attend the conference, please do your part at home. Reach out to your member of Congress either today or early next week. We are targeting 200 signatures on the congressional sign-on letter authored by Rep. Cathy McMorris-Rodgers that will go to HHS Secretary Tom Price and CMS Administrator Seema Verma.

Please do these two things:

  1. Send a message to your members of Congress. We have made this a simple process that only takes a minute. Visit the VGM Action Center to send a message to your representative urging them to support the letter
  2. Follow up with a phone call to your member of Congress. Pick up the phone and call your congressman’s office. Tell them why it is important to the patients you serve and your business that reforming DME policies become a priority.

Also this week, H.R. 2445 – Prior Authorization bill was introduced by Rep. Marsha Blackburn (R-Tenn.). At the core, this legislation seeks to reduce the amount of burdensome audits against which providers fight. The new portion of legislation outlines a more detailed process for home respiratory equipment, which would establish a requirement of medical necessity to be prescribed by a practitioner. The Department of Health and Human Services would establish a standard for the medical necessity evaluation requests for “physician and hospital referral agents and non-physician practitioners.”

Grassroots efforts for the past few years have led to these developments. Recent awareness to our issues has stirred up congressional champions such as Reps. Blackburn, McMorris Rodgers, Dave Loebsack (D-Iowa), Lee Zeldin (R-N.Y.), and Diana Degette (D-Colo.). Please continue to the fight for DME!