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From the Reimbursement Team: CURES Act Retro Adjustments Coming May-Nov

You know the old slogan, “Do you want the good news first or the bad news?” Well, we are optimistic so we will give you the good news first.

Good News – Mass Adjustments Starting in May not July! They are starting two months earlier than expected, AND providers do not have to take any action as these will be processed as a MASS ADJUSTMENT.

Bad News – Mass Adjustments will Take Approximately 24 Weeks to Complete!

Here’s what we know as of today: The DME MACs are beginning to release more information from the CURES Act about the additional reimbursement coming to suppliers in the non-competitive bid areas for dates of service July 1 – Dec. 31, 2016. The initial expectation was that the mass adjustments would begin around July 3, but according to the recent release from the DME MACs, these adjustments have already begun and will continue over the next six months (November 2017). Yes, six months.

Why is it taking six months to adjust these claims? The reason is there are a lot of claims (millions), and the MACs are the only ones that can do this and still process new claims. The processing system couldn’t handle it if they released millions of claims for reprocessing while still releasing new claims. We believe they conducted an analysis of how many claims can be released daily without impacting the processing of current claims and this is it.

Jurisdiction A and Jurisdiction D adjustment starts May 12. Noridian is prepared to begin mass adjustments to all claims covered under the rule and will be initiating adjustments for 20,000 claims each day for Jurisdiction A and 20,000 claims for Jurisdiction D for the next 24 weeks as directed by CMS.

Jurisdiction B and Jurisdiction C adjustment starts May 10. CGS Jurisdiction C will begin adjusting approximately 40,000 claims each day for approximately 24 weeks. CGS Jurisdiction B will begin adjusting approximately 20,000 claims each day for approximately 24 weeks.

According to the DME MACs, they are currently providing CMS a lot of feedback that may or may not change the current direction. They were informed that the adjustments will be done at random, meaning that there will not be a particular sequence that will be followed (not by NPI, not date of service – at this point). Our opinion is that they suspect that once the adjustments start processing, there will be a pattern and a processing schema. Unfortunately, this information hasn’t been shared with the MACs. The only thing being shared by CMS is that the processing will be random.

How will we know a CURES Act adjusted claims? You won’t.

There also will not be a particular identifier (e.g., remark code, unique CCN) that will be associated with these adjustments that would allow suppliers to separate CURES Act adjustments from other adjustments. Suppliers will have to identify the codes and dates of service for the claims to be adjusted internally and reconcile once they are adjusted for additional payment.

Do suppliers have to do anything? Not for the mass adjustment, but you should request a written reopening for the KE claims.

According to the DME MACs, they will accept the KE modifier for those claims affected but not until the mass adjustments have been completely processed. Once the claim has been adjusted, suppliers will need to request a written reopening requesting to add the KE modifier to the affected codes to receive the additional 5 percent.

Suppliers will not be permitted to request escalated processing of these claims.

As a side, the DME MACs know that this is a big deal for the supplier community and will be working to share as much as they can.

What we also know:

  • The claims should automatically crossover to the secondary payer. As we all know, in situations like these, processes do not always run smoothly. This may require suppliers to manually submit to the secondary payer.
  • We suggest you prepare staff for incoming calls from beneficiaries who will get a notice of summary and will have questions.
  • It’s important to be working with your billing software company to understand the best method for posting these payments because the invoices are already closed.

Click on the following links for the announcement about the mass adjustments:

Stay tuned for additional information, and please let us know if you experience issues.

Contact Information:
Ronda Buhrmester: Ronda.Buhrmester@vgm.com; phone: 888-665-6518
Dan Fedor: Dan.Fedor@vgm.com; phone: 844-794-8459

Georgia DME Licensure Bill Signed into Law – A Big Win for Georgia Providers

See the release from the Georgia Association of Medical Equipment Suppliers on the passage of DME state licensure:

May 9, 2017 – Atlanta, GA

Today Governor Nathan Deal signed SB 41 into law. GAMES wishes to thank Governor Deal, Senator Renee Unterman, and Rep. Jesse Petrea for their guidance and support as the bill moved through the General Assembly. 

SB 41 was passed as a result of a multi-year effort by GAMES and our allies in the legislature. After July 1, 2017, the Georgia Board of Pharmacy will have the authority to begin administering the licensing statute for suppliers of durable medical equipment. The bill requires that anyone who wishes to participate in the DME industry in Georgia must apply for a license and have a physical location within the state. This pro-business, pro-patient bill represents a huge step forward for our industry in Georgia, which will join our neighboring states in enacting a DME license requirement.

“We are pleased with the outcome of this lengthy and complex process” says Tyler Riddle, GAMES president. “GAMES wishes to thank our partner, Southern Strategy Group, for walking alongside us in this process, ensuring all the i’s were dotted and the t’s were crossed!”

GAMES leadership looks forward to working with the members and staff of the Georgia Board of Pharmacy as they begin the rule-making process to put SB 41 into operation.

The mission of the Georgia Association of Medical Equipment Suppliers (GAMES) is to facilitate business success, influence public policy, and improve patient care in the home.

These state licensure efforts are an extremely effective way that patients have access to providers with the resources to provide care in their state. The competitive bidding program has opened up patients to be cared for by companies that are hundreds, if not thousands, of miles away. Providers drop-shipping care and bidding with the sole intention to subcontract is not good for patient outcomes, nor is it sustainable for local providers.

Thank you to the leadership of GAMES and Georgia providers for working hard to improve health care access in Georgia.

Providers Meet in Michigan to Discuss Proposed Rate Cut from BCBS

Tom Powers, of VGM Government Relations, traveled to Lansing, Michigan, with a few other Michigan providers yesterday to meet with Al Pscholka, budget director for the state of Michigan, and two Medicaid representatives. The meeting was with a small number of providers in order to start a discussion about the proposed rate cuts from Blue Cross Blue Shield in Michigan. It revolved around ways to take the message to a higher level of Blue Cross Blue Shield and identify ways to be helpful.

Tom reports, “We certainly brought awareness on the reimbursement issues with the representatives of Michigan Medicaid. Out of that discussion we learned that there is no intention of lowering Medicaid rates in Michigan, which was good intel for discussions moving forward.”

Pscholka showed concern about the proposed cuts and will work to find ways to be helpful on the issue. He was very aware of the reductions and the impacts they are having on providers. As a former member of the Michigan legislature, Pscholka is very knowledgeable of health care related issues and will be helpful as providers continue the discussion on securing sustainable rates.

Additionally, the group met with the lobby firm of Michigan Home Care and Hospice Association (MHHA) to discuss strategies and ideas going forward.

Next, the group is planning meetings with Blue Cross Blue Shield at the policy-making level to show impacts on these proposed cuts and will lay out the next steps.

VGM is monitoring several states that are looking at reducing reimbursement rates to align with Medicare pricing. VGM is diligently working with state associations and grassroots providers to mitigate these reductions.

CGS preparing for mass adjustments as a result of 2016 CURES Act

Yesterday DME contractor, CGS announced they are preparing to begin mass adjustments to all claims covered under the Section 16007 of 21st Century Cures Act for DMEPOS items for Jurisdiction B and C. It was indicated in yesterday’s announcement that the process will take approximately 24 weeks to complete, adjusting up to 40,000 claims per day in Jurisdisction C and 20,000 per day in Jurisdiction B.

The van Halem Group published a blog post going into further detail about the announcement, click here to view the article.

As many House members are back in their home districts this week holding townhalls, this time is an excellent opportunity to share concerns about such a long delay in payment. There will be another opportunity to reach members of Congress at the AAHomecare Fly-In May 24 and 25 and request to expedite this payment process in any way possible. Sharing this information with your member of Congress will reinforce the urgency to provide relief for providers in rural areas.

Implementation date is July 3, 2017. Billing staff will need to be versed in the Change Request (CR) 9968 instructions. Click here to view an information video from CGS.

Click here to read the full announcement from CGS.

Competitive Bidding Round 1 2019 – Improper Notification Sent to Providers

A notification was unintentionally sent to providers interested in participating in Round 1 2019 by CMS that can be ignored. The subject of the email read, “IMPORTANT – REMEMBER TO APPROVE FORM A AND CERTIFY FORM B!” Again, suppliers can disregard this notification.

VGM has confirmed that the notification was improperly sent due to software being cued to send automatic updates to remind suppliers to complete proper forms for the next round. The program has been temporarily delayed and there has not been an official release from CMS as to when Round 1 2019 will go back up on the website. We are anticipating that the information will be reposted at the end of May or early June. Once we have official confirmation of the new information on the next round we will notify suppliers.

Call to Action: Continuing the Fight for Sustainable Rates

With yesterday’s release of the update fee schedules for the July 2016 adjustment for rural and non-bid areas, previous estimates have been confirmed that providers were hoodwinked by CMS.

As expected, CMS adjusted the new rates by including prices from the most recent round of competitive bidding. Including the additional round of competitive bidding has reduced the reimbursement that is owed to providers by an additional 6-11 percent, depending on the location and product.

“CMS incorporating July 1 competitive bidding rates into the retroactive payment that providers are owed goes directly against the intent of Congress to provide relief to rural providers who are struggling,” said John Gallagher, VP of VGM Government Relations.

To give providers an idea of what these cuts look like, we have compiled a chart to illustrate the differences in reimbursement and where they are now. Below are the average rates of most commonly used codes in the contiguous United States:

While “something is better than nothing” comes to mind, this clear misapplication of the intent of the Cures Act by CMS is unacceptable. Providers must call their members of Congress to sound the alarm on these constant rate reductions. Many congressional offices know long-term reforms must be made to the competitive bidding program, but they have to hear from constituents about the problems they face. This kind of grassroots outreach is what has garnered such broad bipartisan support from Congress in recent years.

Call your members of Congress through the U.S. Captiol Switchboard at (202) 224-3121.

John Gallagher and Mark Higley will be discussing these latest developments, what the future of competitive bidding might look like, and where there are opportunities for providers to fill the void from unsustainable reimbursement rates. For more information visit: http://www.vgmheartland.com/.

CMS Releases Updated Adjustments for July 2016 Retroactive Fee Schedule

The Centers for Medicare and Medicaid Services (CMS) has released update fee schedules for the July 2016 adjustment for rural and non-bid areas, which the 21st Century Cures Act authorized late last year. As expected, CMS adjusted the new rates by including prices from the most recent round of competitive bidding. Including the additional round of competitive bidding has reduced the reimbursement that is owed to providers by an additional 6-11 percent depending on the location and product.

“CMS incorporating July 1 competitive bidding rates into the retroactive payment that providers are owed goes directly against the intent of Congress to provide relief to rural providers who are struggling,” said John Gallagher, VP of VGM Government Relations.

To give providers and idea of what these cuts look like, we have compiled a chart to illustrate the differences in reimbursement and where they are now. Below are the average rates of most commonly used codes in the contiguous United States:

This reaffirms the need for immediate long-term reforms to the competitive bidding program as the program has proven to be unsustainable. VGM will continue to fight these reductions and we will continue the pressure on Congress and CMS to find real solutions to this highly flawed program.

U.S. Rehab Team Wraps Up Their Week at the NCART/NRRTS Conference

Yesterday (Thursday), Greg Packer, Kayla Mahler, Ron Turzy, Dan Fedor, and Tom Powers attended over 15 congressional meetings on Capitol Hill during the 2017 National CRT Leadership and Advocacy Conference. The group educated legislators on the issues with complex rehab technology and asked them to support H.R. 1361 and S.486, Protecting Beneficiary Access to Complex Rehab Technologies, to permanently exclude complex rehab accessories from competitive bidding.

Packer said, “The meetings went very well. Due to the previous work done in D.C., we did less time educating on what complex rehab technology is and more time asking for their support for our bills. Our bills seem to have strong bipartisan support.”

Improvements to the Adjudication Process of Serial Claims

By Kelly Grahovac, The van Halem Group

A major win for DME suppliers was announced yesterday (Thursday), as CMS released information regarding improvements to the adjudication process of serial claims. Effective April 7, 2017, CMS has implemented changes to improve the processing and adjudication of recurring (monthly) claims for capped rental and certain inexpensive and routinely purchased (IRP) items.

Prior to April 2017, if a monthly rental claim was denied and then appealed separately, the claim was adjudicated independently and without reference to the other claims in the series. As a result, one month could pay while claims for other months in the rental period remained denied and pending at various other levels of appeal. Industry leaders have been working hard to get CMS to see the light and make changes that would get all monthly claims in the rental period adjusted and paid following an effectuation for any month. CMS listened and has directed the DME MACs to change their processes for adjudicating serial claims!

What does that mean?

Click here to see the rest of the article from The van Halem Group.