BALTIMORE--HME stakeholders and CMS officials engaged in a heated discussion about the agency's overhaul of Medicare's mobility benefit at a special Open Door Forum on Tuesday.
More than 500 callers jammed the phone lines and 45 to 55 appeared in person at the three-hour session, which focused on an interim final rule released last month that eliminates the current power mobility CMN. Instead, the proposed rule requires providers to submit a physician's prescription with their reimbursement claims--and, if asked, to supply documentation from the prescribing practitioner about the patient's condition that supports medical necessity for the equipment. (See HomeCare Monday, Aug. 29).
With a number of other new mobility policies set to take effect--including the implementation of new codes and pricing on Jan. 1--some meeting attendees said CMS is rushing the rule, which is currently scheduled to become effective Oct. 25.
Implementation should be delayed until at least April 1, 2006, according to Dan Meuser, president of Exeter, Pa.-based Pride USA. "Folks, providers cannot adapt to this rapid change in this time period," Meuser told CMS officials, citing provider concerns about retooling billing systems to the new requirements, concerns the DMERCs will not be able to adjust their own claims processing systems and a widespread lack of education in the medical community about physicians' new role in the process. "We need for you to truly consider a delay so we transition again in an orderly way as opposed to a rush to disorder," Meuser said.
CMS' Richard Lawler said the agency is "listening" to that request.
Another forum attendee said it is inappropriate to require equipment providers who are not medically trained to gather patient medical records from physicians, and then to hold providers responsible for deciding whether the prescription and documentation physicians supply is appropriate.
As "laymen," non-clinician suppliers are not qualified to make these medical evaluations, said Doug Harrison, president of The Scooter Store, New Braunfels, Texas, the nation's largest power mobility supplier. "Imagine the outcome if pharmacists first requested physician's chart notes from a patient, then analyzed those notes, and finally, refused to fill the prescription based upon his or her reading of the chart notes," he said. "Neither the patients nor doctors would tolerate that outcome at a pharmacy, nor should they in the instance of the prescription of power mobility devices."
But Lawler responded that the agency has no intention of changing the requirement. "We're not asking the supplier to make a diagnostic information or to write the prescription," he said. "But you do have to find between the time the prescription is made and it is supplied an ability to translate that prescription into a physical piece of equipment. That's your business that you're in."
John Warren of CMS also noted that there are no plans to perform random medical reviews, but they will be conducted by the DMERCs in response to "billing anomalies." He said he had no estimate as to what percentage of power mobility claims would be reviewed.
Others at the meeting were concerned that the role of clinicians is not addressed in the policy language, leaving the burden on physicians who may--or may not--have the training necessary to prescribe appropriate equipment.
"It's not been my experience that there are a lot of physicians who feel confident to provide the detailed prescription that's necessary. They neither have the time nor the expertise in the MAE that's necessary in order to have the whole thing turn out right for the beneficiary in the end," commented Ginger Walls, outpatient clinic director at National Rehab Hospital in Washington, D.C. "It's been my experience that I've had to go back and try to fix more patients' problems who had improper devices prescribed for them."
Laura Cohen, a clinical research scientist at the Shepherd Center in Atlanta and co-coordinator for the Clinician Task Force, said because few physicians document the detailed type of information necessary to prescribe the right equipment, the rule should be amended to recognize that it is appropriate for physicians to refer to independent physical or occupational therapists who can then evaluate the patient and work with the supplier to find the appropriate device. "The multi-disciplinary team isn't addressed in this [rule]. And knowing when and where to refer on is not talked about, and I think that that's a problem with the system as it is today," Cohen said.
Steve Furrough of CMS said it would be "appropriate in many cases" for physicians to refer a beneficiary to someone who can assist with the evaluation and prescription, but "we don't feel that's an appropriate thing to regulate through a rule.
"Just like in any other health care provision, we expect providers who are going to order power mobility devices to be competent in ordering those power mobility devices," he said. "We expect [physicians] to do the appropriate evaluation, answering those questions [as outlined in the NCD], and if they are uncomfortable doing that, then we certainly expect them to ask for some assistance."
To help educate physicians about the changes, the agency is planning meetings with physician groups, publishing Medlearns and using DMERCs to get the word out, CMS' Warren said, adding that suppliers also should take responsibility for informing their referral sources about the new rule and its requirements. "This is a huge educational campaign, and I would expect that as suppliers that you have relationships with the physicians that you deal with, and part of that relationship would be educating [them] on what their responsibilities are," he said.
Still other forum participants, such as Phil DiLernia, president of Flemington, N.J.-based Cornell Healthcare Corp., said the interim final rule does not provide the clarity necessary for suppliers to follow its requirements. "All suppliers have asked for for four years consistently is clarity in the guidelines, no ambiguity. If you want to reduce fraud and abuse, it seems ultimately imperative that you make things more clear rather than less clear. The more clear things are, the more easy it is to go after fraudulent providers," he pointed out.
The fact that the equipment prescription is required within 30 days of a face-to-face physician exam also disturbed a number of stakeholders, who said that it could take a much longer time for patients to shuttle among doctors, clinicians and an HME provider. Furrough said that the 30-day clock does not start the first time a patient sees the physician, but the date the prescription for a mobility device is written, which may be a date after the initial exam. Other officials said CMS would have to provide clarification on this point.
"This is not new medicine, new science," Furrough said. "It's just putting a name on what has always been expected to occur. So the actual term 'face-to-face examination' and the requirement that a face-to-face examination happened becomes effective the day the rule ... becomes effective. But it should not, in the larger sense, really change practice. [Physicians] were required by good medical practice to see patients before they wrote a prescription. That doesn't change."
CMS officials at the forum said they will take the comments they heard into consideration before the final rule is issued.
To view the interim final rule, click here.
To comment on the policy, click here.
To participate in HomeCare's monthly Web poll on CMS' new interim final rule for power mobility equipment, visit www.homecaremag.com.
