WASHINGTON, D.C. (May 24, 2016)—CMS’s recently published statement on Medicare assignment rate information is grossly inadequate for evaluating the impact of the first round of deep competitive-bidding derived pricing cuts on patients in rural and non-bid areas. CMS’s report is vague and fails to provide important details:
- Claims data included. CMS did not specify whether or not its data from January through April 2016 was based upon dates of service or date claim was received. If the criteria used is for the date claim was received, it is likely that data included claims for services provided prior to the January 1 payment cut, which should not be included because these claims occurred prior to the payment cut. (Suppliers have 12 months from the date of service to submit claims.) Moreover, four months of claims is a grossly inadequate sampling of the claims for dates of service in 2016 since suppliers have 12 months to file the claim. In addition, this short time frame does not take into account the time it takes to obtain the onerous medical necessity documentation to even submit a claim to Medicare, which can be months. It is not possible to use such limited data and draw expansive conclusions as CMS did.
- Patient populations included. CMS did not specify whether or not dual eligibles were included in the Medicare population group being evaluated. Suppliers must take assignment on beneficiaries with Medicare and Medicaid, which account for a significant percentage of Medicare beneficiaries in total; these beneficiaries should not be included in any assigned claims analysis.
Providing such limited information means that additional time is needed to more fully evaluate the effects of the competitive bidding pricing expansion into rural and non-bid areas before any further cuts can occur.
CMS indicates that it uses real-time data monitoring to track access to DME and clinical outcomes with the same monitoring system used for bid areas, yet it only reported on an isolated, single metric of assignment rates to justify its position that there are no negative impacts as result of the new payment amounts in non-bid areas. No information was provided on:
- Patient access issues, such as volume of claims submitted (number of beneficiaries furnished DME items) or delays in beneficiaries receiving medically necessary equipment/services. Volume of claims is critical to see how many beneficiaries are not getting DME at all or who are having to opt out of the Medicare benefit entirely to get their needed DME.
- Patient outcomes data, such as rates of death, hospitalization and readmissions, ER visits, physician visits, admission skilled nursing facility, length of stay in hospitals, etc. This information has been historically provided on all other CMS Competitive Bidding reports.
- Beneficiary problems and complaints
Such information is critical in order for Congress to evaluate the impact of the expansion of the Competitive Bidding program into non-bid areas starting January 1, 2016, and that complete evaluation must occur before additional dramatic payment reductions occur. In addition, S. 2736 and H.R. 5210 would require CMS to monitor beneficiary access more comprehensively to enable Congress to better evaluate the beneficiary impacts of CMS’s payment reductions.
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