HME News is the monthly business newspaper for home medical equipment providers. This controlled circulation publication reaches 17,100 home medical equipment services providers, including traditional HME dealers & suppliers, hospital- and pharmacy-o
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Rx and Specialty Providers Number of diabetes providers slashed . . . . . . . . . . . . . . . . 1 Vents vs. bi-levels: MACs issue further guidance . . . . . . 16 Private payers exploit O&P; changes . . . . . . . . . . . . . . . . . 16 Byram settles kickback allegations. . . . . . . . . . . . . . . . . . 17 ■ ■ Lymphedema patients would be better served with insurance coverage, says Christa Miehe. See story this page. 16 hme news / june 2016 / www.hmenews.com By T. FlaherTy, Managing editor WASHINGTON – It's no surprise to O&P; stakeholders that pri- vate payers are picking up on a widely criticized proposed r u l e b y Medicare to deny cov- e r a g e f o r prosthetic d e v i c e s that were previously covered. "We pre- dicted that the rule would, ultimately, be exploited by private health insurers," said Michael Oros, president-elect of the American Orthotics and Prosthetics Association during a press in April. The four DME MACs in July released draft local cover- age determinations for lower limb prosthetics that include a number of proposed chang- es, including requiring a face- to-face visit and requiring patients to complete a rehab program. UnitedHealthcare and Cigna have made cover- age changes in the wake of the By Theresa FlaherTy, Managing editor WASHINGTON – Lymphedema advocates took to Capitol Hill in April to gain support for legislation that would address a gap in treatment coverage for the chronic and often debilitating condition. With a presidential election looming in the fall, the Lymphedema Advocacy Group, which held its 2016 Lymphedema Lobby Days April 19-20, wants to take advantage of the time it has now, before lawmakers get too distracted. "There's momentum behind this," said Judy Woodward, chair- woman of awareness for LAG. "We need to make sure that momen- tum builds and we keep the voices coming. The next two months By Theresa FlaherTy, Managing editor WASHINGTON – Recent guidance from the DME MACs on cov- erage criteria for ventilators i s a m o v e in the right d i r e c t i o n , say industry stakeholders. Specifical- ly, the guid- ance removes the so-called " i m m i n e n t death requirement," which stated that patients must need a ventilator 24/7 for coverage. It's a requirement the MACs issued in April 2015 in an attempt to defne criteria for vents vs. bi- level devices. MACs remove 'imminent death' vent requirement The new guidance doesn't go that far, but "makes very clear that any device which would be considered a ventilator that is used either in RAD mode or CPAP mode would be inappro- priate," said Kim Brummett, vice president of regulatory affairs for AAHomecare. Several respiratory groups would like to see CMS go fur- ther and reconsider the Nation- al Coverage Determination for home ventilators, including bi-level devices. The American Association of Respiratory Care, the American College of Chest Physicians and the National Association for Medical Direc- tion of Respiratory Care in April asked CMS to establish specifc Private payers 'exploit' changes Vents Lymphedema advocates push for broader coverage proposed rule, AOPA says. Mark Martin, who lost his leg to an aneurysm in 2014, has experienced firsthand this cookie-cutter approach to providing prosthetic care. "I experienced denials even v e N T S s e e n e x t pa g e p r O S T H e T I c S s e e n e x t pa g e ly m p H e d e m A s e e n e x t pa g e house committee launches inquiry WASHINGTON – The House Committee on Oversight and Government Reform has launched an inquiry into the draft local coverage deter- mination for prosthetics. In a letter to Department of Health and Human Services Secre- tary Sylvia Burwell, the com- mittee says the LCD, released in July, relies on outdated data to limit access to clini- cally appropriate and medical necessary prosthetic care for Medicare benefciaries. "We are concerned that this draft LCD would deny access to advanced and higher quality prosthetics that improve mo- bility, function and indepen- dence of those benefciaries," it stated. Medicare currently pays for pump therapy, but not compression garments, other supplies Tom Fise Policy forum Rep. Renee ellmers, R-n.C., gave the keynote address for the american Orthotic & prosthetic association's 2016 policy Forum, held april 26-27. ellmers on april 25 introduced H.R. 5045, which seeks to halt drastic changes to coverage for prosthetic devices. the forum drew 135 O&p; practitioners and patients who held more than 400 meetings on Capitol Hill to drum up support for the bill. Lymphedema Lobby days in April brought 71 participants from 21 states and the District of Columbia to Capitol Hill. Andrea Stark Briefs Infusystem buys infusion pump assets mAdISON HeIGHTS, mich. – A subsidiary of InfuSystem Holdings, a national provider of infusion pumps and related services in the U.S. and Canada, has reached an agreement to acquire the infusion pump assets of Philadelphia-based InfusAID. Per the deal, InfuSystem will acquire about 400 infusion pumps from InfusAID, a privately held regional provider of ambulatory infu- sion pumps and service to medical facili- ties. "Similar to our acquisition of Ciscura in 2015, the pumps we acquire from Infu- sAID will come to us with 18 medical facil- ity relationships that will help us gain ad- ditional market share as the marketplace continues to consolidate," Erik Steen, CEO of InfuSystem, stated in a press release. Remworks leverages game-based education pITTSBUrGH – REMWorks has partnered with EdLogics to develop a game-based health education platform that provides incentives to patients to better manage their sleep health and associated costly health conditions. REMWorks is the sleep wellness store opened by health insurer Highmark in December 2014. EdLogics is a health education-based consumer en- gagement company. The platform, which involves completing activities and games, and learning strategies for better sleep, was launched with Allegheny County of Pennsylvania employees in September. Docs criticize medicare's diabetes policies leAWOOd, Kan. – The American Academy of Family Physicians sent a letter to HHS Sec- retary Sylvia Burwell on April 13, expressing its concerns that the prescribing process for diabetes testing supplies has become "overly burdensome." The AAFP argues that it should be acceptable for physicians to write prescriptions for "diabetic sup- plies" to encompass syringes, needles, test strips, lancets, glucose testing machine, etc., along with frequency. Current policy requires everything from a documenteddi- agnosis to a patient's testing log. court orders Pharmerica to pay $48.5m tab lOUISvIlle, Ky. – A circuit court judge has told PharMerica Corp., a national provider with 17 specialty home infusion pharma- cies, to honor outstanding invoices from AmerisourceBergen Drug Corp. for about $48.5 million. PharMerica has withheld payment and applied the invoice amounts against rebates and other amounts that it believes AmerisourceBergen owes the provider, which are in excess of $48.5 million. But the Jefferson County Ken- tucky Circuit Court ruled on April 1 that PharMerica must pay the invoices even if AmerisourceBergen failed to pay the pro- vider for rebates and other amounts owed. PharMerica plans to appeal.