HME News

JUL 2017

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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hme news / july 2017 / 7 e ditorial Draining the swamp won't happen overnight With DME claims representing 51% of the appeals backlog at the ALJ, this new process will certainly help, writes Kelly Grahovac By John Galla G her W H at a R e the most important things needed to break a nut loose from a rusty bolt? s ome w D-40, a few good tools, and an abundance of elbow grease. Much like that rusty bolt, Health and Human s er- vices s ecretary t om Price is working to break the bureau- cratic rust loose within the agencies he oversees. t here are plenty of concerned providers who are wor- ried that s ecretary Price, a strong advocate for the HM e industry during his time in Congress, has forgotten about problems that must be solved. w hile the urgency of real reforms increases every day and providers continue to struggle to keep the lights on, the industry must recognize the machine that s ecretary Price is working against and the steps his department has taken to make incremental improvements already. s ecretary Price has already had an immediate im P act on dme Round 1 2019 of competitive bidding was pulled shortly after its introduction because of Price's actions prior to being confirmed as secretary. s omething equally as important, the industry is seeing a much different CM s since s ecretary Price took over the reins. w e are seeing the leadership at CM s , including the new a dministrator s eema v erma her- self, beginning to be much more willing to respond to inqui- ries, something that we have never seen from CM s or HH s . r educed staff numbers slow down change s ecretary Price, as well as many other agency heads, is work- ing with greatly reduced staff numbers. t his is largely due to politics in Congress playing out with confirmations and budgets, but it is having an impact. t his translates into bat- tling with career CM s employees who are working to pro- tect their positions and who are married to flawed programs that are harming providers and patients. a n encouraging response that we have heard from more than one official within CM s is that senior staff that came with s ecretary Price is quickly gaining the respect of the rank-and-file employees. w here is the magic wand? Many are wondering why s ecretary Price cannot just snap his fingers and solve the problems facing the industry. Unfortunately, there is no magic wand to wave over everything to be solved. w hile he has overall authority of the direction that these agen- cies take, there are still rules and statutes in our government that prevent him from having com- plete unilateral power. t here are lawyers and career staff that fol- low lockstep with the bureaucrats and leadership already in place at CM s , and they aren't the most friendly when it comes to interpreting the intent of congressional action. a gencies need a mandate for quick action For a department or agency to act swiftly, they need to be pressured, or shown the demand for change by Congress. w e are seeing an increase in congressional inquiries com- ing from key committees and leadership that raise red flags with the status quo going on within CM s . t his continued concern from Congress is a direct result of the constant out- reach from grassroots providers calling into offices, attend- ing meetings, and messaging members of Congress through the v GM a ction Center, which sees thousands of individual advocates annually. Providers need to continue demanding change by CM s to keep that pressure on. a lot of irons in the fire e ven though HM e plays an extremely important role in the world of health care, we have to recognize that s ec- retary Price has countless "irons in the fire," namely the repeal and replacement of the a ffordable Care a ct. t he unknowns and delays in passing legislation to replace Obamacare have clogged the pipes of legislative and regu- latory action. I have no doubts that s ecretary Price has not forgotten the problems going on within the DM e - PO s industry. t he costs, readmissions, and health care problems that are prevented by this industry do not go unnoticed. t his is especially true with s ecretary Price as he is working to overhaul the health care system to put patients at the center of health care. h ave trust that the nut will break loose t he frustrations that providers hold are not doubted and absolutely understood. Providers have to channel that frustration to the people who will listen most, their members of Congress. It has been just over four months since Price took over as secretary and he has worked with limited staff and resources at his disposal. It takes time and energy to break a nut loose from a rusty bolt and s ecretary Price is doing just that. w hile the industry would love to sheer that rusty bolt off, s ecretary Price doesn't have that luxury because the agency has to still function and we don't want CM s to actively work against him, which only makes things worse. Grassroots HM e providers are some of the most hard- working and driven individuals in health care because of high level of care they provide to their patients. t he industry has to allow s ecretary Price the time to create relationships and drive CM s down the correct road and trust that he is doing so. t he industry has concrete changes to show that the nut is breaking loose from a very rusty bolt. hme John Gallagher is vice president of VGM Government Relations. He can be reached at By Kelly Grahovac a M a JOR w IN for DM e suppliers was announced recently, when CM s released information regard- ing improvements to the adjudication process of serial claims. e ffective a pril 7, 2017, CM s has implemented changes to improve the processing and adjudica- tion of recurring (monthly) claims for capped rental and certain inexpensive and routinely purchased (IRP) items. Prior to a pril 2017, if a monthly rent- al claim was denied and then appealed separately, then the claim was adjudi- cated independently and without refer- ence to the other claims in the series. a s 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 CM s 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. CM s listened and has directed the DM e M a Cs to change their processes for adjudicating serial claims. w hat does that mean? Once the reason for denial for one claim in a series is resolved at any appeal level, the DM e M a Cs will identify other claims in the same series that were denied for the same or similar reasons, and take that determination into consideration when adjudicating such claims. t he DM e M a Cs will also commu- nicate the favorable decision(s) to the DM e QIC and the Office of Medicare Hearings and a ppeals (OMH a ) to con- sider when adjudicating related appeals pending at those levels. CM s has also instructed the DM e M a Cs to update the Certificate of Medi- cal Necessity (CMN) in the v iP s Medi- care s ystem ( v M s ), when appropriate, to reflect when a favorable decision has been rendered for a serial claim, allowing future claims in the same series to pay without requiring suppliers to continu- ally resubmit evidence. Finally, CM s instructed the DM e M a Cs to perform data analysis of all favorable serial claim appeal decisions made over the past three years, in an effort to capture all currently pend- ing appeals in the series that could be included in this initiative. s uppliers do not need to take any action and should not reach out to the DM e M a C within their jurisdiction to request that their appeal be considered for this initiative. how w ill this hel P me? Going forward, any claim in a series that denies but is then paid will result in adjustments for payment to o t h e r d e n i e d months in the series. R e m e m b e r , the data analysis only applies to recurring (serial) claims for capped rental items and certain IRP items adjudicated during the past three years. For a complete listing of HCPC s codes that are included in this initiative please see the list published in Med l earn Matters article se 17010. what's the b ottom l ine? t h i s i s a m a j o r w i n f o r t h e D M e industry! w ith 51% of DM e claims comprising the al J appeals backlog, this new process will most certainly help reduce that number. More importantly, this new process will alleviate the burden on suppliers billing monthly rentals. hme Kelly Grahovac serves as a senior consultant for The van Halem Group. She can be reached at New process for serial claims eases burden richard davis c o n t i n u e d f r o m p r e v i o u s pa g e behavior occurring again must be clear- ly communicated. For example: "Fail- ure to scan the delivery/pick-up tickets in the shared file folder will result in a second written warning". Or, "Future behavior to co-workers using vulgar, inappropriate, or offensive language will result in further disciplinary action up to, and including possible termination of employment." It is very important for the manager to be as positive as possible while commu- nicating each step to the employee. It is also important to put all of this in writ- ing. I always encourage open dialogue to allow the employee to express the opinion or vent. a t the end, the manag- er places the responsibility for improve- ment squarely on the employee. "Before we leave this meeting it is important that you realize that if we discuss this mat- ter again, it will result in (the specific consequence). I don't want that to hap- pen, but I cannot control the outcome; it is totally up to you. I am here to help and support, but you have to meet the expectations we discussed." If this process is consistent, objective, and fair, it will improve performance, change behavior, or remove the employee from the company. t he result is a healthier and productive workforce. a nd, I think every provider could use that. hme Richard Davis is president and founder of HigherPower HR. He can be reached at rich- J O hn gallaghe R kelly g R ah O vac

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