Transcript Medicare Part B Reimbursement

It’s 2007!
Mandatory Accreditation is Here!
Are You Prepared?
Wednesday, April 25, 2007
MedTrade Spring
Mary Ellen Conway
President
Overview
• What is the accreditation requirement?
• Who are the recognized accreditation
providers?
• When do YOU need to be ready?
• First 10 MSA’s, Next 80
• First Ten Products for Bidding
• Final Quality Standards
• Inconspicuous Items”
• Concerns
2
Overview Continued
• Clarifications
• Every Organization’s “Must Haves”
• Accreditation choices- tips to use in your selection
• How do you get started?
• Review of the Final Quality Standards
• Review of the recognized Accreditation Providers
• Ten things you can do now to be ready
3
What is the Accreditation Requirement?
• The Medicare Modernization
Act of 2003 (MMA ’03) states
that ALL DME Providers
billing Medicare for identified
Part B products must be
accredited by 2007--- this will
be enforced initially through
the Competitive Bidding
Requirement
• January 26 announcement
rescinded BUT TODAY???
4
The “Dominos”
• CMS is enforcing the law that requires
competitive bidding in 2007
(Now April 2008)
• Only accredited organizations can submit a
bid and “compete” in the bidding process
• Accreditation must be by “recognized”
accreditors
• Provider must comply with Final Quality
Standards (Released 8-14-06)
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Who Are the Recognized Accreditors?
…And then there were ten…
Changed January 2007
JCAHO
NB of A for Orthotic Suppliers
CHAP
CARF
HQAA
BOC
ACHC
NABP
ABC of O&P
The Compliance Team
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When Does Competitive Bidding
Begin and Where?
• Competitive bidding “rolls out” in
2007 in 10 Metropolitan Statistical
Areas (MSA’s) and in 80 in 2009
– Excludes New York, Chicago and Los
Angeles in 2007
• Only accredited providers can
participate in competitive bidding
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The First 10 MSA’s
Temporarily Listed on CMS Website
at 9:00 AM 3/30/07
Charlotte-Gastonia-Concord: NC-SC
Cincinnati-Middletown, OH-KY-IN
Cleveland-Elyria-Mentor, OH
Dallas-FT Worth-Arlington, TX
Kansas City, KS-MO
Miami, Ft Lauderdale, Miami Beach, FL
Riverside, San Bernadino, Ontario, CA
Orlando, Kissimmee, FL
Pittsburgh, PA
San Juan, Caguas, Guaynabo, Puerto Rico
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The Top 20 MSA’s Were
Charlotte
Miami
Riverside, CA
Phoenix
Cincinnati
Houston
Dallas
Orlando
Tampa
Cleveland
Boston
Kansas City, MO and KS
Pittsburgh
San Francisco
Atlanta
San Juan
St. Louis
Detroit
Seattle
Philadelphia
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Next 80 Largest MSA’s
Los Angeles
Washington, DC
Nassua/Suffolk
Portland, OR
Ft Lauderdale
Columbus, OH
Salk Lake City
Providence. RI
Middlesex/Somerset
Jacksonville
New York
St Louis, MO/IL
Oakland, CA
Ft Worth, TX
Indianapolis
Milwaukee
Greensboro, NC
Raleigh/Durham
Memphis
Rochester, NY
Chicago
Richmond, VA
Denver
Las Vegas
San Antonio
Bergen, NJ
Austin
Hartford
W Palm/Boca
Grand Rapids
San Diego
Louisville
Newark, NJ
San Jose, CA
Virginia Beach
New Orleans
Nashville
Buffalo
Monmouth
Fresno
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Next 80 Largest MSA’s Con’t
Oklahoma City Greenville, SC
Albany
Tucson
Syracuse
Omaha
Knoxville
El Paso
Allentown, PA
Harrisburg
Jersey City
Baton Rouge
Little Rock
Ann Arbor
Charleston
New Haven, CT
McAllen/Edinburg, TX
Dayton, OH
Honolulu
Tulsa
Ventura, CA
Albuquerque
Akron
Bakersfield
Gary, IN
Scranton
Toledo, OH
Youngstown, OH
Springfield, MA
Stockton, CA
Wichita
Mobile, AL
Columbia, SC
Sarasota/Bradenton
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In order to bid in the first round
• You must be accredited by August 31st!
• Means:
– Survey scheduled by early- mid July
– Work through all process through May/June
NOT MUCH TIME!
12
The MSA
Uses US Census Data
– Applies to defined Zip Codes
where the beneficiary resides,
not where the provider is located
– Was excluding Mail Order in the
First Round, but now includes
only diabetic supplies via mail
order
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When Do You Need to Be Ready?
•
If you provide any of the identified products or services to Medicare
beneficiaries in any of the first 10 defined areas and wish to
continue, you will be required to bid.
•
In order to bid, you will need to be accredited.
•
If you provide products and services to Medicare beneficiaries in
such areas as who are NOT in the first defined service areas, you
may be required to participate in Competitive Bidding in 2009 (80
MSA’s identified for Competitive Bidding in 2009)
•
All mail order starts in 2009 in the First 10 MSA’s and the
subsequent 70.
•
All others are required to be accredited (whether or not there is
Competitive Bidding in your service area) as early as 2009-2010—
TODAY”S ANNOUNCEMENT
14
What if You Provide Products and
Services in Rural Areas Only?
• You may never have to participate in Competitive
Bidding
• You will get a rate adjustment as CMS will begin to
reimburse providers the rates paid in the closest
MSA’s
• You must be accredited by some date- no finite date
released yet.
– CMS advisory released Friday, January 26 (CR 5415
Transmittal 188) rescinded
15
Current Legislative Activity
• Tanner Hobson (formerly Hobson Tanner)
www.aahomecare.org Advocacy Updates
Also: Price Repeal of 36 mo Oxygen Cap (H.R. 621)
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Final Product Categories
1. Oxygen Supplies and Equipment
2. Standard Power Wheelchairs, Scooters
and Related Accessories
3. Complex Rehab Power Chairs and
Related Accessories
4. Mail Order Diabetic Supplies
5. Enteral Nutrients, Equipment and
Supplies
6. CPAP, RAD’s and Related Supplies and
Accessories
7. Hospital Beds and Related Accessories
8. Negative Pressure Wound Therapy
Pumps and Related Supplies and
Accessories
9. Walkers and Related Accessories
10. Support Surfaces (Groups 2 and 3
mattresses and overlays) in Miami and
San Juan only
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Product Selection
• CMS selected products for CB based on:
– High cost
– High-volume
– Greatest potential for savings
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Final Quality Standards
• Were released on 8-14-06 !!!
• 14 pages—as compared to 104 in September 2005
• VERY MINIMAL compared to proposed standardsbut don’t be fooled!
Found on the CMS website at: (http://www.)
cms.hhs.gov/CompetitiveAcqforDMEPOS/04_New_Quality_Standards.asp
• Compliance with these standards will be enforced
through the accreditation provider you select
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Final Supplier Quality Standards
2 Sections
First Section: Business Services
– Administration
– Financial Management
– Human Resource Management
– Consumer Services
– Performance Management
– Product Safety
– Information Management
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Final Supplier Quality Standards
Second Section: General Product Specific
Service Standards
• Preparation
– Intake
– Beneficiary Record
• Delivery and Set-Up
• Training/Instruction to Beneficiary and
Caregiver
• Follow-up
21
Final Supplier Quality Standards
Appendix A- C
A: Respiratory Equipment, Supplies
and Services
– Oxygen concentrators, reservoirs, high pressure cylinders,
oxygen accessories and supplies, oxygen conserving
devices
– Home invasive mechanical ventilators
– CPAP Devices
– Respiratory Assist Devices
– IPPPB Devices
– Nebulizers
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Final Supplier Quality Standards
Appendix A- C
B: Manual Wheelchairs, Power Mobility
Devices, Complex Rehab and
Assistive Technology
Key Issues in Complex Rehab and Assistive Technology:
– Check items listed
– Employ at least one qualified RTS per location
– Provide appropriate equipment for trial
– Provide private, clean and safe rooms appropriate for fitting
and evaluation
– Maintain a repair shop located in the facility
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Final Supplier Quality Standards
Appendix A- C
C: Custom Fabricated, Custom Fitted,
Custom-made Orthotics, Prosthetic
Devices, Somatic, Ocular and Facial
Prosthetics and Therapeutic Shoes
and Inserts
• Not off-the-shelf items
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Final Standards
Administrative
1. Obtains and supplies appropriate quality equipment, items and
services
2. Have a physical location and display all licenses, certificates and
permits
3. FDA approved items and obtain copies of features, warranties and
instructions
4. Comply with Medicare policies (coverage, claims processing,
payment policies and disclosure of ownership) Example:
Disbarment List www.oig.hhs.gov/fraud/exclusions.html
5. Implement business practices to prevent and control fraud, waste
and abuse
6. Use procedures that articulate standards of conduct that ensure
compliance with appl. laws and regs.
7. Designate leader(s) responsible for compliance issues
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Final Standards
Financial Management
1. Implement financial management practices that ensure
accurate accounting and billing.
2. Accurate, complete and current financial records
3. Cash or accrual based accounting
4. Link equipment to client
5. Manage revenues and expenses on an ongoing basis:
•
Reconcile charges with invoices, receipts and deposits
•
Operating budget
•
Mechanism to track actual revenues and expenses
26
Final Standards
Human Resource Management
Implement policies on:
Specific qualifications
Training
Experience
Continuing education requirements
Technical personnel:
Competent
Licensed, certified or registered (and current copies on file)
27
Final Standards
Consumer Services
Provide clear instructions on use, maintenance and
potential hazards of item(s)
Provide expected time frame for receipt of delivered
item(s)
Verify item/service was received
Provide contact information and options for rental or
purchase
Provide information and telephone numbers for
customer assistance:
Regular business hours, after hours, repair, emergencies
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Final Standards
Performance Management
Implement performance management plan that
measures outcomes of customer service,
billing practices and adverse events. At a
minimum, measure:
– Beneficiary satisfaction and complaints
– Timeliness of response to questions, problems and
concerns
– Impact of business practices on adequacy of beneficiary
access to items, services, information
– Frequency of billing/coding errors
– Adverse events
29
Final Standards
Product Safety
Equipment management program that promotes the safe
use of equipment and minimizes safety risks and
hazards including:
1. Plan for identifying, monitoring and reporting failures, repair
and preventive maintenance
2. Investigate any accident or injury (within 72 hours or 24
hours if results in hospitalization or death)
3. Contingency plan for response to emergencies and
disasters
30
Final Standards
Information Management
Maintain accurate, pertinent, accessible,
confidential and secure records in accordance
with HIPAA and any state standards
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Other “Inconspicuous” Items
Health screenings, drug testing and criminal
background checks
• According to state requirements
Infection Control
• No specific requirement, but certainly required by
accreditors
Mail Order
• “Verify” training and instructions at the time of initial
mail order delivery
32
Many Concerns
• This is not the program that was used in
the demonstration project that Congress
had in mind when they were voting on this
in 2003
• CMS has been VERY far behind in their
timeline
• They are basing components of the
program on information that may be
inadequate
– Focus groups (44 participants in 22 states)
33
Clarifications
• Final Rule was released on
April 2, 2007
• Networks-TODAY
• Use of American Association for
Respiratory Care Practice
Guidelines (last updated in 1992)
34
Every Organization’s “Must Haves”
• Policy and Procedure Manual
• Complete and Accurate Paperwork for
Patients
• Updated/Complete Educational Materials
• Competency Program
• Complete PI Program
35
Must Have # 1:
Complete Policy and Procedure Manual
•Must meet the needs and
requirements of the accreditation
provider you select
•Not worth trying to create on
your own at this point
36
Must Have # 2:
Complete Paperwork for Patients
Such as:
Consent for Treatment/Services
AOB
Third Party Review
HIPAA Information
Disaster/Emergency Preparedness
How to Reach the Office (Hours)
37
Must Have # 3:
Updated Educational Materials
Many of the requirements of
the standards speak directly
to the educational materials
you provide to your patients
38
Must Have # 4:
Competency Program
•Review the requirements of
your accreditor and be sure
you meet them
•Generally only technical
staff are required to have
competency evaluated
•Can be written (testing) but
must be observed for
technical staff
39
Must Have # 5
Performance Management
1. Beneficiary satisfaction surveys
2. Patient complaint log
3. After hours (on call) log to prove
timeliness of response to questions,
problems and concerns
4. Log that documents frequency of billing
and/or coding errors
5. Log documenting adverse events (as
defined by your P & P manual)
Most accrediting organizations require at
least three months of surveys collected and
summarized with plans for improvement or
you will have to provide written follow-up
and possible a re-visit
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How Do I Get Started???
Tips to Use in Choosing Your Accreditor
• CMS is not your only payer!
– Payer or state licensure requirements to be accredited
• What is the accreditor’s schedule and what are the
requirements for in-between?
– Ex:triennial and 18 month written update
• Fees paid vs. administrative costs
• Network participation
• Other services (infusion, home health)
• Process (electronic vs. paper)
• Interview/discussions with accrediting organization—
your perceptions
• Your peer’s experience
42
The Current
Ten Recognized Accreditors
Comparing “Apples-to-Apples”
Product Category Definitions
DME Limited
Mobility Aids: Manual W/C, Cane, Walker, Crutches,
Stationary Commode Chairs, Wound Care and Ostomy Supplies
Urological Supplies: Bedpans, Urinals
DME includes Limited and- Manual and Electric Beds, Traction Equipment
Medical Supplies-
Diabetic Supplies, Enteral Products (Non-home visit items)
Respiratory-
Home medical equipment and supplies covered include respiratory
equipment and supplies, oxygen, concentrators, reservoirs,
conserving devices, cylinders and oxygen accessories and supplies,
home invasive mechanical ventilators, respiratory assist devices,
continuous and intermittent positive pressure breathing devices,
nebulizers
Rehabilitation-
Power Mobility devices including complex Rehab and Assistive
Technology
Orthotics and Prosthetics- Custom fabricated, custom fitted, custom-made orthotics, prosthetic
devices, somatic, ocular and facial prosthetics, therapeutic shoes, braces
and artificial limbs
44
Accreditation Commission for
Healthcare (ACHC)
www.achc.org
DME- All Equipment
Medical Suppliers (Pharmacies)
Respiratory
Rehabilitation
Orthotics and Prosthetics
45
American Board of Certification for
Orthotics and Prosthetics (ABC of O&P)
www.abcop.org
Orthotics and Prosthetics
DME Limited- Wound Care/Incontinence,
Mobility Aids only if in conjunction with O&P
Merged with the Board for Certification in
Pedorthics (www.cpeds.org)
46
Board of Orthotic/Prosthetist
Certification (BOC)
www.bocusa.org
DME- All Equipment
Medical Suppliers (Pharmacies)
Respiratory
Orthotics and Prosthetics
47
Commission on Accreditation of
Rehabilitation Facilities (CARF)
www.carf.org
Rehabilitation
Orthotics and Prosthetics
48
Community Health Accreditation
Program (CHAP)
www.chapinc.org
DME- All Equipment
Medical Suppliers (Pharmacies)
Respiratory
Rehabilitation
Orthotics and Prosthetics
49
The Compliance Team
www.exemplaryprovider.com
DME- All Equipment
Medical Suppliers (Pharmacies)
Respiratory
Rehabilitation
Orthotics and Prosthetics
50
Healthcare Quality Association on
Accreditation (HQAA)
www.hqaa.org
DME- All Equipment
Medical Suppliers (Pharmacies)
Respiratory
Rehabilitation
Orthotics and Prosthetics
51
Joint Commission (JCAHO)
www.jcaho.org
DME- All Equipment
Medical Suppliers (Pharmacies)
Respiratory
Rehabilitation
Orthotics and Prosthetics
52
National Association of Boards of
Pharmacy (NABP)
www.nabp.net
DME Limited- Wound Care/Incontinence,
Mobility Aids
Medical Suppliers (Pharmacies)
53
National Board of Accreditation for
Orthotic Suppliers (NBAOS)
www.nbaos.org
Orthotics and Prosthetics
54
10 Things You Can Do
10. Download and become VERY comfortable with the
final quality standards---read them carefully
9. Monitor the activity of the first 10 MSA’s and
updates from the recognized accreditors
8.
Review and talk to your payers to make an
informed decision as you choose your
accreditation provider---especially if you are in
any of the first 10 MSA’s
7.
Send for your accreditor’s standards and then
review and update your P&P (or BUY one!)
Identify your team(s)--- review the standards by
team and identify what you need to do
6.
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10 Things You can Do
5
Create a work plan based on what you need to
accomplish (Sample at www.homecaremag.com
March 2006 issue)
4. Create/review your PI program NOW– begin to
collect patient satisfaction data and implement the
required logs ASAP--- Gather at least 3 mos of data
before notifying accreditor that you are ready
3. Review all patient education materials to see what
you will need to update/change so that they match
the final standards
2. Review physical plant, warehouse, vehicles
1. Perform a Mock Survey- make corrections
Notify your provider that you’re ready!
56
Stay Tuned!
• Work with AAHC on legislative endeavors• More updates from the Recognized
Accreditors
• Conferences held by the “CBIC” to instruct on
Competitive Bidding Applications
• Pricing for items for bid in the MSA
57
The Most Effective Way to
Survive and Thrive in Your
Business is to
Be Prepared
58
Your Questions ???
59
Thank You!
Mary Ellen Conway
President
Capital Healthcare Group, LLC
Bethesda, MD
301-896-0193
www.capitalhealthcaregroup.com
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