Transcript Document

W W W . D I N S LA W . C O M
A Primer on CMS’ DMEPOS
Competitive Bidding Program
April 17, 2009
Mark A. McAndrew
Dinsmore & Shohl LLP
255 East Fifth Street
Cincinnati, OH 45202
513.977.8380
[email protected]
DME Competitive Bidding
• Section 302 of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (MMA)
(Pub. L. 108-173) mandated nationwide competitive
bidding for most DME.
• Objectives of the DME Competitive Bidding Program:
– To implement competitive bidding for DME and use the process
to determine appropriate prices for categories of DME covered
by Medicare Part B;
– To protect beneficiary access to quality DME;
– To reduce the amount Medicare pays for DME and bring the
reimbursement amount more in line with that of a competitive
market; and
– To reduce fraud.
2
Where are we?
April 10, 2007
CMS publishes final rules for the new Medicare
DMEPOS Competitive Bidding Program and moves to
implement the program in the ten largest MSAs
Summer 2007 Bids submitted from suppliers; CMS awards
approximately 325 contracts to qualified suppliers amid
widespread criticism from the industry
July 1, 2008
Program implemented
July 15, 2008
Medicare Improvements for Patients and Providers Act
of 2008 (MIPPA) enacted; supplier contracts
terminated; 18 month delay of competitive bidding
program implemented; Round 1 re-bid ordered for
2009.
3
Are we there yet?
January 16, 2009
CMS publishes interim final rules amending
changes to the original final rule as a result of
MIPPA
May 4, 2009
DME providers, as a condition of the issuance
or renewal of a provider number, and therefore
a requirement to bid must have a surety bond
of $50,000 in place
Summer 2009 (est.)
Bidder registration and submission of re-bids
for round one
September 30, 2009
Accreditation deadline
1st Quarter 2010 (est.)
Winners announced; re-bid implemented
4
Surety Bond Requirements
• As of May 4, 2009, applies to suppliers seeking to enroll or change
the ownership of a DMEPOS supplier.
• Applies to each assigned NPI for which the DMEPOS supplier is
seeking to obtain Medicare billing privileges.
• Existing DMEPOS suppliers have until October 2, 2009 to submit a
surety bond for each assigned NPI.
• Suppliers enrolling a new practice location also must submit a new
surety bond or an amendment or rider to the existing bond, showing
the new practice location is covered by an additional base surety
bond of $50,000.
• Some exemptions from bond requirements:
–
–
–
–
Certain physician and non-physician practitioners
OT, PT, speech language pathologists
Registered nurses, clinical nurse specialists
clinical social workers, clinical psychologists
5
Basic Information – Where?
• The Round One re-bid will occur in the following
MSAs:
– Cincinnati--Middletown (Ohio, Kentucky and Indiana)
– Cleveland--Elyria--Mentor (Ohio)
– Charlotte--Gastonia--Concord (North Carolina and
South Carolina)
– Dallas--Fort Worth--Arlington (Texas)
– Kansas City (Missouri and Kansas)
– Miami--Fort Lauderdale--Miami Beach (Florida)
– Orlando (Florida)
– Pittsburgh (Pennsylvania)
– Riverside--San Bernardino--Ontario (California)
6
Cincinnati--Middletown MSA
7
Cleveland--Elyria--Mentor MSA
8
Basic Information – What?
• The initial product categories chosen are:
–
–
–
–
–
–
–
–
–
–
Oxygen Supplies and Equipment
Standard Power Wheelchairs, Scooters, and Related Accessories
Complex Rehabilitative Power Wheelchairs and Related Accessories
Mail-Order Diabetic Supplies
Enteral Nutrients, Equipment, and Supplies
Continuous Positive Airway Pressure (CPAP) Devices, Respiratory
Assist Devices (RADs), and Related Supplies and Accessories
Hospital Beds and Related Accessories
Negative Pressure Wound Therapy (NPWT) Pumps and Related
Supplies and Accessories
Walkers and Related Accessories
Support Surfaces (group 2 mattresses and overlays) in Miami
– Final list of HCPCS codes will be published on the CIBC website at:
http://www.dmecompetitivebid.com prior to the opening of the bid
window.
9
Basic Information - Accreditation
• CMS has approved the following organizations for
accreditation:
–
–
–
–
–
–
–
–
–
–
The Joint Commission (www.jointcommission.org)
National Association of Boards of Pharmacy (www.nabp.net)
Board of Orthotist/Prosthetist Certification (www.bocusa.org)
The Compliance Team, Inc. (www.exemplaryprovider.com)
American Board for Certification in Orthotics & Prosthetics, Inc.
(www.abcop.org)
The National Board of Accreditation for Orthotic Suppliers
(www.nbaos.org)
Commission on Accreditation of Rehabilitation Facilities
(www.carf.org)
Community Health Accreditation Program (www.chapinc.org)
HealthCare Quality Association on Accreditation (www.hqaa.org)
Accreditation Commission for Health Care, Inc. (www.achs.org)
10
Bidder Eligibility and Qualifications
• Be in compliance with the supplier enrollment standards
• Disclosure of certain compliance-related issues
• All necessary licenses required to perform under the
program
• Satisfy quality standards
• Satisfy financial standards, including the submission of
tax, financial or other documents from the most recent
one year period
• Meet accreditation standards at the time of bid
submission unless a grace period applies
– For grace period to apply, a supplier must have submitted its application
for accreditation to a CMS approved accreditation organization and be
waiting for the process to be completed
11
Terms of Supplier Contracts with CMS
•
•
•
•
Three year term, subject to option/renewal
No discrimination against Medicare beneficiaries
Change of ownership notification requirements
Requirement to furnish items to any beneficiary
with permanent residence in, or who visits, CBA
• Certain remedies for supplier breaches
• Disclosure of subcontracting arrangements
12
Creation of Supplier Networks
• CMS expressly permits up to 20 small suppliers (i.e., those with less
than $3.5 million in annual gross revenues) to form networks to join
together to submit bids.
• Requirements:
– A single legal entity must be formed for the purpose of submitting
a bid as a network.
– All legal contracts must be in place and signed before the
network entity may submit a bid.
– No more than 20 members in the network.
– Only small suppliers that are unable independently to serve the
entire CBA may join the network.
– Network members can join only one network per product
category per CBA (i.e., a supplier can join different networks for
different product categories, or join different networks in different
CBAs).
13
Creation of Supplier Networks
• Requirements (cont.)
– Network members may not bid separately (i.e., independently)
for the same product category for which the network submits a
bid in the same CBA.
– Each member of the network must be independently eligible to
bid.
– For bid evaluation purposes, a network’s combined total market
share for each product category cannot exceed 20 percent of the
Medicare demand for that product category in the CBA at the
time of bidding. However, once a network receives a contract,
the network may expand and exceed the 20 percent capacity.
– Each member of a network must furnish all the items in the
product category for which the network is awarded a contract.
– Each member of the network must satisfy all eligibility, financial,
quality and accreditation requirements.
14
What Can You Do to Get Ready?
• Accreditation
• Pay close attention to timetables
– Strict requirements for bid information and follow up
information
– Make sure the application information is correct the
first time; no judicial review or reconsideration of
rejected bids
• If you plan to join a network or engage a
subcontractor, make sure your legal agreements
are carefully and tightly written.
15
Questions
Mark A. McAndrew
Dinsmore & Shohl LLP
255 East Fifth Street
Cincinnati, OH 45202
513.977.8380
[email protected]
16