American Association for Homecare About ABOUT AAHOMECARE - - PowerPoint PPT Presentation

American Association for Homecare

About

Introduction

ABOUT AAHOMECARE

• National voice for home medical equipment providers and

manufacturers in Washington.

• AAHomecare fights for fair regulations and sustainable

reimbursement rates from government payers.

• Member-driven association: guided by our council structure and

board of directors.

• Unifying voice for our industry though strong partnerships with

major stakeholder organizations and state/regional associations.

• Continuing to grow our membership.

YOUR ASSOCIATION, YOUR ADVOCATE, YOUR VOICE

AAHomecare Multi-Pronged Approach

AAHomecare is employing a wide range of resources and working on multiple fronts to achieve goals:

• Continued engagement with CMS, HHS & OMB

 Including Medicare, Medicare Part C, Medicaid, Duals Oversight Offices

• Maintaining interest on Capitol Hill
• Outside counsel & lobbying support
• HME community grassroots engagement

Going Forward

• Work towards relief for relief on rural and non rural

reimbursement rates – impacts broad range of payers.

• Advocate for fair, common-sense regulations that help us

put patients over paperwork.

• Work with state and regional association leaders on

Medicaid rates and other managed care payers

• Continue to grow AAHomecare so we can bring more

resources to fight for HME interests in Washington and at the state level, and continue to build the advocacy capacity of our industry.

Bey eyond M d Medicare e Reimbursement L Landscap ape

• Managed Care Market hiring consultants to save money

and lower employer health care expenses in competitive market place

• Most Consultants recommending large decreases in

DME and Supply Rates

• BCBS Association has a group focusing on cost savings

and value based networks exclusively

• BCBS WNY PAP Pay for Performance Pilot
• Carecentrix Collaboration

Payer Relations Resources

• WWW.AAHomecare.org
• https://www.aahomecare.org/advocacy/payer-relations-resources
• Cures Legislation for Medicare Advantage/Medicare-Based Plans

 Legal Language regarding plans pegging rates to Medicare and their obligations as rates change  Contractual Language may trump

• Medicare Regional Pricing Comparison

 Shows drastic rate decreases in Medicare Pricing  Use Opportunity to discuss CB Program and what it has done to industry

• True Cost of HME Study-Executive Summary

 Dobson Davanzo, LLC Completed-Actuary Firm in DC Area  Data and facts around unsustainable reimbursement based on Medicare rates

• Sample Provider Letter to DOD on Cures

 Information provided citing legislation tying reimbursement to Medicare rates  Use when rates change with Medicare and contractual renegotiations occur with contractors

• Summary of Medicaid Cures Implementation

 Information for discussion with State Medicaid Programs  Information for discussion with Medicaid MCO plans incorrectly linking rates to Medicare based on Cures  Use with “Federal Match for DME Expenditures & Medicaid Payment Rates Analysis (January 2017)-Legal Opinion from B&F

• New Supplier Tracking

 https://www.aahomecare.org/uploads/Document-Library/27dc166162dc8758a8a1abecb1531d7f.pdf  Information on Suppliers and Locations out of Business by State

Impact o

• f Competitive B

Bidding o

• n Medicare

Benefic icia iary ry Acc Access to to D DME ME

• The survey was completed by

428 patients, 358 case managers, and 266 suppliers.

• 52% of beneficiaries reported

problems.

• 77.6% of case managers

experienced difficulties with timeliness of discharge process due to HME access issues.

• 89% of case managers report

an inability to obtain DME in timely fashion.

• 62% of case managers say

patients are having medical complications, some of which result in readmission to the hospital.

Comparison of T Two I Independent S Studies

ATS Survey Dobson Davanzo Survey # of Respondents 1,926 1,064 (428 beneficiaries) Survey Timeframe 54 days (9/1/16- 10/24/16) 34 days (8/11/17-9/13/17) Geographic Focus Nationwide Survey, comprised of those in Competitive Bidding Areas (CBAs) and outside CBAs. Nationwide Survey, comprised of those in Competitive Bidding Areas (CBAs) and

• utside CBAs.

Process for Identifying Content for Survey Input from patient, advocacy, professional, and payor organizations Input from industry stakeholders, including former executives and advocacy personnel

Two S Studies R Respon

• nses
• ATS Study-51% of respondents reported “problems” in

accessing oxygen, DME, and services.

• Dobson Davanzo Study-52.1% of beneficiaries reporting

problems accessing DME and supplies.

• Both studies point to approximately half of patients who

require DME and supplies associated with oxygen therapy expressing or experiencing problems.

CURES Legislation

• Will limit the federal contribution for DMEPOS for 244 select E, K, and A codes.

List available from CMS or AAHomecare

• States can still set their own payment rates to ensure access to care.
• States do not have to do anything to be in compliance with this regulation.
• States will have to complete annual reconciliation by 3/30/2019.

 Primary Fee For Service Claims Only  No MCO  No secondary claims  Aggregate expenditure for HCPCS code listing only  Include area patient lives or reconciliation will occur to lowest Medicare

allowable in the state

• Medicare Rates Unsustainable Due to Flawed Competitive Bidding Program

Medicaid Landscape-CURES

• 75,179,773 Medicaid Enrollees Nationwide
• 72.70% of Medicaid Beneficiaries are enrolled in Medicaid MCO
• Cures impacting 20.5 million beneficiaries directly
• Cures impacting 54.6 million beneficiaries indirectly through

MCO plans following Medicaid rates

AAHomecare Cures Actions

• Guidance requested early 2017
• In Person Meeting with CMS to update guidance to include
• ption for Cures related HCPCS only and to provide HCPCS list-

September 2017

• CMS Webinar 12-7-17-First guidance from CMS-Missing

Information States Needed

• State Medicaid Director Letter-12/27/17 with 12/31/17 deadline
• Updated State Medicaid Director Letter-1-4-18
• Foley Hoag Engagement-CMS Pressure
• Legislative Pressure from Congress
• State Association Involvement
• 23 State Medicaid Meetings
• 6 Other States Involved with State Associations

State Responses on CURES

• 11 States changing rates to Medicare
• 6 States already at Medicare rates
• 13 States Not Changing Rates and will complete

reconciliation

• 10 States Analyzing Decision
• 1 State Accepted Proposal of limited codes

State Responses on CURES

CURES Medicaid Implemenation Analysis States Already At Or Below Medicare Rates (6) DC – Mississippi – Nevada [will be reducing to 2018 rates] – Virginia – West Virginia - California States Changing Rates to Medicare (11) Vermont [all HCPCS] – Montana [ll HCPCS but CRT] – Washington [all HCPCS but CRT] – Colorado [CURES codes only] – Kentucky [Cures codes only] -Alabama [CURES codes only] – North Dakota [CURES codes only] – Connecticut [CURES codes

• nly] – Maine [need information on which codes] – Massachusetts [need Information on which codes] - Tennessee [Cures

codes directive to MCO plans] States Not Changing Rates (13) Florida – Georgia – Hawaii – Michigan – Minnesota – North Carolina – Ohio – Pennsylvania – South Carolina – Iowa – Texas – Indiana – Rhode Island States Currently Analyzing Fee Schedule and Data (10) Oregon – Illinois – Kansas – New York – Oklahoma – New Hampshire – Wisconsin – Nebraska – South Dakota - Alaska

**Information based on meetings and/or discussions with state Medicaid plans or State Plan Amendments filed with CMS. Listing is subject to change as further analysis occurs. States not listed have not discussed their plans or filed State Plan Amendments.

Updated July 9, 2018

AZ & NM Responsibility with CURES

• MCO Plans are not included in legislation
• Secondary Claims not included in legislation
• Arizona 88.31% MCO
• New Mexico-88.81% MCO
• To date no SPA updates posted
• Work with State Medicaid programs as necessary
• Partner with MCO plans and SWMESA as necessary

Medicaid MCO Strategy

• State associations relationships with state Medicaid

programs even when population is mainly MCO

• Collaborate with state associations and state

Medicaid programs to evaluate RFP for new MCO states and existing as they are up for renewal

• Some states have allowed for submission of

regulations for review by state to be entered into RFP

 consistent medical policy  consistent prior approval policy  Medicaid rate floor  Timeframes for switching plans

Engage S State Le Legislators to Better O Our Industry

• State Legislative Day on the Hill
• Consistent Meetings/Relationship Building
• Reach out for help with state Medicaid programs
• Impact is on jobs in the state-commercial payer stance

State Legislative Items-Not Just a Federal Fight

• Any Willing Provider
• Medicaid Rates-Payment Floor
• Medicaid Rates cannot follow competitive bidding
• No Audits for Medical Necessity for Prior Approved Items
• Consistent Medical Policy for State Medicaid Programs
• Audit and Recoupment timeframes
• Sole Source-Narrow Network Elimination or Approval
• Opt in or Out of Sole Source Arrangements
• MCO Ownership of own DME company
• Proof Of Delivery Consistency

State Legislative Items-Not Just a Federal Fight

• AZ Senate Health and Human Services Committee

» Senator Nancy Barto » Senator Kate Brophy McGee

• AZ House Health Committee

» Representative Heather Carter » Representative Regina Cobb

• NM Interim Legislative Health Human Services

Committee

» Representative Deborah Armstrong » Senator Gerald Ortiz y Pino

Tricare Contractor Changes/Cures Payback

• Tricare Contracts Changed Effective 1/1/2018
• Tricare West-HealthNet Federal Services

March 31, 2018-Last day to contact UHC for claims prior to 12/31/17. April 1, 2018-UHC Call center closed April 30, 2018-Last day to submit claims & appeals to UHC

• Tricare East-Humana Military Services

WPS-New Claims Processor

• Providers must enroll with WPS for EMC, ERA, and EFT
• Payer ID-TREST
• Backlog in claims on both contractors
• Backlog in providers being loaded into system
• Verify if you are on their provider network for all locations
• Tricare Cures Payback
• Formal Complaint to Defense Health Agency

Open Access for Quality Outcomes

• Workgroup developed to promote access to care,

patient choice, quality outcomes

• Working on reference materials to be used in

education with plans and legislative staff on importance of patient choice and issues with sole source arrangements

• Partner with Patient Advocacy Groups
• Patient and Case Manager Surveys
• Schedule meetings with payers limiting access to

care

Alternative Payment Methods for COPD

• Nick McMillan, MedGroup Workgroup Chair
• Respiratory Workgroup-Create an alternative

payment method that can be piloted to commercial payers and state Medicaid programs that enhances patient care and creates additional revenue for providers around COPD

• Care

e Plans ns C Completed ed

• Outcomes

es D Dev eveloped ped

• Marketing P

g Prese esentation C Compl pleted ed

• Sev

everal P Payers I Inter eres ested ed

REGULATORY AFFAIRS UPDATE

• Competitive Bidding:
• AAH submitted response to IFR, FY2019 President’s Budget, and MedPAC

Draft June Report. President’s budget and MedPac had expansion of Competitive Bidding included in reports.

• Met with Competitive Acquisitions Ombudsmen, CMS Program Integrity

Group, and is scheduled to meet with Ombudsman for manufacturers.

• Audit and Appeals:
• Currently 57% of appeals sitting at the ALJ are from DMEPOS.
• PMD PA Demonstration HCPCS extended to national PA program.
• CERT Improper Payment rate for DMEPOS is at 44%.

CERT IMPROPER PAYMENT RATE 2003-2017

14% 9% 74% 61% 66% 39% 46% 44% 0% 10% 20% 30% 40% 50% 60% 70% 80% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

ERROR RATE YEAR

AAH UNIQUE SUPPLIER NUMBERS

• Number of unique traditional suppliers have decreased by 33% since

implementation of CBP.

*ESIMATES BASED ON PDAC DATA AS OF JANUARY 20178.

9,769 8,837 7,158 6,538

• 2,000

4,000 6,000 8,000 10,000 12,000 11/10 7/13 7/17 1/18 SUPPLIERS YEAR

TOTAL NUMBER OF UNIQUE TRADITIONAL SUPPLIERS

AAH SUPPLIER LOCATION NUMBERS

• Number of traditional supplier locations have decreased by 31% since

implementation of CBP.

14,066 12,898 10,579 9,716

• 5,000

10,000 15,000 11/10 7/13 7/17 1/18 SUPPLIERS YEAR

TOTAL NUMBER OF TRADITIONAL SUPPLIER LOCATIONS

*ESIMATES BASED ON PDAC DATA AS OF JANUARY 20178.

HME Su Supplie lier M r Mark rket in Ar Arizona

• 34.3% of unique HME

suppliers in Arizona have gone out of business or been purchased since CB.

• 43.7% of DMEPOS locations

have closed since CB.

HME Su Supplie lier M r Mark rket in Ne New M Mexi xico

• 40.7% of unique HME

suppliers in New Mexico have gone out of business or been purchased since CB.

• 37.3% of DMEPOS locations

have closed since CB.

Accomplishments 2018 – so far

• CMS creates new appeal settlement option LVA allowing

low volume suppliers to settle without negotiation for 62% of allowed amount.

• CMS fixed an issue that has existed in the claims

processing systems for years where physicians who are no longer in PECOS due to retiring or expiring were not extended for 13 months to allow DMEPOS claims to

• process. Now even if a prescriber retires or expires,

claims will continue to be paid up to 13 months. Implemented 3/5/18. Suppliers can resubmit denied claims!

Lates est S Settlem ement Of Offer er!

• CMS will make available the Low Volume Appeals (LVA) option for certain

suppliers with appeals pending at OMHA and the Medicare Appeals Council.

• The option will allow for settlement of the outstanding appeal in exchange

for timely partial payment of 62% 62% of the net approved amount of the appeal.

• Must have less than 500 appeals across all your NPIs pending in total as of

November 3, 2017 at both OMHA and the Council levels.

• Appeal are eligible if: •pending before the OMHA and/or Council level of

appeal as of November 3, 2017; •The appeal has a total billed amount of $9,000 or less; •The appeal was properly and timely filed at the OMHA or Council level as of November 3, 2017; •The claims included in the appeal were denied by a Medicare contractor; •The claims included in the appeal were not part of an extrapolation; and •The appeal is still pending at the OMHA or Council level of review. You must settle all eligible appeals!!

Kim Brummett

LAURA WILLIARD

Vice President, Payer Relations

Lauraw@aahomecare.org Follow me on Twitter @williardlaura