In brief: President’s budget includes DME provisions, L codes up for prior auth

Friday, February 14, 2020

WASHINGTON – The President’s Fiscal Year 2021 Budget includes provisions that could impact the HME industry, including a proposal to expand competitive bidding to other geographic areas.

The budget, published Feb. 10, proposes that, beginning in 2024, the single payment amounts will be based on individual winning bid amounts (rather than the maximum winning bid methodology employed in Round 2021) and expands competitive bidding to other geographic areas, including rural areas, according to an analysis by AAHomecare. This proposal also appeared in last year’s budget, but this is the first time the president states a timeframe, says the association.

The budget also proposes using available retail prices to create the DME fee schedules, which AAHomecare says does not take associated services into account.

Additionally, the budget also calls for a “10% reduction from 2020 enacted levels” for the Department of Health and Human Services, and improved access to rural health care by expanding access to telemedicine services, according to an analysis by VGM Government Relations.

“History has shown that items listed in the budget can and do show up in legislation later in the year,” it stated in a blog.

Other DME-related provisions in the budget, which have appeared in past budgets, include: eliminating the face-to-face requirement; using a benefits manager for DME claims to reduce improper payments; and changing the appeals process.

Certain L codes up for prior authorization

ATLANTA – CMS plans to update the Federal Register today to add certain L codes to the prior authorization list for DMEPOS, according to the van Halem Group.

CMS will add the following codes to the list of items that require prior authorization as a condition of payment:

L5856 – (Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type)

L5857  – (Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type)

L5858 – (Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type)

L5973 – (Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source)

L5980 – (All lower extremity prostheses, flex foot system)

L5987 – (All lower extremity prosthesis, shank foot system with vertical loading pylon)

In phase one of the implementation on May 11, CMS will limit the prior authorization requirement to California, Michigan, Pennsylvania and Texas, one state in each of the four DME MAC jurisdictions.

In phase two on Oct. 8, CMS will expand the program to the remaining states in all four jurisdictions.

As part of the process, providers must submit prior authorization requests that include evidence that the item complies with all applicable Medicare coverage, coding and payment rules. Such evidence must include the order, relevant information from the beneficiary’s medical record and relevant supplier produced documentation. After receipt, CMS or one of its review contractors will conduct a medical review and communicate a decision that provisionally affirms or non-affirms the request.

CMS has previously added codes for power mobility and pressure reducing support surfaces to the prior authorization list.

Infusion stakeholders urge changes to home infusion benefit

WASHINGTON – The National Home Infusion Association and more than 250 stakeholders have asked CMS to overhaul home infusion therapy rules.

In a letter to HHS Secretary Alex Azar and CMS Administrator Seema Verma, they ask CMS to model reimbursement for home infusion after the private sector, which pays for services each day an infusion drug is administered.

Under the Medicare Part B model, payment is only made for days in which a “skilled professional,” is in the home. Under CMS’s interpretation, reimbursement for services by pharmacists and other professionals are not recognized.

“Numerous studies indicate that patients overwhelmingly prefer the home over other sites of care—and when they receive home infusion services, they are highly satisfied,” said NHIA President & CEO Connie Sullivan, BSPharm. “We urge CMS to reconsider their flawed interpretation of the benefit, which negatively impacts the ability of patients to get the care they need.”

The letter also cites concerns with delays in access to new FDA-approved medications, which currently can take over a year under the local coverage determination reconsideration process; and emphasizes that a patient’s decision about where to receive infusion therapy should be the result of a dialogue between the physician and patient—particularly given the impact on a patients’ quality of life and out-of-pocket costs.

NHIA in February 2019 filed a lawsuit against HHS over its reimbursement model for home infusion services.

Insulet identifies potential inaccuracy

ACTON, Mass. – Insulet has announced a voluntary medical device correction for its Omnipod DASH Personal Diabetes Managers. As part of an ongoing monitoring process, the company found that PDMs may suggest an inaccurate bolus amount based on a blood glucose value that is more than 10 minutes old when the user does not exit the bolus calculator as designed or when a system alarm interrupts a bolus calculation. No injuries have been reported and the Omnipod DASH is safe to use. All affected Omnipod DASH users are being notified by email and local mail, and replacement devices will be made available starting in March. Additional information can be found at

Ascensia participates in fundraiser

BASEL, Switzerland – Ascensia Diabetes Care is supporting the 2020 Spare a Rose Campaign, a fundraiser to provide insulin, testing supplies and education for children with Type 1 diabetes in countries with limited access. The Spare a Rose campaign, created by Life for a Child, encourages people to buy at least one less rose for their loved ones on Valentine’s day and instead donate $5 to Life for a Child. Ascensia will match employee donations up to $8,500, representing one rose per employee. Over the past two years, Ascensia and its employees have donated more than $23,000 to Life for a Child. “We are delighted to be supporting Life for a Child for the third time, as we believe in the ability of this campaign to change the lives of young people with diabetes,” said Robert Schumm, diabetes management domain head and head of BGM Business at Ascensia.

Numotion to distribute NOW Technologies products

BRENTWOOD, Tenn. – Numotion has partnered with NOW Technologies to distribute its power wheelchair control systems. Numotion will also leverage the company’s clinical experts and collaborate with them on future product design. “This partnership has the potential to bring incredible change for people living with disabilities,” said Numotion CEO Mike Swinford. “We see a path to create major leaps forward in how users interact with their power wheelchair, as well as other technology, which is long overdue.” Budapest-based NOW Technologies has received awards in Europe for innovation and social impact. Its Gyroset Glory and Gyroset Vigo are small, lightweight devices that resemble a mobile phone headset and that turn the wheelchair user’s head into a virtual joystick.

Amylior appoints Brad Peterson

VAUDREUIL-DORION, Quebec – Amylior has named Brad Peterson as vice president of sales, USA. Peterson has more than 30 years of experience in the complex rehab business as a clinician, provider and manufacturer’s rep. He has also presented at seminars and symposiums, including RESNA, Medtrade and the International Seating Symposium. “Brad will assume a key role in the U.S. business development and vision for our business,” said Sylvain Dugas, vice president of business development. Amylior is a privately owned company specializing in manufacturing high-end power wheelchairs and accessories in North America and abroad.

Rehab Medical leads employees to ‘Your Better Self’

INDIANAPOLIS – Rehab Medical and its affiliate of companies has invested $250,000 in a new “Your Better Self” initiative to improve its employees’ “mind, health and soul.” “The company is only as great as its employees,” said CEO Patrick McGinley. “This investment reinforces our commitment to our employees’ development.” Rehab Medical’s previously announced L.E.A.D program will be part of the “mind” component of the initiative, while a wellness program that helps employees find ways to improve their eating, sleeping and exercise will be part of the “health” component. Company culture and creating a positive work environment through team building initiatives will be part of the “soul” component. “With a clear focus of improving our patients’ and customers’ lives, it is important to also invest in ourselves,” McGinley said. “Your Better Self is designed to allow our employees to accomplish precisely this.”

Integra, QS/1 team up on iQ

ANACORTES, Wash. – Integra and QS/1 are combining their customer events into one “immersive, rich” iQ Conference. The inaugural combined conference will take place in Louisville, Ky., May 12-15, bringing institutional and community pharmacy stakeholders under one roof to share educational and networking opportunities. “Integra and QS/1 have a long history of engaging customers and making their conferences something pharmacy owners and staff anticipate nearly a year in advance,” said Kevin Welch, president of Smith Technologies. “By combining these two conferences into one, we are going to demonstrate how we are uniquely qualified to span the waterfront of healthcare pharmacy in ways that will elevate how our customers compete.” QS/1 recently launched a new interface for its System One and Point-of-Sale software solutions that seamlessly connects to Integra DeliveryTrack 6.1.

InfuSystem enters NPWT market

ROCHESTER HILLS, Mich. – InfuSystem Holdings, a provider of infusion pumps and related DME support services, has added negative pressure wound therapy to its Integrated Therapy Service platform. InfuSystem’s solutions will now include providing DME, overseeing logistics, supplying biomedical services and managing third-party billing for the product category. The provider added NPWT after a “premier global health care services company (sought) out InfuSystem and (its) expertise in providing clinic-to-home DME solutions,” says CEO Richard Dilorio. “We are excited to collaborate with a Top 10 health care services company on this new therapy,” he said. “As seen with past new business wins, the nature of our ITS business involves an initial period of on-boarding the participating facilities. We will soon begin that on-boarding, but we do not expect to see meaningful revenue from NPWT until the second half of this year.” InfuSystem projects the NPWT market to be $600 million per year.

CareCentrix receives certificate

HARTFORD, Conn. – CareCentrix has been recognized by independent analysts at the Great Place To Work Institute as a 2019-2020 Great Place to Work. The certification process considered feedback from more than half of the employees across the company’s six locations. “We are in a new era of what defines business success,” said CEO John Driscoll. “For business to compete and win today, we need to create companies that deliver for all of our teammates.” Great Place to Work defines a great workplace as one where employees trust their managers, take pride in what they do and enjoy the people they work with, according to a press release. It evaluates more than 60 elements of employee experience on the job. As part of the recognition, CareCentrix highlighted programs like its “CareCentrix Cares Fund” to help meet the critical needs of employees who are undergoing difficult challenges, and “The Women’s Network” to support and promote advancement of female teammates. CareCentrix has also been named a 2019 Top Workplace by the Tampa Bay Times.

LifeStation launches next gen medical alert device

UNION, N.J. – LifeStation, a provider of medical alert monitoring systems and connected health solutions for aging seniors and caregivers, has launched LifeStation Mobile LTE. The Mobile LTE leverages the company’s monitoring center, staffed with certified care specialists, to provide seniors with help quickly, anywhere in the country. It uses a proprietary combination of GPS, WiFi and Bluetooth to pinpoint a user’s location, even indoors. Other features of the device include its small size and light weight, its long battery life and its real-time diagnostics. Mobile LTE also integrates with the LifeStation skill on Amazon Alexa.

Survey: Media coverage of coronavirus drives run on surgical masks

ARLINGTON, Va. – Sixty-three percent of local pharmacists say customers are buying surgical masks as a precaution against the coronavirus, and 96% say they’re selling them faster than they can restock, according to a new survey from the National Community Pharmacists Association.

Respirator masks, hand sanitizer and gloves are also selling quickly, they say.

Thirty-two percent of pharmacists surveyed say the coronavirus is a significant public health threat, according to the survey. Forty-two percent disagree, while 26% are unsure.

Wall-to-wall news coverage of the coronavirus is driving concern among patients, even though only a handful of cases have been reported in the U.S., compared to China, where parts of the country are under quarantine, and other parts of the world.

“It’s wise to be prepared, but there’s no reason for Americans to panic,” said Brian Caswell, president of the NCPA and owner of Wolkar Pharmacy in Baxter Springs, Kan. “The flu kills tens of thousands of Americans every year. Only a handful of Americans have been diagnosed with coronavirus in this country and there are not yet any fatalities. Americans should remember to wash their hands frequently, avoid crowds if possible, and disinfect the things they touch.” 

RAC adds beds, manual wheelchairs to audits

WASHINGTON – The Recovery Audit Contractor (RAC) has received approval to audit hospital beds and manual wheelchairs, according to a bulletin from AAHomecare. The issue names are “Hospital Beds: Medical Necessity and Documentation Requirements” and “Manual Wheelchairs: Medical Necessity and Documentation Requirements.” These are both complex reviews and the RAC will be determining whether the items were reasonable and necessary based on the medical record. The RAC will be reviewing codes E0250 and E0260 for hospital beds and K0001 and K0003 for manual wheelchairs. The RAC will exclude claims that were paid more than three years prior to the additional documentation request date and claims with date of service on or after Jan. 1, 2020.

Healthline appoints new regional director

WITCHITA FALLS, Texas – Healthline Medical Equipment has named Dr. Gerald "Jerry" George Mannikarote as its new regional director of ventilation & clinical marketing. He has more than two decades of health care experience, including roles at Philips Health Care, Diabetes America and VOCSN Ventilators. In his new role, Mannikarote will lead Healthline’s ventilation and complex patient care efforts. “We are extremely pleased to add Jerry to our team here at Healthline,” said Michael Dick, chief strategy officer. “With his knowledge in the sleep and ventilation space and our desire to remain the top clinical respiratory provider in the state, we are poised to have a very busy 2020 and beyond." Healthline, which focuses on clinical respiratory and complex rehab services and supplies, has 14 locations in Texas.

Allegiance Group, BASYS integrate

OVERLAND PARK, Kan. – Allegiance Group, a provider of healthcare billing solutions, will partner with BASYS Processing, which offers customer service and credit/debit card processing solutions. The partnership will allow Allegiance to integrate its CollectPlus system with BASYS’ proprietary payment gateway to allow users to achieve better financial results, increase productivity and streamline workflows. “Allegiance Group has partnered with BASYS because of their superior product platform capabilities and dedication to providing exceptional service for our customers,” said Bruce Gehring, senior vice president, business development manager for Allegiance Group. “Both companies agree the collaboration will allow our providers to capture patient payment information conveniently, securely and more cost effectively.”