CMS does about-face on re-supply items

BALTIMORE - CMS plans to change the requirements for certain respiratory supply re-orders and that will have a direct impact on how providers do business, say industry stakeholders.

The biggest change: Providers can no longer replace an item unless the beneficiary's current item doesn't work.

"Now, it's not, 'You are eligible for a new mask,' it's, 'You are eligible for a new mask but is your current mask leaking?'" said Jason Holzman, general manager for cpapdropship.com.

In a notice published June 8, CMS states that for items that need periodic replacement, like PAP and respiratory assist device supplies, providers must determine whether the items remain functional and they can only provide replacements when the supplies are no longer functional.

The change contrasts with CMS's local coverage determination (LCD) for PAP, which allows supplies like cushions, headgear, tubing and filters to be replaced every three months.

"CMS has clearly established quantity replacement guidelines for all these products," said one stakeholder. "Now it would seem they are implying those guidelines are not valid."

Also problematic: The change, as currently described, is really vague.

"What's dysfunctional?" says Scott Lloyd, president of Extrakare in Norcross, Ga. "With CPAP tubing, does there have to be a hole in it or can the patient just suspect an accumulation of bacteria?"

Additionally, stakeholders worry if providers have to wait if an item is no longer functioning to replace it, that will affect compliance, which affects not only the patient's health but also their reimbursement.

"Patient outcomes need to be more closely considered in this case," said one stakeholder. "Many times over the years, patients will present to the HME provider with complaints of, 'My therapy doesn't seem to work anymore.' Upon questioning, it is learned the appliance is old, poorly fitting now, and just plain worn out."

While the change seemed to come out of nowhere, it's likely in response to the overall increase of auto-shipment of supplies, like glucose test strips, say stakeholders.

"I think Medicare's goal is to eliminate auto replacement of supplies when they're not needed," said Sylvia Toscano, owner of Professional Medical Administrators. "But, I think the practicality portion of this wasn't considered."