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Clint Geffert
Clint Geffert is president of VGM & Associates

If you’re anything like my family, making a visit to the local cinema to watch the new Star Wars film was a must-do. My three boys were fascinated with the movie and characters, just as the original Star Wars had captured imaginations a generation ago. Based on the enormous box office numbers, it’s still a great time to be in the Star Wars business, just as it was when the original movie premiered in 1977.

The original Star Wars debut coincided with the beginning of the modern DME business. The Health Care Financing Administration launched a DME demonstration project in 1976 that helped lay the ground work for the evolutions in wheelchairs and home oxygen, among other assistive technology used outside institutional settings. 

The 38 years between Star Wars’ first and most recent editions brought tremendous growth in HME. There are some surprising statistics for this time period regarding demographic changes in the U.S. 

There were 24 million Americans 65 and older in 1977. Today there are 48 million. That’s an increase of 24 million seniors in a span of 38 years. But in the next 15 years, we’re going to add 26 million more seniors. There will be 3 million more people over 85 in 15 years, five times the number than when Star Wars originally debuted. 

In 1977, 13% of America was obese. Today 36% of Americans are obese and by 2030 that will likely reach to nearly half the U.S. population. Fourteen million more Americans have diabetes than in 1977. Sadly, on many measures of health, our society is much worse off today than back in 1977. 

Today, approximately 90% of our population has health insurance coverage of some type. Perhaps surprisingly, that’s about the same level of coverage as there was back in 1977. But in between, the insured rate dropped to less than 80%. There are 16 million more people with a third-party payer, as compared to a few years ago, which is a huge win for healthcare providers of all types. 

It’s also worth noting that seniors still are not asking, “How soon can I move to the nursing home?” There are very few markets with this type of growth built into the next two decades.

Just as Jedis must combat the forces from the dark side, we in HME face daunting challenges. Reimbursement rates continue to decline, payers are narrowing open panels, and restrictive regulatory requirements cut into our business. HME suppliers must make changes in order to thrive. New revenue sources are needed—from capturing more market share of key referral sources, to offering compelling solutions beyond equipment, to adopting new products and technologies, to implementing cash business, to targeting more cost-effective operations. Make no mistake: These required changes will involve more tough decisions and some pain. But there will be a payoff. Investors are actively buying up HME assets and operations; they see the long-term opportunity.

The Star Wars franchise is alive and well, with even more movies to come. Our HME industry is also alive and well. Sure we face immense challenges, but the future is bright for those willing to mimic Luke Skywalker and persevere, adjust and evolve to meet the needs of the rapidly growing market.

George Kucka
George Kucka is president and CEO of Fairmeadows Home Health Care.

Historically, items like hospital beds, oxygen tanks and concentrators, wheelchairs, commodes, ambulatory aids, compressors and other items that could be used to support a medical need on an ongoing basis were referred to as DME. This is clearly an accurate, but one-dimensional definition.

Health insurance carriers, Medicare included, covered these items as a “DME” benefit when a doctor indicated that there was medical necessity requiring the use of any of these items.

This one-dimensional view of DME never took into consideration that the item is DME, but providing these items is HME services. Providing medical equipment services to patients in their homes has never been one-dimensional.

From the beginning, HME services has always been multi-dimensional. In almost all cases, the patients needing DME required the following:

1.   Delivery

2.   A home assessment to verify the appropriateness and safety of the prescribed item.

3.   Set-up

4.   Instruction:

  • On use and operation with return demonstration.
  • Maintenance.
  • How to seek assistance in the case of operational failure.
  • How to report changes in medical conditions

5.   Assistance in verifying insurance coverage.

6.   Gathering needed documentation to support the medical necessity for such items.

7.   24/7 availability of assistance for emergency after hours and holiday service.

8.   Billing insurance carriers on behalf of the patients and caregivers.

9.   Advocating on behalf of the patient where reimbursement was challenged by the insurance carriers.

10.      Eventually, in most instances, the retrieval of such DME items where purchase was not met.

This is HME services. This is what has always been required, this is what patients and their insurance carriers were paying for, never was it only the DME.

For a provider to adequately support patients with HME services, the providers needed to do the following:

1.    Hire and train staff in the following disciplines:

  • All insurance carriers coverage criteria for all DME items
  • Communication with medical professionals
  • Communication with ailing patients and non-medical caregivers.
  • The operation and maintenance in all types of DME items.
  • Sanitation and reconditioning of returned DME items.
  • Safe vehicle practices and maintenance processes.

2.    Establish communication processes that make the provider available to patients 24/7 for emergency service.

3.   Establish processes for internal communication on handling patient needs

4.   Procure necessary transportation equipment

5.   Procure necessary communication equipment and services such as pagers, cell phones, computers, and answering services.

6.   Where required, become licensed and/or certified in their state to operate.

7.   Undergo elaborate, expensive accreditation preparation and surveys.

8.   FDA licensure for oxygen

9.   Have associates go through rigorous manufacturer training programs to become proficient in the operation and maintenance of all DME items.

DME is one-dimensional; it refers only to the items. HME services is multi-dimensional and specific to the home and everything that is necessary to help patients maintain themselves safely in their own places of residences.

A 1,000-bed hospital facility can operate with an economy of scale. They can inventory and staff accordingly, knowing that their patients are in a compact, defined area. HME providers run 1,000-bed hospitals in 1,000 different locations. They need to inventory, staff and maintain the logistics and communication procedures to service 1,000 patients in 1,000 different locations when needed, 24/7.

Since 1965, when Medicare was implemented, the array of medical equipment designed to maintain patients at home has exploded. Items have become more technical, more reliable, easier for patients and caregivers to use, and more accessible to patients in need in a timely manner.

In 1965, HME services were provided by delivery technicians and, occasionally, respiratory therapists. Today, HME services are more sophisticated and technical, and need to be provided by highly trained clinicians with multiple disciplinary backgrounds: pharmacists, nurses, dieticians, diabetic counselors, physical therapists, respiratory therapists, etc.

In 1985, the average length of stay in a hospital was 8.5 days.  Today, the average length of stay is less than 4.5 days. One of the main reasons for this drastic reduction in the length of stay is because of the development and availability of more sophisticated HME items to help get and maintain sicker patients back to their home environment sooner.

Healthcare costs are soaring out of control in the skilled environments. In such environments, patients incur costs for their health care, their healthcare items, their room and their board. At home, the only costs are the healthcare services that keep them safely at home.

Today, HME services are still viewed by payers and legislators as DME, a one-dimensional line item, and reimbursement rates are shrinking to the point that the following is happening:

1.    There is almost no R&D to develop new technology to help even sicker patients get home sooner.

2.   The provider base has been reduced so that timely availability of services is more and more difficult to find.

3.   Patients are staying longer in skilled environments due to lack of accessibility.

4.   Providers that are still in business are forced to cut back staff and, therefore, services.

5.   The ill patients and caregivers are being forced to find ways to get to providers for services or go without.

6.   Providers are forced to buy equipment based upon cost, not reliability.

CMS can talk all they want about how the quality of care has not been affected by lower reimbursement rates, but the reality is that nowhere in the country where there is national competitive bidding are Medicare patients being cared for as well as areas not yet affected by NCB.

If Medicare wants to create a warehouse in each state where patients can go and take what they need off the shelf by themselves, take it home, learn how to safely use it, then you can talk about DME. By definition, ailing patients can’t do that and need individual and personal care to save money by keeping and maintaining safely in the cost effective environment of their home.

HME services is multi-dimensional and needs to be recognized and reimbursed as such to be effective. DME is a tool requiring HME services to make it work.  

Between 2007 and 2013, by Medicare’s own figures, the cost of Part A increased 70%. In that same time frame, Part B remained flat despite more people turning 65 daily. Contrary to the common wisdom, Part A and Part B are related. If HME services are not recognized and supported, Part A will continue to spiral out of control.

DME is what we use, HME services is what we do. HME services saves lives—and healthcare dollars.

George Kucka is president and CEO of Fairmeadows Home Health Care. He is a member of AAHomecare’s board of directors and chairs the association’s HME/Respiratory Therapy Council. He is also a member of AAHomecare’s Regulatory Council and its State Leaders Council. Additionally, Kucka is secretary for the Great Lakes Association of Home Medical Equipment Services and treasurer for the Indiana Pharmacist Alliance.

It is with great sadness and shock that I learned this morning of Van Miller's passing. Van Miller, the founder of the VGM Group passed away Sunday at his home. Van has indeed been a hero in our industry and the truest of friends! Regardless of whether you ever belonged to VGM or not, Van Miller was always there to help! Few people I have ever associated with in my life have ever left me with the impression Van Miller left with me. Van Miller was inspiring! One could not help but to be motivated when he was engaging you. Van Miller was an extraordinary figure to so many, but wanted most, to simply appear ordinary.

Van and I had our best talk ever about a year ago, at a great VGM event, as they are, always! Van and I talked about our past, and come to find out, we both had served in the United States Army, and we were both Combat Medics! This was a bond that brought us together in a special way and a conversation I will always cherish. A couple weeks after that, I sent him one of my old unit patches. About a week later, he sent me a note back, thanking me for the patch and ensured me it was going amongst other treasures that adorned his office! I recently had the good fortune just weeks ago to spend some quality time with him again, and I am grateful that I did. I even told my wife after my last visit with Van that if I had to work for someone, I could work for Van Miller!

To all my friends at The VGM Group, a big part of our MAMES family, I can't imagine the sadness you are feeling and the void you must be experiencing. I pray for your strength and perseverance through these very sad times. While there is no doubt VGM is strong, it has lost a great leader. But any of us who know the character of the VGM team, know you will continue to make Van proud as he looks down from heaven, because that is who each of you are, and you wouldn’t have it any other way.

To Christine, Vance, Dax, Christopher and the whole Miller family, words cannot begin to express the sadness we feel for the heart break you must be experiencing. You will remain in our prayers and know we are thinking of you. Thank you for sharing this amazing man with us, we are so blessed, as you are to have had him in our lives!

Van Miller, thank you for being in our lives and engaged so fiercely and so passionately in our industry. Because of you, we truly are better off! Van Miller will be sorely missed and never replaced.

May you rest in peace my friend!

Patrick Naeger is executive vice president of Healthcare Equipment & Supply Co., and president of the Midwest Association of Medical Equipment Services.

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Andrea Stark
reimbursement consultant, MiraVista

We are down to the wire on the ICD-10 transition deadline, and healthcare professionals everywhere are feeling the heat. MiraVista has developed some last minute advice to aid DME suppliers in their final steps:

1.      Focus on the highest and best use for your resources. If you are staring down a massive data set, don’t work top to bottom. Parse out your data set to focus on active rentals, as these orders will create invoices on their own post-transition.

2.      Scale down where you can. Medicare requires that a valid ICD-10 code be present for claims to transmit. If your claim has four ICD-9 codes that need to be mapped, and the product is not diagnosis-driven (such as wheelchairs, hospital beds, commodes, walkers, enteral, oxygen, patient lifts, etc.), then place your most relevant code in the first position and eliminate the other non-priority codes.

3.      Grab that low hanging fruit first. There are two types of ICD-9 codes: (1) those that map neatly to one single code in the ICD-10 code set, and (2) those that map to multiple codes in the ICD-10 code set. Prioritize the one-to-one maps first, as they are the most straightforward and require no digging in medical records.

4.      Leverage the tools available to you. Not sure which codes map to which? The AAPC translator tool is an excellent resource to identify potential matches for your ICD-9 codes. This tool allows you to plug in a single ICD-9 code to identify potential ICD-10 matches.

5.      Make sure you have the “right” code.  If you are heavy in diagnosis-driven products (AFOs, KAFOs, KOs, breast prostheses, glucose monitors, nebulizers, ostomy, PAPs, Group 2 and 3 support surfaces, therapeutic shoes, trach supplies, wheelchair seating, etc.) utilize the future LCDs posted to the CMS website. These LCDs will become active on Oct. 1st and can help you match up your diagnosis driven products.

6.      Know the rules. CMS has notified the industry that DME claims processing logic will be based on the from date of service. Therefore, if your claim has a from DOS on or after Oct. 1st, you must utilize ICD-10 codes. For claims with a from DOS on or before Sept. 30th, claims should be submitted using ICD-9 codes. A single claim cannot, at any time, contain both ICD-9 and ICD-10 codes. Claims submitted with dual codes will be rejected. When submitting claims with ICD-9 codes (with a qualifying from date) the ICD-10 indicator should be 9. When submitting claims with ICD-10 codes (with a qualifying from date of service) the ICD-10 indicator should be 0.

7.      Prepare your team. Claims that do not contain compliant codes after the ICD-10 deadline will be rejected. Suppliers should be checking their front-end rejections, which appear in the form of a 277CA report. ICD-10 rejections will appear with claims status category code (CSCC) A7 (Acknowledgement/ Rejection for Invalid Information) and will be accompanied by one or more of the following claims status codes (CSCs) below:

·         Issue:  The ICD-10 code is not a valid ICD-10 code or is not valid for the date of service reported.

o   CSC 254: Primary diagnosis code and

o   CSC 255: Diagnosis code

·         Issue: Diagnosis code must not contain a decimal

o    CSC 511: Invalid character and CSC 254: Primary diagnosis code  OR

o   CSC 511: Invalid character and CSC 255: Diagnosis code

·         Issue: ICD-10 codes that begin with letter “V”, “W”, “X”, or “Y” are not allowed.

o   CSC 254: Primary diagnosis code and

o   CSC 509: E-Code

·         Issue: Cannot have both ICD-9 and ICD-10 codes on the same claim. If principle diagnosis code is an ICD-9 code the subsequent diagnosis codes must be an ICD-9 code. Likewise, if the principle diagnosis code is an ICD-10 code the subsequent diagnosis codes must be an ICD-10 code.

o   CSC 255: Diagnosis codes

The deadline is approaching quickly and suppliers should take note that rejected claims will ultimately result in stalled revenue. If you need assistance in your transition contact our office.

Andrea Stark is a reimbursement consultant with MiraVista.

Tammy Zelenko
president/CEO, AdvaCare Home Services

This is exactly the situation that we said would happen with this type of model that limits providers and limits access to care  (“Chaos erupts as Univita loses contracts”).

We need to get this story out to Congress and to state Medicaids across the country. Our words mean nothing to them; however, the result of this bankruptcy should resonate loud and clear that the train needs to stop rolling down the track because the only light at the end of the tunnel is the train!

We need to let consumers know that this will happen to their care if they don’t get involved. They need to shout that they are not going to let their benefits continue to erode right in front of them by preventing quality providers into these networks.

The only way that you get quality is through competition and when you limit competition you limit care.

The model of limited providers and limited reimbursement will never be able to sustain the exponential growth of the baby boomers. We need to make this front page news everywhere!

This is exactly what we needed to happen; however, unfortunately, it’s at the cost of the providers who will never get paid for the services and equipment rendered and the patients who are being held hostage by their state Medicaids for allowing this to happen.

Let’s not let this opportunity pass us by; let’s use this as our springboard to get their attention to the real issue that they have created.

I can’t even begin to image what is going to happen to the rural areas when they get hit with reimbursement cuts and to the patients who won’t have providers to care for them.

What immediate action steps can we take to get this story in front of our legislators, managed care companies and the consumers? We must act quickly!

Bob Lichtenstein
Hollywood Medical Supply

I am reading the Univita story in the latest edition and something is missing or was lost in translation (“Chaos erupts as Univita loses biz,” p. 1, September 2015).

Univita did not contract with AHCA (Agency for Healthcare Administration) who oversees the Statewide Medicaid Managed Care (SMMC)—Managed Medical Assistance Program (MMA). Univita contracted with the various standard managed health care plans. I do not know if all the plans were using Univita, but many where.

It is easy for us to point the finger at AHCA, however, it was the health plans who were trying to save money on DME. Many of the plans are large providers who have DME contracts for Medicare Advantage and similar plans. They know what DME costs. It is the health care plans who signed the DME contracts with Univita, not AHCA.

It would seem reasonable that AHCA has some sort of contractual performance requirements for the health care plans. Given that assumption, shouldn’t industry be watching to see what AHCA’s direction is regarding the affected health care plans noncompliance or nonperformance of contract?

Univita is history; we should be looking forward to see if the managed care plans will have adequate reimbursement levels to provide the DME services mandated by AHCA. Florida Medicaid has many provision of service requirements exceeding Medicare. The health care plans need to take this into consideration, too.

—Bob Lichtenstein, Hollywood Medical Supply, Hollywood, Fla.

Ryan McDevitt
Laboratory Tactical Consulting

As the summer nears its end, I’m always excited to experience the HME News Business Summit. Liz approached me earlier this year to lead a panel on connected health and as we’ve worked to assemble the content, we’ve created a foundation to frame the discussion around, but we’d like a bit of input from providers.

We’re curious what questions you have about increasing your use of technology and data collection between your devices and your business.

I’ll summarize your questions and bring them to the Summit stage in Nashville, where Tim Murphy at Philips Respironics, Jim Hollingshead at ResMed and Robin Randolph at Fisher & Paykel will join us to share their thoughts on connected health.

As a consultant in home care, there are two things that seem apparent to consider about the term “connected health” and what it really means.

1. The existing niche where your company excels that could benefit from the addition of technology and data collection.

For example, excelling at patient care of a specific condition will provide details and data to use in outside relationships. Collecting empirical data and distilling it is less of a challenge than it has been in years because of integration with tools like Microsoft Power BI and DOMO. This translates to outcomes-driven examples of your successes in the home.

2. Being prepared to launch a newer, tech-based strategy still requires traditional budgeting, timelines and concept presentations.

Investing in technology can be intangible, particularly at first. It’s important that you build a fully vetted project concept before pushing off to development. If you’re going to take the step of increasing technology investment on a device that you already dispense, you want to be confident of what payoff can be expected for the risk. This should include a budget, a payback goal and a revenue projection.

Don’t overestimate the value of buzzwords and don’t be shy about your concepts. Technologies like video chat and connected devices can deliver efficiencies to the patient’s continuum of care. There is also pending legislation that could increase parity in billing for clinical professionals.

Granted, these may not be your current revenue streams, but as we move to a more outcomes-based model, being able to prove success is easier than it has ever been. Using these details to confidently instruct your teams is a valuable tool to navigate a changing market like home care.

I’m curious to hear what you want to know about connected health and how it might affect your business.

Send me an email (ryan@labtactical.com) or tweet a question with the hashtag #hmesummit and we’ll be sure to take it under consideration when preparing to discuss the subject with leads from Respironics, ResMed and Fisher & Paykel.

Still need to register? Go to www.hmesummit.com for more information.

Andrea Stark
reimbursement consultant, Mira Vista

A new enforcement of quantity details on detailed written orders for enteral nutrition is manifesting in claim denials.

CGS recently updated the language on the enteral documentation checklist (as of Jan. 27, 2015) that mentions a new description for quantity on the detailed written order to be represented on a “per fill” basis. This is new terminology and a compliance expectation that CGS and other MACs are now beginning to enforce.

We have not seen these quantity errors in prior claims because the medical reviewers were using discretion to calculate proper quantities using other elements on the detailed written order. However, because there are so many variations and fluctuations with the prescription and how claims are billed, they are now requiring the orders to be more specific to avoid denial. The provider education departments are also increasing their discussion of this expectation. The MACs are interpreting this nuance to be a part of the quantity requirement of the LCD.

This enforcement has been hardest felt in Jurisdiction C, but other MACs are incorporating this into their education, as well. To avoid future denials, providers are encouraged to secure updated orders for nutrition that comply with the details of a per-fill quantity:

·      Quantity to be dispensed (Should correspond with the total amount of each item to be provided per refill. This information may be expressed as cans, bottles/bags, cases, or billing units [1 unit=100calories]).

Under this new guidance the contractors are expecting language to appear on detailed written orders along the lines of:

·      1200 calories per day X 30 days X 12 refills

·      120 units at 100 calories X 30 days X 12 refills

If the patient is on a formula that consists of 300 calories per can, the suitable example might read:

·      4 cans per day X 30 days X 12 refills.

If you provide enteral nutrition, we encourage you to connect directly with your POE (Provider Outreach & Education) department of your MAC to confirm their expectations as there may be slight nuances from DME MAC to DME MAC. As additional details become available on this topic, MiraVista will keep you informed.

Andrea Stark can be reached at andrea@miravistallc.com.

I would like to respond to Doug Harrison’s letter to the editor "Warning shot" (see below). I am on the side of those who think the PMD demo is working in as much as it does give the provider some assurance that their claim is not technically flawed in some way before the equipment is delivered to the customer. If a prior authorization process helps keep expensive claims out of audit hell, it’s a good thing. Utilization may be down, but legitimate utilization is probably no better or worse than it ever was. What’s important is that what’s provided through the Medicare program gets paid for and stays paid for.

Mr. Harrison has a lot of gall to warn us about the “sadistic pain and suffering inflicted by CMS.” Overly aggressive advertising and abusive business practices by some in the business exploited Medicare beneficiaries and led directly to the punitive regulatory environment everyone else must now live with. Notoriety surrounding the fall of the Scooter Store has been used by industry critics to damage the credibility of everyone in the power mobility business.

Warning shot

Please think hard about this warning! In the March issue of HME News, industry stakeholders proudly state that the “PMD demo is working” (page 19). What do they mean by “working”? Utilization is down by 69%. A substantial number of other articles in the same issue (and every other issue for the last few years) describe, in horrific detail, the sadistic pain and suffering inflicted by CMS’s various audit schemes. So, what do the PMD demo and these schemes have in common? The PMD demo allows Medicare to inflict all of the same ridiculous and sadistic “standards” on all claims before they’re processed. It’s no surprise that utilization is down by 69%. The big surprise is the industry and the press keep celebrating this as a success. Please watch out for prior authorizations coming to any other product categories! Imagine the joy of having to pass 100% of your business through the irrational hurdles of today’s punitive audit environment. You might be lucky to have 31% of your claims survive. Is that enough for your business to survive?

—Doug Harrison, founder, The Scooter Store

I need to call a patient's family and tell them that I either have to pick up the hospital bed they are renting from me, or they have to sign a document that states they are willing to pay privately.

I provided them a bed and the claim for that bed was randomly picked by the Medicare contractor Noridian to be audited. An audit of a claim should not scare anyone—you would expect that they look at the documentation and see if the patient needs the equipment. Well it does not work that way.

Medicare first goes through every piece of paper looking for a mistake. When there is a mistake, it is an all-or-nothing mistake. It finds any type of mistake and the DME company gets its money taken back. It could be something like a doctor signing an order, but not dating his signature. Not fixable, not payable. Noridian states a 91% denial rate for three quarters in 2013.

DME companies are not dumb. We have had to figure out what words Medicare needs to see to cover equipment and make sure the doctors say something along those lines. You see, we have clients who need equipment and the doctors want to know what has to be done to accomplish that. Medicare will not make sure the doctors are educated; we are forced to.

Most DME companies are not crooked. I am definitely not a crooked person and Sandcreek Medical is not a crooked company. We fight every claim we are denied and we win most times. In fact, most of the DME companies have started fighting every claim and that has created a new problem. The final level of appeal, alone, is out 27 months to 12 years, depending on who you ask. Either way, you cannot afford to work your way through the appeals process anymore.

This particular claim is for a bed needed to take a patient home from the nursing home. The patient's daughter asked us about procuring a bed and we explained we needed chart notes from the doctor stating the need. She said that her mom had seen the doctor, so that part should be taken care of.

I explained that very few doctors will document the need for medical equipment without some one pushing them on how much documentation there needs to be. As usual, when we received the documentation from the doctor, there was no talk of needing a hospital bed, let alone the required phrases Medicare wants to see in the notes, i.e. “frequent changes of body position” “alleviate pain” and “immediate change of body position”

So this family had to take their mom back to the doctor for a visit that would document the need for the bed. I provided them a sheet that explains the basic rules of Medicare and that there needs to be talk of the reasons she needs the bed. Well this doctor did a fair job. I would have liked a little more detail, but I did not get it. I believe in my heart that she needed and still needs the bed. Then I did what every DME company in America does: hope that this claim will not be chosen for an audit.

Here is the real problem. Medicare has changed the rules of the game. According to its own statements, the agency cannot use clinical inference to say, “Oh yeah, this client really does need a hospital bed.” Instead, it has to go to the Local Coverage Determination or LCD for the rules and it sticks to the letter of the rule. Hence, a hospital bed will not be covered if a doctor did not have a statement like this: “This patient needs positioning in ways not feasible in an ordinary bed. This patient needs frequent changes in body position in order to alleviate pain.” If those words were not in the chart notes, then Medicare was going to deny the claim. In the real world, that means one of three things: 1) The DME company is going to loose money, 2.) the patient is not going to get the equipment they need, or 3.) the patient will have to pay privately. With the tighter profit margins and amount of time and money it takes to fight claims, many times we are forced to tell the patients they have to pay.

Back to changing the rules of the game. I believe that Medicare started to see the words it wanted to see in the chart notes. It saw the word “frequent” and it saw the word “alleviate.” It should be happy, but instead of quoting the LCD verbatim, we have a new weapon called the PIM 5.7. Now Medicare is going to focus on the statement, “For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable).” What is sufficient enough and when is it inapplicable—that is up to Medicare and its auditors.

Medicare still wants to know that it is frequent, but how frequent. It wants to know not only that it will alleviate pain, but also what are the levels of pain, and the frequency of that pain, or how the bed is likely to alleviate that pain. It wants to know if the patient has had experience with this equipment before. It wants to know if the patient has had any therapeutic interventions. Most importantly, it wants it detailed and it does not want any vague answers.

Unfortunately, in our business we deal with real people in their worst part of life. Some times a hospital bed is needed for someone who is dying and the doctor does not really know that the hospital bed will alleviate his or her pain. The doctor knows that the patient is in pain, and the patient needs a hospital bed to be able to be at home with family. The doctor is sometimes just hoping that the bed will alleviate pain. Sometimes morphine will not alleviate the patient’s pain.

Below is Medicare's answers to why this patient does not meet the medical criteria for the bed. As you read these statements, remember that the doctor is required to document this in his normal chart notes. Even if he wanted to write a letter or a 500-word essay stating why this client needs a hospital bed, the letter or essay would not be considered part of the medical record. The documentation must be in the doctor’s normal chart notes. This particular doctor has a unique way of doing his chart notes. He has forms where he will X out words and circle others. He will write little statements to the side and makes notes that tell him how the patient is doing. These same chart notes have been used for years and used to document conditions that are more complex than a hospital bed referral. I do not believe that his chart notes could ever get a hospital bed covered and that is sad.

As you read the statements from Medicare, pay close attention to this: “Verbiage such as pain is vague, subjective, and insufficient. Clear objective documentation and quantifying information is lacking.  This type of verbiage does not provide a clear picture of the beneficiary's pain.” Then keep in mind that Medicare does not have objective rules on what frequent is. It cannot tell you what level of pain is acceptable. It cannot tell you what functional limitation it is looking for, or what therapeutic intervention is acceptable. It will not tell you exactly why the documentation does not support that the beneficiary requires frequent changes of body positioning and it will not say exactly what part of pages 5-8 are illegible, just that they are partially illegible.

What Medicare is really saying is, do as we say, not as we do. It is saying that we must provide clear, objective data, written in the doctor’s normal chart notes, and only the agency can be subjective on the reasons it denies the equipment. It says that verbiage such as pain is vague, subjective and insufficient—the doctor used the words severe pain. Maybe that was one of the illegible words; I do not know because Medicare does not have to be clear, objective, or quantified.

Noridian Medicare Denial Documentation

Medical records submitted to not support the beneficiary has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed, the beneficiary requires position of the body in ways not feasible in an ordinary bed in order to alleviate pain, the beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic obstructive pulmonary disease, or problems with aspiration or the beneficiary requires traction equipment.

The documentation does not support the beneficiary requires frequent changes in body position and or has an immediate need for change in body position and or has an immediate need for change in body position.

When a hospital bed is needed for positioning, the medical documentation should describe the severity and frequency of the symptoms of the medical condition that necessitates a hospital bed for positioning.

The information should include the beneficiary's diagnosis and other pertinent information including, but not limited to, duration of the beneficiaries condition, clinical course, (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc.

Verbiage such as pain is vague, subjective, and insufficient. Clear objective documentation and quantifying information is lacking.  This type of verbiage does not provide a clear picture of the beneficiary's pain.

Medical documentation should describe the severity and frequency of the symptoms of the medical condition that necessitates a hospital bed for positioning and how it will alleviate pain.

A semi-electric hospital bed is covered if the beneficiary meets one of the criteria for a fixed and requires frequent changes in body position and/or has an immediate need for a change in body position.

ABN dated 11/14/2014 invalid as incomplete section C.

Pgs. 5-8 partially illegible.

Deny E0260

I now have to do the part of the job I do not like. I am going to have to call the family and give them a choice between paying privately for the bed, or having me pick the bed up. I no longer can fight a bed like this through the appeals process. Money is too tight and the time it takes is too long. You see, you would think that the requirement of an Administrative Law Judge hearing your case in 60 days would happen within 60 days. Somehow that has turned into a minimum of 27 months and a letter asking us to be patient, but that is a different issue.

I now have to do the part of the business that I do not like and I have to call this patient and say that the bed is not covered. I am also going to say that until patients start contacting their elected officials, these are only going to be seen as numbers and not as someone's mother.

Gary Rench is the owner and manager of Sandcreek Medical in Sandpoint, Idaho, a small DME and respiratory company started in 1989. He can be reached at grench@sandcreekmedical.com.

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