In brief: DME’s value, FTC’s lawsuit, DMEscripts’ integration 

WATERLOO, Iowa – The cost of treating injuries and illnesses due to lack of DME far exceeds the cost of providing the necessary equipment, according to a new report from Leitten Consulting. 

For example, every dollar spent on mobility equipment can save Medicare $62.53 in treatment costs, the report found. 

“An ounce of prevention is now worth several pounds of cure,” said Brian Leitten, CEO of Leitten Consulting, which specializes in health care policy analysis and strategic consulting. “It’s time for Medicare to recognize the immense value of DME in improving patient outcomes and reducing costs.” 

Bigger picture, investing in DME could potentially save Medicare up to $200 billion annually, substantially lowering health care expenditures, according to the report. 

With the growing trend toward home-based care, the role of DME in preventing hospitalizations and managing chronic conditions has become increasingly critical, says Ike Isaacson, senior vice president, VGM Government Relations. 

“Our industry continues to be on the front lines of the fight to keep people in their homes, close to family and friends, and in the community where they want to live,” he said. “Our services save lives, and at the same time, they save money. This study further validates the need to promote prevention and early intervention of heath challenges through fully funding the DME/HME services that enhance quality of life and reduce the costs of facility-based care.” 

• Related: Leitten Consulting and VGM worked together in 2022 to look at the cost savings related to appropriate access to and coverage for wound care, diabetes and incontinence supplies. 

FTC sues PBMs 

‘Caremark, ESI, and Optum—as medication gatekeepers—have extracted millions of dollars off the backs of patients who need life-saving medications’ 

 WASHINGTON – The Federal Trade Commission has sued the three largest prescription drug benefit managers (PBMs) – Caremark Rx, Express Scripts and OptumRx – and their affiliated group purchasing organizations for engaging in anticompetitive and unfair rebating practices that have artificially inflated the list price of insulin drugs. 

These practices have also impaired the ability of patients to access lower list price products and shifted the cost of high insulin list prices to them, the FTC argues. 

“Millions of Americans with diabetes need insulin to survive, yet for many of these vulnerable patients, their insulin drug costs have skyrocketed over the past decade thanks in part to powerful PBMs and their greed,” said Rahul Rao, deputy director of the FTC’s Bureau of Competition. “Caremark, ESI, and Optum—as medication gatekeepers—have extracted millions of dollars off the backs of patients who need life-saving medications. The FTC’s administrative action seeks to put an end to the Big Three PBMs’ exploitative conduct and marks an important step in fixing a broken system—a fix that could ripple beyond the insulin market and restore healthy competition to drive down drug prices for consumers.” 

The FTC alleges that the three PBMs created a perverse drug rebate system that prioritizes high rebates from drug manufacturers, leading to artificially inflated insulin list prices. The complaint charges that even when lower list price insulins became available that could have been more affordable for vulnerable patients, the PBMs systemically excluded them in favor of high list price, highly rebated insulin products. It also alleges these strategies have allowed the PBMs and GPOs to line their pockets while certain patients are forced to pay higher out-of-pocket costs for insulin medication. 

The FTC’s Bureau of Competition also made it clear in a statement that it remains deeply troubled by the role drug manufacturers like Eli Lilly, Novo Nordisk and Sanofi play in driving up list prices of life-saving medications like insulin. It says all drug manufacturers should be on notice that their participation in this type of conduct raises serious concerns, and that it may recommend suing drug manufacturers in any future enforcement actions. 

Read the FTC’s full announcement here. 

Industry reaction:  

“One of the many ways that PBMs manipulate the system against patients, taxpayers, and small pharmacies is the rebate game,” said B. Douglas Hoey, CEO of the National Community Pharmacists Association. “The PBMs determine which drugs are covered by health insurance plans. They get bigger rebates for the most expensive drugs. Naturally, the most expensive drugs end up on the formularies even when there are cheaper alternatives. Patients end up paying more. Employers end up paying more. Taxpayers end up paying more. And more small business pharmacies are driven out of business. The rebates create a powerful incentive for higher drug prices, which is completely upside-down. We are very pleased that the FTC is seeking to end that practice.”   

• Related: The NCPA in July launched a TV ad on CNN criticizing PBMs. 

Noridian responds to orthotics inquiries 

WASHINGTON – Noridian Healthcare Solutions has published an update for billing custom-fitted orthotics when no custom fitting is completed with no off-the-shelf equivalent available. “Due to recent inquiries from suppliers, it has come to our attention that some miscellaneous codes used for billing off-the-shelf orthotics, when a custom fit orthotic is provided but no custom fitting is performed, may require specific policy and laterality modifiers,” it states. These claims must also include a narrative with this information: 

Miscellaneous Codes 

When no corresponding prefabricated off-the-shelf HCPCS code is available, use one of the following codes: 

• L1499 - Spinal orthosis, not otherwise specified 
  • Apply any policy-specific modifiers as required 
• L2999 - Lower extremity orthosis, not otherwise specified 
  • Apply any policy-specific modifiers as required 
  • Use RT or LT modifiers as appropriate 
  • For bilateral items on the same date of service, list each item on a separate claim line with the RT and LT modifiers and 1 unit of service (UOS) on each line (e.g., L2999 RTKX) 
• L3999 - Upper limb orthosis, not otherwise specified 
  • Apply RT or LT modifiers as appropriate 
  • For bilateral items on the same date of service, list each item on a separate claim line with the RT and LT modifiers and 1 unit of service (UOS) on each line (e.g., L3999 RT) 

Narrative Requirement 

Include a narrative on the claim with the following information: 

• HCPCS code of the item being provided 
• Indication of "OTS" (off-the-shelf) 
• Supplier's Retail Price (SRP) 

If providers have received denials for these claims, they should correct and resubmit them or pursue redeterminations through the appeals process. Noridian encourages providers to use the Noridian Medicare Portal for Redeterminations/Appeals submissions. Go here to read the full announcement. 

DMEscripts integrates, names new exec 

INDIANAPOLIS – DMEscripts has integrated with Rovicare, a transitional care management platform, and has named its co-founder, Pankaj "PJ" Likhmania as its new CIO. Together, the two companies will launch a “hospital-to-home” strategy that will tackle provider bottlenecks, miscommunication and inefficiencies that can lead to delays in care, subpar patient experiences, preventable hospital admissions and lack of accountability, they say. "We are thrilled to partner with the team at Rovicare," said John Brady, CEO of DMEscripts. "This partnership connects an industry network to best equip and serve clinicians, health care systems and payer organizations. Together, we can advance our shared goal of empowering providers and patients through improved care coordination and provider transparency while reducing health care costs." Phoenix-based Rovicare is a digital platform that automates patient transition and care coordination, engaging all stakeholders throughout a patient’s care journey. It is used by health care organizations across the United States, spanning medical, behavioral, social determinants of health, ancillary services, technology-based services, long- term care and beyond. "I am excited to join the DMEscripts team as CIO," Likhmania said. "DMEscripts has built an impressive industry network that connects key health care stakeholders. I look forward to working closely with the team to enhance the platform and drive technology innovation that improves patient care and outcomes."  

Owens & Minor names EVP, CFO 

RICHMOND, Va. – Owens & Minor has named Jonathan Leon, who has served as interim CFO and corporate treasurer since June 2024, as its executive vice president and CFO. Previously, he served as senior vice president and corporate treasurer, leading the company’s financial operations, since 2017. “After a comprehensive process, the board and I unanimously agreed that Jon is the ideal candidate to serve as Owens & Minor’s next chief financial officer,” said Edward Pesicka, CEO. “His extensive knowledge of the health care sector, financial acumen, established relationships with investors, and proven leadership capabilities will be invaluable as we continue our progress toward achieving our long-term goals outlined at our recent Investor Day.” Leon, who will report to Pesicka, has more than 25 years of experience in corporate finance, treasury and strategy. Before joining Owens & Minor, he spent 18 years at The Brinks Company, where he served in several related investor relations and corporate finance roles. 

Medtrade bits: Tech Talks is on, Notable Systems signs on 

DALLAS – Medtrade has announced that Tech Talks will return to the expo floor next year. Tech Talks will feature 30-minute live interactive presentations to provide attendees with a comprehensive overview of various tech solutions. “We were once again able to carve out space on the expo floor with seating for about 50 people,” explains Chris Kinard, COO, Valere Health, the exclusive sponsor of Tech Talks. “We are going through the list of exhibitors and extending invitations for technology vendors to come and participate. We are looking for innovative technology solutions for the industry and keeping our search to those companies.” Topics for Tech Talks will include enterprise resource planning, RCM-AR, patient collections, patient management, sleep tech, prescribing, inventory management and document management. Three exhibitors have signed on for Tech Talks so far: Tennr, Notable Systems and Atlas Technology…Medtrade has also announced that data extraction specialist Notable Systems has signed on to exhibit at the show. “Our technology streamlines data management and workflows throughout the HME revenue cycle management process,” said Steve Johnson, CEO. “Notable Systems combines traditional technologies like OCR (optical character recognition) with cutting-edge AI and LLM (large language model) capabilities, delivering solutions that accelerate processes and reduce costs. We can process a wide range of medical documents such as prescriptions, patient demographics, clinical notes, insurance forms, and more—providing customized solutions.” Medtrade will take place Feb. 18-20 in Dallas. 

EZ-ACCESS, PBR partner on marketing campaign 

HOPKINSVILLE, Ky. – EZ-ACCESS, the official ramp and accessibility provider of Professional Bull Riders, has outfitted the Davis Rodeo Ranch in Archdale, N.C., with ramps and viewing platforms to provide world champion bull rider Jerome Davis with unfettered access to his world-class ranch and training facility. Following his debilitating bull riding accident in 1998, Davis remains a successful and inspirational figure within the PBR community. “EZ-ACCESS has provided me with the mobility tools I need to continue mentoring riders,” he said. “Their accessibility products allow me to move freely around the ranch, and the enhancements have truly made a difference in my ability to coach and train without barriers.” Davis and his wife, Tiffany, have raised top bucking bulls on their ranch, which also hosts one of PBR’s longest-tenured events, and Davis now serves as head coach of the Carolina Cowboys, and Tiffany is assistant general manager. EZ-ACCESS says the visibility generated through PBR events, broadcasts and sponsorships will position the company as a key player in both accessibility and high-performance environments and allows the company to showcase its products live and in front of 79 million U.S. fans. “We’re excited about this partnership and the exposure it provides for our partner-dealers to reach customers through PBR and beyond,” said Don Everard, CEO of EZ-ACCESS. “The endorsement by Jerome Davis and the equipment we installed at his ranch serve as a perfect model of the quality products we offer everyone for home, work and play.” 

SDS Rx, Virtue Technologies simplifies delivery 

CLARK, N.J. – SDS Rx, a health care delivery and logistics company, has partnered with Virtue Technologies to offer a streamlined delivery management solution for home infusion and specialty pharmacies. The partnership allows SDS Rx to offer an integration with Virtue Technologies' logistics platform, VirtueScript, which is designed to optimize and automate delivery workflows for providers utilizing multiple delivery methods. "As part of our ongoing effort to integrate with key partners across various classes of trade, we're thrilled to join forces with Virtue Technologies," said Drew Kronick, CEO of SDS Rx. "By combining our logistics expertise with their industry-leading software, we're delivering a unified solution that simplifies delivery management, strengthens compliance, and helps home infusion and specialty pharmacies better serve their patients." Key benefits of the partnership a unified approach to logistics, reducing complexity and management burdens; real-time tracking and proof-of-delivery for all shipments; providing access to actionable data insights; and streamlined workflows that help reduce costs and improve operational performance.