Triangle Aftercare NEWS

We Won!!! Competitive Bidding -

Tuesday 30 November, 1999

SENATE OVERRIDES PRESIDENT BUSH'S VETO 70-26 HOUSE OVERRIDES PRESIDENT BUSH'S VETO 383-41 Late this afternoon, the Senate voted to override the president's veto of H.R. 6331 - the Medicare Improvements for Patients and Providers Act of 2008 - by an overwhelming margin of 70-26. H.R. 6331 will stave off the 10.6 percent physician fee cut, as well as delay the competitive bidding program, exempt complex rehab and repeal the title transfer of oxygen. It will NOT however eliminate the first month purchase option for power wheelchairs. House vote Summary: http://clerk.house.gov/evs/2008/roll491.xml Senate vote Summary: http://www.aahomecare.org/associations/3208/files/SenateVoteSummaryHR6331VetoOverride071508.pdf All 13 Members of Congress from NC voted to override! What This Means - Now What? With a successful override of Bush's veto in both the House and the Senate, H.R. 6331 will become law without his signature. As the information becomes available, we will ensure that providers are aware of how CMS responds to the newly enacted law. It is our belief however, that with this enactment, all non-contracted suppliers in competitive bid areas should now be able to supply competitive bid items. HomeCareMonday reports that CMS said it could not comment on the means the agency would take to stop the program, how it would alert beneficiaries and providers, what delay, if any, providers could expect in reimbursement and how much it will cost to shut down round one. "Until the bill is enacted into law, we can't answer any of those questions," a CMS spokesperson said. Now that the bill is law, however, guidance should come soon as the measure requires CMS to suspend provider contracts--implemented July 1--in the 10 bid areas. According to the American Association for Homecare, CMS is expected to issue an immediate fact sheet on the legislation's impact for providers. MEDICARE IMPROVEMENTS FOR PATIENTS AND PROVIDERS ACT, 2008 Background: On July 15, 2008, the Medicare Improvements for Patients and Providers Act of 2008 was enacted, making changes to the Medicare program. Information about some of the changes is outlined below. Detailed instructions about these changes have been communicated via listserv to CMS providers and other affected parties. CMS will be implementing other provisions of the legislation in the coming months and will announce additional information as it becomes available. DME: The Durable Medical Equipment Competitive Bidding Program, which affects only Medicare beneficiaries in traditional fee-for-service in 10 competitive bidding areas, has been delayed. Medicare beneficiaries may use any Medicare-approved supplier for Durable Medical Equipment. If a beneficiary changed suppliers when this new program started (July 1, 2008), they can either continue to use the new supplier or choose another supplier. The original DME payment rates in effect prior to July 1 are reinstated retroactively. All Medicare households in the 10 competitive bidding areas will be notified of this change directly in a letter from CMS within two weeks.

Medicare Cuts Jeopardize Power Wheelchair Owners -

Tuesday 30 November, 1999

Click on the link below to view the video. http://ww2.abc11tv.com/global/video/popup/pop_player.asp?clipid1=1675894&at1=News&vt1=v&h1=Medicare+Wheelchairs&d1=114000&redirUrl=www.abc11tv.com&activePane=info&LaunchPageAdTag=homepage&playerVersion=1&hostPageUrl=http%3A//ww2.abc11tv.com/global/video/popup/pop_playerLaunch.asp%3Fclipid1%3D1675894%26at1%3DNews%26vt1%3Dv%26h1%3DMedicare+Wheelchairs%26d1%3D114000%26redirUrl%3Dwww.abc11tv.com%26activePane%3Dinfo%26LaunchPageAdTag%3Dhomepage&rnd=85962545 As some Medicare funding cuts roll into the Triangle, patients with special needs who depend on power wheel chairs and scooters could be stopped in their tracks. The government keeps cutting the amount of money paid to local medical suppliers. It's a move that could force them out of business and leave some patients caught in the middle. "Because I have cerebral palsy, I need to use my wheelchair everyday....," 23-year-old Jenny LaRocco said. Everyday, instead of a stroll, it's a motorized roll for LaRocco. "My wheelchair is basically my legs," she said. LaRocco is returning home from a job she works as a camp counselor. She enjoys her independence with the help of her motorized chair. "I carry my purse on my chair, I carry my bags. "I have special buttons on my chair," LaRocco said. "I can layback during the day if I need to... I can stretch out my body." LaRocco fears cuts in Medicare coverage could force her to exchange her power chair for a manual chair. "Most people with a disability. They don't want people pushing them around in wheelchairs all day," she says. That's the message motivating medical suppliers across the country to unite in Washington, D.C. to block a cut in Medicare spending on power wheelchairs that could garnish as much as $900 million over the next 10 years. Medical equipment supplier Marcia Ladd owns and operates Triangle Aftercare, a medical needs store with locations in Durham and Roxboro. She says another Medicare cut would add to many recent moves by Congress that have already crippled suppliers. "This time last year Medicare reimbursed me $5500 to put out a power wheelchair.," Ladd said. "The end of last year they cut the reimbursement down to $3500." It's a drop in the bucket when you consider the real cost of Jenny's wheelchair at $11,000. Short-changed suppliers carry a huge burden, but Marcia believes in the end, patients young and old pay the biggest price. "If I'm no longer here, who's going to take care of the little old lady at two o'clock in the morning as she lays dying," Ladd said. Jenny LaRocco adds, "I don't have the money to pay for it and my family doesn't have the money to pay for it, so where am I going to get it from." Medicare cuts would apply to all power wheel chairs and scooters. Suppliers are now subject to a competitive bidding process. Congressman David Price's office released a statement related to the proposal: "As Medicare moves to a competitive bidding system for durable medical equipment, the government must ensure that the new system does not compromise patient care or put homecare providers at a disadvantage. In order to maintain quality care and fair competition, I have urged Medicare to adopt essential safeguards, and I will continue working in Congress to ensure that it does."

Medicare Coverage for specific types of home medical equipment -

Monday 11 December, 2006

BiPaps/Respiratory Assist Devices For a respiratory assist device to be covered, the treating physician must fully document in the patient's medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, dyspnea, etc. A respiratory assist device is covered for those patients with clinical disorder groups characterized as (I) restrictive thoracic disorders (i.e., progressive neuromuscular diseases or severe thoracic cage abnormalities), (II) severe chronic obstructive pulmonary disease (COPD), (III) central sleep apnea (CSA), or (IV) obstructive sleep apnea (OSA). Various tests may need to be performed to establish the above diagnosis groups. Three months after starting your therapy, both your physician and you will be required to respond to questions in writing regarding your continued use along with how well the machine is treating the condition. Breast Prostheses Breast Prostheses are covered after a radical mastectomy. Medicare will cover: One silicone prosthesis every two years or a mastectomy form every six months. Mastectomy bras are covered as needed. There is no coverage for replacement prostheses due to wear and tear before the listed time frame. However, Medicare will cover replacement of these items due to: Loss Irreparable damage, or Change in medical condition (e.g. significant weight gain/loss) Patients are allowed only one prosthesis per affected side, others will be denied as not medically necessary even if attempting asymmetry (need ABN). Mastectomy sleeves are not covered in the home setting because they do not meet Medicare's definition of a prosthesis; however, it is possible that they may be covered under the hospital per diem if you request one during your hospital stay. Triangle Aftercare does not carry breast prostheses, but has several local options to which we refer our patients. Cervical Traction Cervical traction devices are covered only if both of the criteria below are met: The patient has a musculoskeletal or neurologic impairment requiring traction equipment. The appropriate use of a home cervical traction device has been demonstrated to the patient and the patient tolerated the selected device. Commodes A commode is only covered when the patient is physically incapable of utilizing regular toilet facilities. For example: The patient is confined to a single room, or The patient is confined to one level of the home environment and there is no toilet on that level, or The patient is confined to the home and there are no toilet facilities in the home. Heavy-duty commodes are covered for patients weighing over 300 pounds. Compression Stockings Gradient compression stockings worn below the knee are covered only when used for the treatment of open venous stasis ulcers. They are not covered for the prevention of ulcers, prevention of the reoccurrence of ulcers or treatment of lymphedema without ulcers. CPAPs Continuous Positive Airway Pressure (CPAP) Devices are covered only for patients with obstructive sleep apnea (OSA). You must have an overnight sleep study performed in a sleep laboratory to establish a qualifying diagnosis. Home and mobile sleep labs/studies are not accepted. Medicare also will pay for replacement masks, cannulas, tubing and other necessary supplies. After three months of use, you will be required to verify if you are benefiting from using the device and how many hours a day you are using the machine. Diabetic Supplies For diabetics, Medicare covers the glucose monitor, lancets, spring-powered devices, test strips, control solution and replacement batteries for the meter. Medicare does not cover insulin injections or diabetic pills unless covered through a Medicare Part D benefit plan. Diabetics can obtain up to a three month supply at a time. Medicare will approve up to one test per day for non-insulin dependent diabetics and three tests per day for insulin-dependent diabetics without additional verification. Patients who test above these guidelines are required to be seen and evaluated by their physician within six months of ordering these supplies. In addition, patients must provide their provider with evidence of compliant testing every six months to continue getting refills at the higher levels. Any time your testing frequency changes, your physician needs to give your provider a new prescription. Triangle Aftercare does not carry diabetic supplies, but we have agreements with several organizations to whom we routinely refer our patients. Glasses One complete pair after the last cataract surgery: frames two lenses tint, anti-reflective coating, UV (only when the doctor specifically orders these services for a medical need) Hospital Beds A hospital bed is covered if one or more of the following criteria (1-4) are met: The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed, or The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out, or The patient requires traction equipment which can only be attached to a hospital bed. Specialty beds that allow the height of the bed to vary are covered for patients that require this feature to permit transfers to a chair, wheelchair or standing position. It is very unusual that Medicare will approve this. Typically patients want this for the benefit of their caregiver, this is not a suitable reason according to Medicare. A semi-electric bed is covered for a patient that requires frequent changes in body position and/or has an immediate need for a change in body position. Typically a respiratory related diagnosis is required. Heavy-duty/extra-wide beds can be covered for patients that weigh over 350 pounds. The total electric bed is not covered because it is considered a convenience feature. If you prefer to have the total electric feature, your provider usually can apply the cost of the semi-electric bed toward the monthly rental price of the total electric model by using an Advance Beneficiary Notice. You would be responsible to pay the difference in the retail charges between the two items every month. Lymphedema Pumps Medicare-covered drugs (other than Medicare Part D coverage) As of February 2001, all providers of Medicare-covered drugs are required to accept assignment on these items. Traditional Medicare will cover nebulizer drugs, infused drugs, immunosuppressive drugs, oral anti-cancer medications and parenteral nutrition. Mobility Products: Canes, Walkers, Wheelchairs, and Scooters General Coverage Guidelines: Essentially the new Mobility Assistive Equipment regulations will ensure that Medicare funds are used to pay for: Mobility needs for daily activities within the home Least costly alternative/lowest level of equipment to accomplish these tasks. Most medically appropriate equipment (to meet the needs, not the wants) Medicare requires that your physician and provider evaluate your needs and expected use of the mobility product you will qualify for. They must determine which is the least level of equipment needed to help you be mobile within your home to accomplish daily activities by asking the following questions: Will a cane or crutches allow you to perform these activities in the home? If not, will a walker allow you to accomplish these activities in the home? If not, is there any type of manual wheelchair that will allow you to accomplish these activities in the home? If not, will a scooter allow you to accomplish these activities in the home? If not, will a power chair allow you to accomplish these activities in the home? Keep in mind if you have another higher level product in mind that will allow you to do more beyond the confines of the home setting, you can discuss with your provider the option to upgrade to a higher level or more comfortable product by paying an additional out of pocket fee using the Advance Beneficiary Notice select the product you like best. A face-to-face examination with your physician is required prior to the initial setup of a power chair or scooter. House must accommodate the use of any mobility product. Nebulizers Nebulizer machines, medications and related accessories are usually covered for patients with obstructive pulmonary disease, but can also be covered to deliver specific medications to patients with HIV, CF, brochiectasis, pneumocystosis, complications of organ transplants, or for persistent thick or tenacious pulmonary secretions. Non-covered items (partial listing): Adult diapers Bathroom safety equipment Hearing aides Syringes/needles Van lifts or ramps Exercise equipment Humidifiers/Air Purifiers Raised toilet seats Massage devices Stair lifts Emergency communicators Low Vision Aides Grab bars Orthopedic Shoes Orthopedic shoes are covered when it is necessary to attach the shoe(s) to a leg brace. However, Medicare will only pay for the shoe(s) attached to the leg braces. Medicare will not pay for matching shoes, or for shoes that are needed for purposes other than for diabetes or leg braces. Ostomy Supplies Ostomy supplies are covered for people with a: colostomy ileostomy urostomy Patients can obtain up to a three month's supply of wafers, pouches, paste and other necessary items at a time. Triangle Aftercare does not carry most ostomy supplies, but we have agreements with several organizations to whom we routinely refer our patients. Oxygen Covered for patients with significant hypoxemia in the chronic stable state when: patient has a chronic lung condition or disease or hypoxemia that might be expected to improve with oxygen therapy, and patient's blood gas levels or oxygen saturation levels indicate the need for oxygen therapy, and alternative treatments have been tried or deemed clinically ineffective. Categories/Groups are based on the test results to measure your oxygen: I 55<= mmHg, or 88%< saturation For these results you must return to your physician 12 months after the initial visit to continue therapy for lifetime or until the need is expected to end. II 56-59 mmHg, or 89% saturation For these results, you must be retested within 3 months of the first test to continue therapy for lifetime or until the need is expected to end. III >=60 or >=90% not medically necessary Medicare is currently not paying for this equipment beyond a 36 month period. There is, however, heavy debate in Congress about changing this. Parenteral and enteral therapy Parenteral therapy requires all or part of the gastrointestinal tract be missing. Nutritional formulas are delivered through a vein. Triangle Aftercare does not carry parenteral equipment, but we have agreements with several organizations to whom we routinely refer our patients. Enteral therapy is covered for patients who cannot swallow or take food orally. Nutrition must be delivered through a tube directly into the gastrointestinal tract. Medicare will not pay for nutritional formulas that are taken orally. Patient Lifts A lift is covered if transfer between bed and a chair, wheelchair, or commode requires the assistance of more than one person and, without the use of a lift, the patient would be bed confined. Medicare must also have paid for or be paying for a hospital bed for the patient. An electric lift mechanism is not covered; because it is considered a convenience feature. If you prefer to have the electric mechanism, your provider can usually apply the cost of the manual lift toward the purchase price of the electric model by using an Advance Beneficiary Notice. You would be responsible to pay the difference in the retail charges between the two items. Seat Lift Mechanisms In order for Medicare to pay for a seat lift mechanism, patients must be suffering from severe arthritis of the hip or knee, or have a severe neuromuscular disease. In addition they must be completely incapable of standing up from any chair, but once standing they can walk either independently or with the aid of a walker or cane. The physician must believe that the mechanism will improve, slow down or stop the deterioration of the patient's condition. Transferring directly into a wheelchair will prevent Medicare from paying for the device. Medicare will not pay for the lift mechanism if they are also paying for a wheelchair. The two, according to Medicare are contraindicated. Medicare will only pay for the lift mechanism portion. The chair portion of the package is not covered, and the patient will be responsible for the full amount of the chair. Support Surfaces Group 1 products are designed to be placed on top of a standard hospital or home mattress. They can be utilize gel, foam, water or air, and are covered for patients that are: Completely immobile OR Have limited mobility with any stage ulcer on the trunk or pelvis (and one of the following): impaired nutritional status fecal or urinary incontinence altered sensory perception compromised circulatory status Group 2 products take many forms, but are typically powered pressure reducing mattresses or overlays. They are covered for patients with one of three conditions: Multiple stage II ulcers on the pelvis or trunk while on a comprehensive treatment program for at least a month using a Group 1 product, and at the close of that month, the ulcers worsened or remained the same. (Monthly follow-up is required by a clinician to ensure that the treatment program is modified and followed. This product is only covered while ulcers are still present.) OR Large or multiple Stage III or IV ulcers on the trunk or pelvis (Monthly follow-up is required by a clinician to ensure that the treatment program is modified and followed. This product is only covered while ulcers are still present.) OR A recent myocutaneous flap or skin graft for an ulcer on the trunk or pelvis within the last 60 days who were immediately placed on Group 2 or 3 support surface prior to discharge from the hospital and the patient has been discharged within last 30 days. TENS Units TENS units are covered for the treatment of chronic intractable pain that has been present for at least three months or more, and in some cases for acute post-operative pain. Not all types of pains can be treated with a TENS unit. TENS units have proven ineffective in treating headaches, visceral abdominal pains, pelvic pains, and TMJ pains, and therefore Medicare will not pay for the device when used to treat these conditions. For chronic pain sufferers, Medicare will pay for a one or two month trial rental to determine if this device will alleviate the chronic pain. You must return to your physician exactly 30-60 days after initial evaluation to authorize the purchase of this equipment. For acute post-operative pain sufferers, Medicare will consider rental payment for a maximum of 30 days. Any duration longer than that will require individual consideration. Medicare track record on payment for these items is not good, and Triangle Aftercare will not accept assignment for TENs units. Therapeutic Shoes Special therapeutic shoes, inserts and modifications can be covered for diabetic patients with the following foot conditions: previous amputation of a foot or partial foot history of foot ulceration peripheral neuropathy with callus formation foot deformity poor circulation in either foot Urological Supplies Urinary catheters and external urinary collection devices are covered to drain or collect urine for a patient who has permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in that patient within 3 months. Article Courtesy of Triangle Aftercare - Medical Equipment and Supplies serving Durham, Chapel Hill, Roxboro, Pittsboro and Raleigh

Guide to Medicare Coverage -

Monday 11 December, 2006

Who qualifies for Medicare benefits? Individuals 65 years of age or older Under 65 with permanent kidney failure (beginning three months after dialysis begins), or Under 65, permanently disabled and entitled to Social Security benefits (beginning 24 months after the start of disability benefits) The Different Benefits of Traditional Medicare Medicare Part A benefits cover hospital stays, home health care and hospice services Medicare Part B benefits cover physician visits, laboratory tests, ambulance services and home medical equipment While oftentimes you do not have to pay a monthly fee to have Part A benefits, the Part B program requires a monthly premium to stay enrolled. In 2008 that premium is set at $93.50 per month. Typically, this amount will be taken from your Social Security check. Part B also has an annual deductible that has to be met at the beginning on the year. In 2008 it was $150. Typically, Medicare deducts this amount from the first Provider's bill that is sent to them on any given patient. Some co-insurance pick up the Medicare deductible, most do not. What Can You Expect to Pay? Every year, in addition to your monthly premium, you will have to pay the first $124 of covered expenses out of pocket and then 20 percent of all approved charges if the provider agrees to accept Medicare payments. Unfortunately, your medical equipment provider cannot automatically waive this 20 percent or your deductible without suffering penalties from Medicare. They must attempt to collect the coinsurance and deductible if they are not covered by another insurance plan; however, certain exceptions can be made if you suffer from qualifying financial hardships. If you have some type of supplemental insurance, that plan may pick up this portion of your responsibility after your supplemental plan's deductible has been satisfied. If your medical equipment provider does not accept assignment with Medicare you may be asked to pay the full price up front, but they will file a claim on your behalf to Medicare. In turn, Medicare will process the claim and mail you a check to cover a portion of your expenses if they approve the charges. Other possible costs: Medicare will pay only for items that meet your basic needs as prescribed by a physician. Oftentimes you will find that your provider offers a wide selection of products that vary slightly in appearance or features. You may decide that you prefer the products that offer these additional features. Your provider should give you the option to pay a little extra money to get a product that you really want. To take advantage of this opportunity, a new form has been approved by the Centers for Medicare and Medicaid Services (CMS) that allows patients to upgrade to a piece of equipment that they like better than other standard options prescribed by their physician. The Advance Beneficiary Notice, or ABN, must detail how the products differ, and requires a signature to indicate that you agree to pay the difference in the retail costs between two similar items. Your provider will typically accept assignment on the standard product and apply that cost toward the purchase of the fancier item, thus requiring less money out of your pocket. Purpose of ABN The Advance Beneficiary Notice also will be used to notify you ahead of time that Medicare will not probably pay for a certain item or service in a specific situation, even if Medicare might pay under different circumstances. The form should not be generic and you should understand why Medicare will not pay for the item you are requesting. The purpose of the form is to allow you to make an informed decision about whether or not to receive the item or service knowing that you may have additional out-of-pocket expenses. Durable Medical Equipment (DME) Defined In order for any item to be covered under Medicare, it typically has to meet the test of durability. Medicare will pay for medical equipment when the item: Withstands repeated use (excludes many disposable items such as underpads) Is used for a medical purpose (meaning there is a condition which the item will improve) Is useless in the absence of illness or injury (thus excluding any item preventive in nature such as bathroom safety items used to prevent injuries) Used in the home (which excludes all items that are needed only when leaving the confines of the home setting) Understanding Assignment (a claim-by-claim contract) When a provider accepts assignment, it is agreeing to accept Medicare's approved amount as payment in full. You will be responsible for 20 percent of that approved amount. This is called your coinsurance. You also will be responsible for the annual deductible, which is $150.00 for 2008. If a provider does not accept assignment with Medicare, you will be responsible for paying the full amount upfront. The provider will still file a claim on your behalf and any reimbursement made by Medicare will be paid to you. (Providers must still notify you in advance, using the Advance Beneficiary Notice, if they do not believe Medicare will pay for your claim.) Mandatory Submission of Claims Every provider is required to submit a claim for covered services within one year from the date of service The role of the physician with respect to home medical equipment: Every item billed to Medicare requires a physician's order or a special form called a Certificate of Medical Necessity (CMN), and sometimes additional documentation will be required. Nurse Practitioners, Physician Assistants, Interns, Residents and Clinical Nurse Specialists also can order medical equipment and sign Prescriptions/CMNs when they are treating a patient. All physicians' have the right to refuse to complete documentation for equipment they did not order, so make sure you consult with your physician before requesting an item. Prescriptions Before Delivery: For some items, Medicare requires your provider to have completed documentation (which is more than just a call-in order or a prescription from your doctor) before they can deliver these items to you: Decubitus care (wheelchair cushions and pressure-relieving surfaces placed on a hospital bed) Seat lift mechanisms TENS Units (for pain management) POVs/Scooters Electric Wheelchairs How does Medicare pay for and allow you to use the equipment? Typically there are three ways Medicare will pay for a covered item: They will purchase it outright, then the equipment belongs to you, They will rent it for 13 months and then ownership reverts to the beneficiary. After an item has been purchased for you (either outright or after 13 payments), you will be responsible for calling your provider anytime that item needs to be serviced or repaired. Medicare will pay for a portion of repairs, labor, replacement parts and for temporary loaner equipment to use during the time your product is in for servicing, if necessary. All of this is contingent on the fact that you still need the item at the time of repair and meet Medicare's criteria. Article Courtesy of Triangle Aftercare - Medical Equipment and Supplies serving Durham, Chapel Hill, Roxboro, Pittsboro and Raleigh