Pure Home Care Services

The American Association for Homecare supports tough anti-fraud measures for Medicare, and we hope that the Energy and Commerce subcommittee hearing on this issue this week will focus on effective measures to prevent theft of taxpayer dollars. The American Association for Homecare represents providers of durable medical, or home medical equipment and services.

We have zero tolerance for fraud and will continue to work to help federal officials more effectively regulate this sector.

Several years ago, the American Association for Homecare proposed to Congress a 13-point Medicare Anti-Fraud Legislative Action Plan that included tougher penalties for fraud, more site visits, and real-time claims audits to prevent fraud at the front-end of the process rather than relying on the ineffective pay-and-chase system. Parts of our 13-point plan have been proposed in several congressional bills and were adopted in the recent health reform law. However, we encourage Congress to adopt all of our proposals to ensure a comprehensive approach that shuts down avenues for Medicare fraud. Details of the 13-point plan can be viewed here.

It’s important to point out that providers of home medical equipment must now be accredited by a deemed accrediting organization and they must also post a surety bond. These two requirements took effect a year ago, October 2009, and fraud associated with the home medical equipment sector has likely declined since then. We encourage federal officials to assess and report the rate of fraud since those requirements took effect.

Spending in the home medical equipment sector represents less than two percent of total Medicare spending, and fraud associated with durable medical equipment represents a tiny fraction of total fraud in Medicare.

A number of important new anti-fraud measures are now in place, which were long overdue. But Congress, CMS, and the Office of Inspector General should not promote or impose unreasonable burdens on the existing, accredited home medical equipment providers.

Correcting the Record: Myths Associated with Fraud Debate

During discussions on the issue of fraud in the home medical equipment sector, policymakers frequently commingle issues that distort and misrepresent the homecare community.

Competitive Bidding Is a Payment Mechanism, Not an Anti-Fraud Measure

Competitive bidding is simply a payment mechanism-not an anti-fraud tool. When competitive bidding was enacted in 2003, Congress adopted a number of separate measures to address fraud and abuse through the establishment of quality standards and mandatory accreditation. CMS also has taken additional steps recently to prevent fraud through the implementation of surety bonds and more stringent supplier standards. Medicare has also issued enhanced provider enrollment rules and more stringent supplier standards.

Internet Pricing Is Not an Accurate Benchmark for Medicare Payment Levels

Several studies conducted by federal agencies such as the GAO and the OIG highlight the disparity between Internet prices and Medicare payments. This is not an accurate comparison. First, these studies clearly cite that the analyses did not look at service-related costs in the provision of home medical equipment. The studies also overlook overhead, staffing costs and mandatory accreditation, 24/7 emergency care, adherence to quality standards, and FDA’s home use requirements. There has been only one comprehensive study that has evaluated both service and equipment costs. This study found that in the oxygen arena, equipment costs only account for 28 percent of the Medicare payment rate. The remaining 72 percent is related to service and general and administrative costs.

Payment Rates that Differ from Internet Pricing Do Not Promote Fraud

Criminals out to defraud the Medicare program are intent on stealing. They do not provide equipment and services and they do not follow Medicare rules and regulations. However, recently, the OIG stated that because home medical equipment reimbursement rates are often higher than pricing for HME available on the Internet, it inherently leads to fraud and abuse. The OIG reasons that excess revenues attract criminals who intend to defraud the Medicare program and can be used to promote kick-back arrangements. This is an unsubstantiated assumption. AAHomecare is not aware of any federal study conducted by the OIG or the GAO that demonstrates that excessive payment promotes fraud. The real point is that criminals intent on defrauding Medicare are not suppliers and have no intention of providing items and services to Medicare beneficiaries regardless of the payment rate.

There Is Not an Excessive Number of HME Providers

Federal officials frequently point to the need to reduce the number of suppliers that participate with the Medicare program. What is overlooked is that there are only approximately 15,000 home medical equipment providers nationwide-or about one for every 2,500 Medicare beneficiaries. Even CMS cites the statistic that only 20 percent of suppliers in the round one areas of competitive bidding bill more than $10,000 to the Medicare program annually. The vast majority of entities that have supplier numbers are pharmacies like CVS or Rite Aid, physical therapists, physicians, ophthalmologists, prosthetists, neurosurgeons, dentists, and other similar providers. Moreover, some policymakers have stated that the DMEPOS fee schedule is outdated. This is incorrect as Congress and CMS have adjusted DME pricing multiple times over the past decade so that current Medicare payments are sometimes 50 percent less than they were a decade ago.

Improper Payments Should Not Be Confused with Fraud

There have been a number of audit samples of specific HME items such as oxygen therapy, power wheelchairs and continuous positive airway pressure (CPAP) devices that indicate a high improper payment rate. As the OIG correctly points out, the increase in the Medicare error rate in the home medical equipment sector is “not necessarily due to more fraud in the program. In fact, the error rate is not a measure of fraud.” In 2009, the OIG implemented a strict adherence to policy documentation requirements, retro application of rules, signature legibility requirements, and lack of physician documentation and the removal of claims history as a valid source for review information. In this latter example, in previous years, auditors could use clinical inference to determine if a claim was reasonable and necessary. Now, they cannot use their education and training to determine if a claim is appropriate.

However, when there is an error rate of 78 percent as was the case in a recent oxygen probe audit, this points to a larger problem with the overall system-not with HME providers. We maintain that CMS is not doing an adequate job of educating physicians and homecare providers and the policies have become so complex that the vast majority of HME providers are not able to reasonably comply. In this example and others, federal bureaucrats are overturning physician decision making and judgment in more than 3 out of every 4 cases. Upon appeal at the Administrative Law Judge (ALJ) level, the ALJs are reversing CMS’ decisions 3 out of 4 times suggesting that there is an institutional disconnect that is hurting legitimate providers of HME.

Homecare providers and the Medicare beneficiaries they serve require clear, reasonable, consistent, and unambiguous guidance that does not change from auditor to auditor.

CMS and Its Private Contractors Have Failed in their Oversight of Supplier Enrollment

A number of reports have pointed to the low barrier to entry that has made home medical equipment vulnerable to criminal activity and fraud. In south Florida, for example, the OIG conducted unannounced site visits to 1,581 providers and found that 31 percent of these providers did not maintain a physical facility or were not open and staffed during business hours. In another analysis, the GAO found that a supplier number was granted to a broom closet.

AAHomecare believes that CMS and its contractors have failed in their oversight responsibility. It is CMS’ responsibility to determine whether a supplier should be granted billing privileges. CMS is required to conduct a site visit for any new supplier and upon renewal of the supplier number every three years. If CMS were doing an adequate job, these egregious lapses would not have occurred. Congress has also addressed this vulnerability by requiring mandatory accreditation and quality standards for all home medical equipment providers. This should serve as a double check on CMS and raises the bar of entry and protect the Medicare program. Finally, policymakers and the media focus on fraudulent activity that occurred prior to the implementation of enhanced screening tools in 2009.

Source:
American Association for Homecare

Pure Home Care Services, located in Macomb County, MI, specializes in home care services for you or your loved one.  Call us today at (586) 293-2457 for more information about how we can help you!

Seniors’ Programs Squeezed as Congress Approves 2012 Budget

In the end, plan cuts 0.2 percent from 2011 budget

A year of brutal battles over federal spending ended with a whimper — and is likely to curb some programs that affect older Americans. Social Security and Medicare, however, were largely spared the financial pinch.

Republicans, empowered by the tea party movement and a strong House majority, pressed to slash government spending, saying the deficits will overwhelm the nation’s economy otherwise. Democrats pushed back, saying a recession was no time to make drastic cuts, especially to programs such as Medicare, Social Security and aid to the needy.

That clash of ideas almost took the government to the point of shutdown more than once in 2011, but with just a few hours before a shutdown would have occurred at midnight on Friday, Dec. 16, the parties agreed on a $915 billion spending bill.

The House passed the bill 296-121 on Dec. 16; the Senate passed the bill 67-32 the next day.

When previous spending bills are added, the total for discretionary spending for the year is $1.043 trillion. And that’s just about back to square one, according to budget experts.

“After all the debate and negotiations that went on this year, in the end nothing came of it,” says Patrick Louis Knudsen, a federal budget expert at the Heritage Foundation. The $1.043 trillion was a combination of 12 budget appropriations bills. Knudsen says that’s $7 billion less than 2011, but Congress left itself wiggle room to add “disaster funding” that could bring it near or above the 2011 number.

The agreement likely leaves some programs that affect older Americans short of funds.

“We’re tremendously concerned about the growing number of impoverished seniors,” says Timothy J. Gearan, AARP’s appropriations lobbyist. “We know there’s a greater need out there.”

The Low Income Home Energy Assistance Program, which has many older recipients, will receive nearly $3.5 billion — about $1.2 billion less than last year. That means about 2 million fewer households will get help with their heating or air conditioning bills, according to Gearan.

Some states will stretch the money by giving each household half as much to buy fuel, leaving some households without heat halfway through the winter. “Heat, eat or take drugs. It’s a Hobson’s choice,” Gearan says.

Older Americans Act programs stayed level. The caregivers program will get $160 million. The nutrition program, which pays for home-delivered meals and those served at senior centers, will get $818 million. And supportive service programs, which pay for transportation to doctors and other home- and community-based services, will get $368 million.

“It’s nothing to cheer about,” Gearan says, adding that he’s happy the programs weren’t cut, but he worries how the level funding will accommodate the wave of boomers now retiring — at a rate of one person every eight seconds.

Continue Reading »

What You Need to Know About Medicare Plans in 2012

Save money by taking the time to comparison shop

If you have Medicare Part D prescription drug coverage, the chances are very high that this year you’ve been paying a lot more for your medications than you needed to.

Sign up for AARP’s Health Newsletter.

That’s because so few enrollees bother to compare the Part D drug plans available to them. As a result, in 2011 fewer than 7 percent are in the Part D plan that offers them the lowest out-of-pocket costs, according to a recent analysis.

Comparing plans during open enrollment is the best way to ensure that you don’t miss out on your best deal for 2012, which could produce savings of several hundred dollars next year, especially if you take a lot of medications.

But be warned: This year’s seven-week open enrollment period begins Oct. 15 and ends at midnight on Dec. 7 — a deadline three weeks earlier than in previous years.

If you enroll in a different plan during this period, coverage in your current plan will automatically end at midnight on Dec. 31 and your new coverage will begin Jan. 1.

If you choose to keep your current plan (and it is still offered in 2012), you don’t need to take any action — your enrollment automatically continues next year.

Medicare Part D prescription drug plans in 2012

All Part D plans can change their costs and coverage each calendar year. So pay attention to the “Annual Notice of Change” you should have received from your current plan in September. This spells out any changes for 2012 — in premiums, deductibles, copayments or coverage — and may contain good news or nasty surprises.

Among “stand-alone” Part D drug plans — the kind you have if you’re enrolled in traditional Medicare rather than a Medicare Advantage plan — a few that operated in 2011 will no longer be available in some states in 2012.

If you’re in one of these plans, you may be automatically enrolled in another offered by the same insurance company, if available, or you can switch to a different plan. There are still plenty of choices in each state, ranging from 25 in Alaska and Hawaii to 36 in Pennsylvania and West Virginia.

Overall, monthly premiums for stand-alone plans in 2012 will range from $15.10 to $131.80. On average, premiums will fall slightly, according to the Centers for Medicare & Medicaid Services. But some premiums will rise significantly.

For example, the country’s most popular drug plan, AARP MedicareRx Preferred, run by UnitedHealthCare, will increase its monthly premiums by an average of 14 percent, ranging from 20 cents in Arizona to $8.10 in California. UnitedHealthCare spokesman Matthew Burns says that the plan “covers more branded drugs than most of our competitors and has no deductible,” adding that on average “our premiums for 2012 are slightly lower than 2010 levels,” given that they fell in most states in 2011.

Source: AARP.org

Contact Pure Home Care Services at (586) 293-2457 today!  If you live in Macomb or the surrounding area, we can help you care for your loved ones.

Home care is a diverse and dynamic service industry that began in US in the 1880’s. Approximately 7.6 million individuals currently receive care from 17,000 providers because of acute illness, long-term health conditions, permanent disability, or terminal illness.1 In 2007, annual expenditures for home health care were projected to be $57.6 billion.2

Home Care Providers
“Home care organizations” include home health care agencies, home care aide organization, and hospices. Some of these organizations are Medicare certified, which allows providers to bill Medicare for reimbursement. Agencies that are not Medicare certified cannot be reimbursed through Medicare.

Author: The National Association for Home Care & Hospice

Our network includes specialists in the fields of:

• Medicare – what are coverage details?
• Medicaid – is your loved one eligible
• Veteran’s Benefits – do they qualify?
• Legal Concerns – are wills, trusts, medical advocates necessary?
• Real Estate – must a reverse mortgage be considered?
• Home Modifications – is the home safe and livable?
• Home Monitoring Systems – is a home or personal emergency system needed?
• Nursing Homes – what are the options?

When your worries multiply, rely on Pure Home Care Services, Inc., for caring answers to the questions you never thought you’d have to ask.  Call us today at (586) 293.2457