Editor's Note

Built to Fail

CMS's audit program needs serious retooling.

• By David Kopf
• Dec 01, 2015

Quality is a word that dictates much of what home medical equipment providers do. They ensure quality care and they provide quality products, and nothing is more frustrating than when a piece of equipment winds up not being of the quality the provider had expected. It’s bad for the patient and it’s bad for the provider, both of whom are invested in seeing a good experience and a positive outcome from that equipment.

Ensuring that level of quality is getting harder to do these days. With Medicare winnowing away reimbursement through programs such as competitive bidding, some providers are seeking lower price points. Unfortunately those lower price points can sometimes mean lackluster quality.

To put it simply, things are not built to last they way they used to. For many Americans, that’s a tough pill to swallow, as it used to be that you could depend on something you bought to stick around for the long haul.

For instance, my parents were both of the Greatest Generation. My dad was born in 1918 and my mom was born in 1925. Growing up through the Depression, my parents learned to hold onto everything of use — and I mean everything. And a lot of that stuff came into my possession as hand-me-downs when I moved out of the house or when my parents moved into smaller places during their senior years.

I have measuring cups and other cooking accouterments in my kitchen that date back to the 1920s. Handtools from the turn of the century and power tools from the 1950s now call my garage home. I have a coffee can full of oddly shaped tacks and nails that I’m almost certain originated from my great grandfather Freidrich’s late 19th Century carriage shop.

Those items were built to last, and so should DME. But that concept of quality and longevity sometimes feel like fleeting ideals in today’s bottom line-oriented era. For example, looking at current headlines, we know that an international, decades-old company like Volkswagen has purposely manufactured automobiles that did not do what they were supposed to do in order to fool its customers and sucker the governments of the countries in which it does business.

A Broken System

Building something to fail will never sit right with me, and that’s why I find CMS’s Medicare claims audit program so frustrating. Just looking at the face of things, the system seems made to implode.

For example, the audit contractors are essentially awarded for recoupments before the appeals process concludes, which only incentivizes the contractors to recoup on as many claims as possible, rather than claims that are truly out of order. Also, because contractors are allowed such loose interpretation of LCDs, this only gives them greater latitude to recoup more claims.

Of course, because so many of the recoupments border on the frivolous, providers are going to appeal, and because providers have seen so much success when their appeals are finally heard by the administrative law judges, claims have completely backed up CMS’s Office of Medicare Hearings and Appeals. Fewer than a score of Federal judges must now wade through hundreds of thousand of claims (quickly approaching 1 million), a process that will take so many years that OMHA has stopped assigning appeals to ALJs until progress is made. And meanwhile providers are still on the hook!

That is a system that, in my opinion, was built to fail. If a lowly editor can look at that system on its face and instantly conclude it’s faulty, surely some of the experts within CMS must have drawn the same conclusion. Yet no fixes are being made.

This is why I am eagerly waiting for the industry to resume the legislative fight against CMS’s faulty audit system. I realize that our industry has a priority item on its hands when it comes to fighting the national expansion of competitive bidding, which hits Jan. 1, 2016, but as soon as reforming the audit program can be placed at the top of the industry’s advocacy agenda, it should.

Your Call to Action

And speaking of the expansion of competitive bidding, providers must consider December as their moment of truth. As I write this column, industry representatives and lawmakers are just about to launch legislation that will reform CMS’s expansion pricing scheme and timetable in order to diminish the impact on providers, and rural providers in particular.

But groups like the state associations and the American Association for Homecare can’t do it on their own; they need your help. It’s critical that you call on your lawmakers to educate them on the issue, and ensure they support this legislation as co-sponsors. Otherwise, a lot of providers and patients will be left out in the cold this winter.

This article originally appeared in the December 2015 issue of HME Business.