WASHINGTON, D.C. – AAHomecare has responded to a CMS request for information on Medicare Advantage (MA) data with recommendations to improve transparency in MA programs for HME suppliers and the broad scope of healthcare stakeholders.

Recommendations include:

• Require MA plans to publish data that demonstrates they provide sufficient access to care and patient choice, including measures of beneficiary satisfaction and complaints, as well as the number of in-network DME suppliers by product category and geography.
• Require MA plans to publish data regarding their appeal process for Prior Authorization (PA) decisions, as well as disclosing detailed PA approval/denial statistics by product category.

• Require MA plans to disclose their use of Artificial Intelligence in PA and claims processing.

• Require MA plans to disclose data on what benefits they cover under Part D that are also covered under Part B. Despite the fact that Medicare has determined that continuous glucose monitors (CGMs) are covered as DME under Part B, and that MA plans are required to provide CGMs under Part B, many MA plans are instead covering these devices and related supplies under Part D prescription drug plans.

Comprehensive data on beneficiary satisfaction, access to care, authorization processes, denials/approvals, and coverage policies under MA plans benefits patients, caregivers, and healthcare providers. This data is also critical to effective oversight and evaluation of these plans by legislators and regulators. AAHomecare will continue to press for measures that increase transparency in the Medicare Advantage space. See full comments to CMS here.

NCART: Latest On Power Standing And Seat Elevation

EAST AMHERST, N.Y. – The National Coalition For Assistive & Rehab Technology (NCART) and the ITEM (Independence Through Enhancement of Medicare and Medicaid) Coalition continue to request an expected date for the opening of the NCD (national coverage determination) for power standing.

Both organizations have continued to work with the Clinician Task Force, the University of Pittsburgh, and other clinical and medical stakeholders to gather additional supporting documentation that proves the importance and medical need for power standing.

NCART and the ITEM Coalition met with CMS to discuss the pricing methodology and data utilized in the gap-filling method (legislatively approved), which was used to develop the fee schedule of $2,003 for seat elevation.

To ensure access for all consumers, the organizations shared their concerns about how this low fee schedule could impact consumers’ ability to receive seat elevation. They submitted data at CMS’ request and the information is being reviewed.

HHS OIG Shares New Portfolio Report On OTS Orthotic Braces

WASHINGTON, D.C. – Last week, the Dept. of Health and Human Services’ Office of Inspector General (OIG) prepared a portfolio report titled Medicare Remains Vulnerable to Fraud, Waste, and Abuse Related to Off-the-Shelf Orthotic Braces, Which May Result in Improper Payments and Impact the Health of Enrollees.

The report is not a typical OIG audit report. While a regular OIG report is on individual audits or investigations, a portfolio report aggregates and synthesizes findings from multiple reports to address larger, systemic issues within a program area.

In this portfolio report, the OIG identified vulnerabilities in Medicare related to off-the-shelf (OTS) orthotic braces. Between 2014 and 2020, Medicare spent approximately $5.3 billion on these braces, often finding them among the top items with the highest improper payment rates. The report highlights several issues, including:

• providers ordering braces for patients without a prior treating relationship;
• new suppliers emerging in areas with known Medicare fraud;
• Medicare pays more for OTS braces than private insurers; and
• suppliers engaging in prohibited telemarketing practices.

To address these vulnerabilities, the OIG recommended that CMS enhance its oversight mechanisms. Suggested actions include:

• preventing payments for improperly billed replacement braces;
• identifying and educating providers who order braces without treating relationships; and
• conducting additional reviews based on suspicious billing patterns.

Additionally, OIG suggested CMS ensure that Medicare payments are in line with those of private insurers and educate suppliers and enrollees on proper telemarketing practices. The OIG also recommended the use of data analysis to identify emerging fraud schemes. While CMS has acknowledged its efforts to reduce improper payments, it has not specifically committed to the OIG’s recommendations.