ARLINGTON, VA – As senior vice president of Payer Relations at AAHomecare, Laura Williard is on the road about 30 times a year. That includes some states that haven’t had much advocacy until now. Medtrade Monday checked in with Williard (who took a break during a trip to Florida) to get a sense of the current payer relations challenges faced by the DME industry.

Medtrade Monday: What issues are you hearing about right now?
Williard: The biggest issue of late has been the change in the United Healthcare relationship in North Carolina and Georgia with Synapse Health and what’s happening there. We are asking; How can we as an industry have a supportive value-based platform that would work for our industry?

We’ve looked at that for several years now and are trying to get something pulled together. We were looking at it from too big of a perspective. We’ve learned that payers from the DME perspective want some of the customer satisfaction and operational deliveries happening to get them out of the hospital. Those are important.

It’s definitely got some renewed energy around it of late with what’s happened with United Healthcare and I know that these payers are looking at all the ways they can automate and be more efficient with their network. We’re trying to make sure that we fit into the networks and with the large and small providers from across the country.

Medtrade Monday: What’s going on with Medicare Advantage?
Williard: There are still ongoing challenges with Medicare Advantage medical policies and denials, specifically with regards to non-invasive ventilation which continues to be a huge issue for providers and patients—mainly the patients. We still have some payers that are removing patients off of therapy after they’ve been on non-invasive ventilation for three months and then they remove them and say they don’t meet medical criteria. We still have big issues like that going on that we’re working on.

Medtrade Monday: Can you be a bit more specific about the NIV situation?
Williard: We’re still seeing patients who have been on NIV for three months and they are used to the therapy. They are finally getting their lives stabilized and suddenly they’re told, ‘You can’t have this anymore. You don’t qualify and you have to find something else.’ It’s tough for those patient populations to really navigate through this, and it’s happening more in the Medicare advantage world. The Medicare fee for service seems to be working just fine. They’re paying for the appropriate diagnosis, the appropriate patients—whereas the Med Advantage are still denying a lot of those.

Medtrade Monday: What payers are making those denials?
Williard: United Healthcare and Humana are the two main players from a denials perspective—denying the PA [prior authorization] or getting audits on those types of things. That continues to be a struggle and that’s something that we’re working on. We’ve met with CMS and we’re going to continue to push it with them.

Medtrade Monday: What tools can you use in that conversation?
Williard: We’re working on a study right now on non-invasive ventilation to show what’s happening and how to improve outcomes of non-invasive ventilation for the COPD population. We worked pretty hard on the neuromuscular earlier this year and feel like we made some headway with some of the payers and making sure that’s getting covered the way it should.

The COPD population continues to be a huge problem. That study is probably going to be out in the first quarter next year, probably in a 10-month timeframe. We had our first technical advisory panel call two weeks ago, so we’ll be looking at the outcomes from non-invasive ventilation on COPD, chronic respiratory failure and compare patients who were put on non-invasive ventilation earlier than those that were not put on invasive ventilation and look at their outcomes.

We’re going to compare Medicare fee for service to Medicare Advantage to see if there are different utilization patterns. Because you would think that it would be the same for those populations. We compare Medicare fee for service to the Medicare Advantage as well.

Medtrade Monday: What else is worrying you these days?
Williard: The biggest thing that’s worrying me now, and I’m seeing an industry response, is with the 75/25 not being extended. At this point, we are seeing the impact on the Medicaid programs, and a lot of them publish their fee schedules in July. I don’t think a lot of people have really felt the pain or problems with those fee schedules in the Medicaid world. The decreases are getting ready to start now. Those fee schedules are starting to get published, and it’s taken the drastic rate reductions that the Medicare world has taken with that 75/25 blend going away. It’s definitely something that I think over the next six months is going to be top priority for us and continuing to work with those Medicaid programs to delay updating their fee schedules so they can see what happens with the 75/25 blend, and if we can get something passed this year.

Medtrade Monday: Why are Medicaid cuts so troubling?
Williard: A lot of people have changed their business models, taking on more payers, and Medicaid has been a pretty stable payer for a lot of providers in several states. Seeing those rates go down is really going to put an impact on providers who have relied on that to balance their business model and business operation. I’m very worried about that.

I’ve seen more activity at the state level, probably this year than I have seen in a very long time. There are states that are jumping in and starting to work on things and getting really organized around what they’re asking for, and trying to get budget increases and build relationships with state legislators. It’s a top priority for many in the industry.

Medtrade Monday: What should providers be doing during Congress’ August recess?
Williard: I definitely think that inviting legislators, federal or state, to your offices can help to build those relationships—especially at the state level. Now is the time to build relationships, because you don’t want to go to legislators when you need them. You need to already have those relationships established. AAHomecare is working on that. Many states, Connecticut comes to mind, is one that we’ve been working on recently. There are several states where that is happening. Start from the bottom up.

I think we’ve done a great job at the federal level. They understand DME. They understand our issues. We don’t have to go in there and explain from the bottom up anymore at a federal level. But at the state, there’s some who understand it very well, but the majority do not. We need champions and a supportive group of state legislators who understand DME. It’s kind of an odd time because legislators are focused on the elections coming up.

Now is the time to build the relationships, and when they set all the committees we’ll have to hit the ground running. Legislation sessions start January of next year, so we must have those champions lined up. We’re asking providers to go out and build those relationships. Every state is a little different, but the common theme across the board is rate increases for these state Medicaid programs. Some of them have still not had great increases in 18 to 20 years, and so that creates a problem that’s not keeping up with the rate of inflation as well.