Group fights rule on 'inherent reasonableness'
Group fights rule on 'inherent reasonableness'
Rule gives carriers tremendous power
While wound care providers in the home health, nursing home, and ambulatory arenas adjust for massive prospective payment system changes, a national organization is fighting one element: "inherent reasonableness."
The fight is being led by the National Coalition for Wound Care (NCWC), a five-year-old group that consists of 11 organizations, including the American Physical Therapy Association, the Association for the Advancement of Wound Care, the Wound Ostomy and Continence Nurses Society, the National Pressure Ulcer Advisory Board, and the Health Industry Manufacturers Association.
Under the Balanced Budget Act of 1997, HCFA and Medicare carriers that cover Medicare Part B claims have the authority to reduce or increase reimbursement for services or supplies that HCFA has deemed inherently unreasonable, explains Karen Simon, NCWC director. She also is director of governmental affairs for the National Pressure Ulcer Advisory Panel. "This means carriers are able to decrease the amount paid for any service or supply by up to 15% with virtually no notice, comment, or accountability," she says.
For instance, if HCFA decides the price of a certain piece of durable medical equipment is 60% too high, the agency can cut the reimbursement rate by 15% for four years without first notifying the supplier or those who purchase the equipment, and without soliciting any comments or defense. The same goes for services provided, including physical therapy. If HCFA or Medicare carriers deem that physical therapists are getting paid too much, they can decrease fees up to 15% every year, according to Simon. Only physicians are excluded from the inherent reasonableness provision.
"As HCFA keeps ratcheting down reimbursement, we will have problems with what's being provided to patients and problems with accessibility to care and quality of care," says Simon. "The focus of the NCWC is to gain assurance that patients will get quality wound care. Reimbursement is tied into many aspects of health care. We don't want to lose sight of patient care issues. When the NCWC talks about the issue of inherent reasonableness, we're looking at it not only from a financial perspective, but from the perspective of patient welfare, too."
Though HCFA is required to provide a list of new reimbursement rates 30 days before invoking its inherent reasonableness authority, it usually does not. "By the time they're published and received by the people who need them, there's usually not time to make adjustments," says Simon.
For example, Medicare carriers recently sent out a notice of inherent reasonableness for gel mattress pads, which reduced reimbursement by about 14% for that item. The agency said comments would be accepted, though such input never ensures HCFA will repeal a decision. However, the notices were sent out more than a month after the new rates actually went into effect, according to Simon.
The NCWC is pushing HCFA to not only follow the 30-day notification requirement, but to extend the period to at least 60 days. Simon also would like HCFA to disclose the reasons for invoking inherent reasonableness, why a particular item is chosen, and how the agency calculates an item's costs, benefits, and percentage reimbursement reduction. "Currently they don't do that, and they're not required to," she says. "We also want to know if any wound care products are targeted, and we'd like to work with HCFA and the carriers to provide data and help them understand the products with the most up-to-date information.
The NCWC also is concerned about the consolidated billing components stipulated by the balanced budget act and the revamped prospective payment system. This, says Simon, is a major development for skilled nursing facilities. Under consolidated billing, costs for many items and services, including wound dressings, shift from ancillary to routine costs in HCFA's eyes. Billing responsibilities shift from suppliers to nursing facilities. According to the NCWC, both of these actions will significantly reduce the amount of value-added services provided by suppliers to the facilities and place additional financial burdens on the facilities in caring for patients with wounds. As a result, says the NCWC, patient care may suffer.
Simon says the NCWC is fighting to ensure that wound care is well-represented in the new system, that there are adequate classification systems for wound care, and that Medicare payment schedules take wound acuity into consideration. Position papers dealing with the central issues addressed by the NCWC are currently being written.
For more information about the NCWC, call (703) 548-3100, or write to 1321 Duke St., Suite 304, Alexandria, VA 22314-3563.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.