YARMOUTH, Maine – Andrea Stark says the HME industry hasn’t experienced a coverage expansion like what’s in the new NCD for home oxygen therapy in recent history.
Stark, the head of reimbursement at MiraVista LLC, was a guest on a recent HME News in 10 podcast to talk about the ripple effects of the new NCD, which expands coverage to acute conditions and eliminates the CMN requirement, and how the DME MACs will interpret the new policy.
Caught by surprise
“CMS was responding to a pandemic and COVID-19 required a sense of action,” she said. “It required CMS to bend the rules to respond to this respiratory pandemic. So, on the one hand, that’s where I thought it was going to end. What surprised me is not that it was the temporary changes to begin with but the permanence of the doubling down. That CMS made these changes permanent – to say that caught me by surprise is an understatement.”
Ripple effects
“It comes with some baggage that suppliers didn’t have before,” she said. “The industry is configured to offer long-term oxygen therapy support, so adding coverage for acute conditions opens up logistical and compliance challenges. Acute conditions require short-term support. That means delivery technicians have to be dispatched twice in a very short time period. They have to set up the equipment and then subsequently retrieve that equipment once a patient recovers. Furthermore, acute conditions require additional follow up by customer support teams. They have to affirm that the equipment remains in use to perpetuate the billing and then they have to find out when that equipment is stopped and dispatch techs to collect the equipment. So, it displaces inventory in a different way.”
Gaps?
“CMS laid out their intentions pretty clearly in the NCD memo, so I’m not expecting a great departure from the MACs, but what I’m looking for is how they’re going to fill in the gaps on two specific areas,” she said. “First of all, what will continued coverage for acute conditions look like after that initial four months of therapy; and second, how will the MACs assess cases where patients don’t have hypoxic test results?”
Predictions
“I predict there is going to be a follow up face-to-face component for each of these categories (above) and am hopeful they’re going to give us some specific criteria for what the medical records have to say to secure a favorable coverage determination, but I really don’t see how they’re going to be as specific as we want them to be,” she said. “My gut tells me they’re likely to rely on individual consideration and that has its own set of issues. It’s extremely difficult to build a policy on precedent that is set by one-off cases. Systematically, it’s possible for the MACs to create a special modifier to trigger document review and I wouldn’t rule out prior authorization pathway for these claims down the road.”
Listen to the entire podcast at https://www.hmenews.com/hme-news-in-10.