Unless you’re a healthcare worker using durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) or are a home healthcare company, you probably have no idea what Medicare’s DMEPOS Competitive Bidding Program (CBP) is or how it affects healthcare equipment suppliers and patients.

Frankly, it’s been a thorn in the sides of many DMEPOS companies for years. Imagine their glee when the Centers for Medicare & Medicaid Services (CMS) proposed changes to the program.

All Medicare Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) Competitive Bidding Program contracts expired on December 31, 2018. As of January 1, 2019, there is a temporary gap in the entire DMEPOS Competitive Bidding Program that CMS expects will last until December 31, 2020. 

During the temporary gap, any Medicare enrolled DMEPOS supplier may furnish DMEPOS items and services to people with Medicare. In most cases, people with Medicare won’t need to switch suppliers on or after January 1, 2019. 

• Medicare beneficiaries may receive DMEPOS items from any Medicare-enrolled supplier until such time as new CBP contracts go into effect.
• When competitive bidding resumes, it will be under new program rules, as discussed below.

Future Competitive Bidding Program Rules

In a final rule scheduled to be published on November 14, 2018, CMS adopted a number of “market-oriented reforms” and technical policy changes for future rounds of competitive bidding. According to CMS, the new rules will simplify the bidding process, preserve beneficiary access to items and services, and make the DMEPOS CBP more sustainable.

Of particular note, CMS has finalized its proposed “lead item pricing” methodology. Rather than bid on each item/HCPCS code in a product category for each competitive bidding area (CBA), suppliers will submit a single bid for the item in the product category designated by CMS to have the highest total nationwide Medicare allowed charges.

Proposed Changes Are a Win/Win

According to a CMS Newsroom Fact Sheet, “Beginning on January 1, 2019, beneficiaries may receive DMEPOS items from any willing supplier (until new contracts are awarded under the DMEPOS CBP).”

Home healthcare supply companies are breathing a big sigh of relief about the proposed changes.

The proposed changes will benefit to small DME companies by allowing them to market their products and company to providers, facilities, and nursing agencies without limiting their customer base to non-Medicare insurances.

Even though Medicare fee schedule is low, it opens up the market to more customers and creates a fairer playing field for all companies, which will result in better service to beneficiaries.

For those companies who didn’t have contracts due to CBP, but now do, the only downside is they’ll need to jump back through the hoops of government regulations to get their Medicare claims paid.

To learn more about Medicare’s Temporary Gap Period or the future of Medicare Competitive Bidding, follow the link http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSCompetitiveBid/index.html?redirect=/DMEPOSCompetitiveBid/

CMS Proposed Polices and Payments rates for End-Stage Renal Disease providers for CY 2015

On July 2, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2015.

• This proposal would introduce new quality and performance measures to improve the quality of care by outpatient dialysis facilities treating patients with end-stage renal disease and proposes to implement the Affordable Care Act mandate to bring more competitive bidding for durable medical equipment.
• The rule also proposes changes to the ESRD Quality Incentive Program (QIP), including for payment year (PY) 2017 and PY 2018, under which payment incentives are applied to dialysis facilities to improve the quality of dialysis care.
• This rule also addresses issues related to the coverage and payment of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).

A separate fact sheet addressing the payment provisions of the ESRD PPS for CY 2015 can be found here: http://www.cms.gov/Newsroom/Newsroom-Center.html.

CMS Updates to Policies and Payment Rates for End-Stage Renal Disease Facilities for CY 2016 and Changes to the ESRD Quality Incentive Program

On October 29, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a final rule to update payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2016.

• The ESRD final rule is one of several rules for calendar year 2016 that reflect a broader Administration-wide strategy to provide quality care at lower cost by improving ways to deliver care, pay providers, and use information.
• Provisions in these rules are helping to move our health care system to one that values quality over quantity and focuses on reforms such as measuring for better health outcomes, focusing on disease prevention, helping patients live successfully at home, helping manage and improve chronic diseases, and fostering a more efficient and coordinated health care system.

To read the complete update click the link https://www.cms.gov/newsroom/fact-sheets/cms-updates-policies-and-payment-rates-end-stage-renal-disease-facilities-cy-2016-and-changes-esrd

CMS releases final rule for 2017 ESRD payment bundle

The Centers for Medicare & Medicaid Services issued a final rule on Oct. 28, 2016 that updates payment policies and rates for the End-Stage Renal Disease Prospective Payment System for 2017. The final rule also made changes to the ESRD Quality Incentive Program (QIP), including payment years 2019 and 2020.

Changes to the ESRD PPS for 2017

• The finalized CY 2017 ESRD PPS base rate will increase $1.16 to $231.55, compared to the 2016 rate of $230.39.
• The 2017 home and self-dialysis training add-on payment adjustment will be $95.60, an increase of $45.44, compared to the 2016 add-on of $50.16.
• CMS will provide coverage and payment for renal dialysis services in 2017 by an ESRD facility to an individual with acute kidney injury. Under the law, the payment will be the amount of the ESRD PPS base rate, as adjusted by the wage index.

CMS Updates to Policies and Payment Rates for ESRD Prospective Payment System, Quality Incentive Program, and Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury for 2017

On October 27, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2018.

• The ESRD PPS rule is one of several rules for calendar year (CY) 2018 that reflect a broader Administration-wide strategy to support the patient-doctor relationship in health care and promote flexibility and innovation in the delivery of care.
• In addition, this rule finalizes updates to the acute kidney injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI, as well as updates to the ESRD Quality Incentive Program (ESRD QIP), including for payment years (PYs) 2019, 2020, and 2021, under which payment incentives are made to dialysis facilities to improve the quality of care that they provide.

The ESRD PPS rule is one of several rules for calendar year (CY) 2018 that reflect a broader Administration-wide strategy to support the patient-doctor relationship in health care and promote flexibility and innovation in the delivery of care.

CMS is committed to transforming the health care delivery system – and the Medicare program – by putting a strong focus on patient-centered care, so providers can direct their time and resources to patients and improve outcomes.

To know about the changes read the complete text https://www.cms.gov/newsroom/fact-sheets/cms-updates-policies-and-payment-rates-end-stage-renal-disease-prospective-payment-system-quality

CMS release ESRD/DMEPOS Competitive Bidding Program Temporary Gap Period Announcement for 2019

Centers for Medicare & Medicaid Services (CMS) has released its final End-Stage Renal Disease (ESRD)/ Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) rule, which contain some, but not all of the additional competitive bidding and reimbursement reforms for which HME stakeholders have been calling.

On November 1, 2018, the Centers for Medicare & Medicaid Services issued a final rule that updates payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2019.

1. This rule also updates the acute kidney injury dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI, and finalizes changes to the ESRD Quality Incentive Program.
2. The policies in this final rule aim to increase access to items and services for patients, drive competition, increase affordability, encourage facilities to adopt transformative and innovative therapies, and reward ‘out of the box’ ideas that will produce long-term savings that can be passed on to patients.

This rule also finalizes changes to bidding and pricing methodologies under the:

• Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
• Competitive Bidding Program (CBP);
• Adjustments to DMEPOS Fee Schedule amounts using information from competitive bidding for items furnished on or after January 1, 2019.
• New payment classes for oxygen and oxygen equipment and a new methodology for ensuring budget neutrality for oxygen payment classes; and special payment rules for innovative multi-function ventilators or ventilators that perform functions of DME.

Starting January 1, 2019, there will be a temporary gap period in the entire DMEPOS CBP that CMS expects will last until December 31, 2020. During that time, Medicare beneficiaries may receive DMEPOS items from any Medicare enrolled DMEPOS supplier and in most cases, they won’t need to switch suppliers.

In addition, in the proposed rule, CMS solicited comments in a request for information (RFI) on the gap-filling process for establishing fees for new DMEPOS items.

Footnotes:

CMS is committed to transforming the healthcare delivery system and the Medicare program by putting a strong focus on patient-centered care, so providers can direct their time and resources to patients and improve outcomes. The ESRD PPS and QIP DMEPOS final rule is one of several rules for calendar year (FY) 2019 that reflect a broader Administration-wide strategy to relieve regulatory burdens for providers, support the patient-doctor relationship in healthcare, and promote transparency, flexibility, and innovation in the delivery of care.

In this final rule, CMS summarizes comments it received in response to an information solicitation on how the gap-filling process could be revised in a way that complies with the exclusive statutory payment rules for DMEPOS, but also prevents excessive overpayments or underpayments for new technology items and services.

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