Groups urge new Medicare supplier standards

Success likely to pay off for home infusion agencies

With Operation Restore Trust showing no signs of slowing, it’s clear the government — and the Health Care Financing Administration (HCFA) in particular — is looking to stop the fraud and abuse it says is so prevalent in the health care industry.

But HCFA’s not the only one looking to stop the misuse. Also taking aim is the Alexandria, VA-based Health Industry Distributors Association (HIDA) and other associations that are currently working together to develop a set of draft Medicare Part B supplier standards. If these groups have their way, these standards could open the door for a more practical common sense approach to providing health care for suppliers and care providers.

HIDA recently held a conference where it brought together various member interests to focus on establishing new specific standards for those serving Medicare beneficiaries. The conference included five subgroups, one of which was Supplier Standards for Suppliers of Home Infusion Therapy, led by Alan Parver, JD, president of the Washington, DC-based National Alliance for Infusion Therapy. The goal was to come up with an in-depth set of standards that would ensure quality of care and professionalism for Medicare beneficiaries.

The group attending HIDA’s consensus conference completed an "outline" draft set of standards, currently under wider industry review for refinement before being presented to HCFA and being used on Capitol Hill to refine the current standards for Medicare Part B reimbursement.

Parver notes that the president’s budget proposal won’t likely affect the standards, but a later version of the budget could.

"There very well could be provisions in there that address standards, but there’s not now," he says.

Direct impact on home infusion providers

Parver notes that the draft standards were aimed at durable medical equipment, prosthetics, orthotics, and supplies. However, home infusion agencies would be wise to follow developments closely regarding the new standards.

"Medicare covers parenteral and enteral nutrition as if these therapies were prosthetic devices, so supplier standards will directly affect them," says Parver.

The problem with the current standards, says Parver, is a lack of substance and a failure to address clinical areas. That’s exactly what the draft standards look to change.

"Standards should let [suppliers] know what is expected of them generally and what is required for providing quality care," he says. "Standards are an important means of defining what it is the industry is trying to do for the patient."

For that reason, Parver’s group who addressed standards for suppliers of home infusion therapy feels that professional services are integral to the provision of infusion therapy have been excluded from Medicare Part B recognition for too long.

"Medicare Part B does not cover infusion therapy per se; it covers individual therapies," says Parver. "If nursing and pharmacy are integral parts of providing patient therapy and are included in the standards, then those services should be covered, and providers should be paid for providing them. One of the things we on the infusion side did was flesh out clinical areas."

However, the standards are still in an early stage and don’t address specific infusion therapies, says Parver. But it’s likely they will in the future.

"That is something that would occur down the road, and somewhere that sort of detail is needed," says Parver.

Parver notes that adding such clinical detail to supplier standards has HCFA concerned — and not without cause.

"[HCFA] feels that if they refine the standards, they will be subject to arguments regarding whether reimbursement is sufficient for providers to meet the standards, and they’re quite right." If HCFA agrees to "raise the bar" for providers, they will have to make sure reimbursement is adequate for these providers to meet the standards, i.e., more standards lead to more cost for providers, whether it be in time, money, clinical expertise, etc.

In the end, Parver says three issues must come together to improve the care provided to Medicare beneficiaries: standards, coverage policies, and reimbursement policies. That’s anything but the case now.

"Parenteral and enteral nutrition are covered as prosthetic devices, but other infusion therapies are covered only if a pump is required," notes Parver. "The key nexus is that a pump has to be required, and that doesn’t make sense. It produces a result that defies common sense."

Cara Bachenheimer, executive director of HIDA home care and long-term care, agrees with Parver that a more realistic set of standards that truly measures a company’s legitimacy and ability to provide quality care is needed.

"Even though Medicare has some limited supplier standards, we’ve never believed they have any teeth in them," she says. "One of our key objectives was to develop standards that really paint a picture of what a real company does so you would have some legitimacy so Medicare could require those things." (See list of 10 proposed standards for providers of infusion therapy, above.)

While HIDA’s emphasis is in reducing fraud through a more realistic set of standards, more infusion therapies and associated pharmaceuticals could become reimbursable under Medicare Part B.

"[Standards are] becoming even more important with all the focus on fraud and abuse in the [Medicare] program as well as reimbursement reduction," says Bachenheimer. "There is a limited understanding, we believe, of the array of services that beneficiaries receive, and this is one way to really communicate more effectively what our members provide for beneficiaries."

The standards presented at the conference have gone through a handful of drafts, says Bachenheimer, the latest being an industry review among HIDA members. A final draft could be ready within the month, at which time the standards will be used on the regulatory and legislative front.

"HCFA has been working on a draft of proposed regulations for supplier standards, so we’ll be using them in that context," she says. "We’ve met with the OIG [Office of Inspector General] to get their support for our standards, and we’ll be using them on Capitol Hill advocating them as part of the legislative process and getting Congress to require these standards."

The intent of the draft standards is to take a detailed look at a wide range of topics, says Bachenheimer. However, she notes that they are not designed to simply become more red tape or hoops for suppliers and/or providers to jump through. In fact, it’s unlikely any provider of quality care would have to significantly change how it does business.

"The idea is not to erect barriers but to create standards that legitimate companies right now would be able to meet without doing anything different than what they’re doing right now," says Bachenheimer, adding that a likely change would be requiring more information on the application for a Medicare supplier number. For example, the draft standards recommend that "non-governmental independent organizations verify that providers/suppliers comply with the Medicare Supplier Standards, both initially and on an ongoing basis." They also support a "reasonable application fee."

"The biggest immediate benefit is that companies would be assured that the bad actors would not even be able to get a [supplier] number," says Bachenheimer. "The idea is to define in black and white what makes a legitimate company legitimate. And if you don’t have the bad actors coming in on the front end, you won’t have the difficulties on the back end."