What Pro2 is Up2

The results of the Round 2 competitive bidding program are raising red flags when it comes to patient care. This program will go into effect on July 1, 2013, so the time to speak out is now.

People for Quality Care analyzed 17 Competitive Bidding Areas (CBAs) throughout the country and found that on average, bid-winning medical equipment providers were located more than 500 miles from the center of that geographic area. Senior citizens and people with disabilities throughout the CBA will be required to get their medical equipment from far away.

This leads to many concerns by beneficiaries and People for Quality Care that medical equipment will be delivered to beneficiaries without assistance from a professionally trained provider. Interviews of beneficiaries from Round 1 already show that, in some areas of the country, providers are spending less time inside the homes of beneficiaries. That time, used to instruct the patient how to use and maintain the equipment, is no longer available because of an influx of Medicare patients assigned to providers in larger delivery areas. Here are some of their other concerns:

• Delays in receiving equipment will disrupt the health and lives of beneficiaries and caregivers.
• Delays in receiving equipment will cause increased visits to the ER or hospitalization.
• The trusting, personal relationship formed between beneficiary and provider will be gone.

The graphs below summarize their analysis, which includes the following bidding areas:

Wichita, KS, Colorado Springs, CO, Denver-Aurora-Broomfield, CO, Salt Lake City, UT, Milwaukee- Waukesha - West Allis, WI, Minneapolis - St. Paul - Bloomington, MN-WI, Omaha, Council Bluffs, NE-IA, Detroit-Warren-Liyonia, MI, Flint, MI, Grand Rapids - Wyoming, MI, Atlanta-Sandy Springs-Marietta, GA, Augusta - Richmond County, GA-SC, Chattanooga, TN-GA, Central - Chicago Metro CBA, Northern - Chicago Metro CBA, Southwest - Chicago Metro CBA, St. Louis, MO

It's not too late to voice your opinion about this issue. After the graphs is a link for you to contact your Congress person in support of H.R. 1717.





Take Action!

H.R. 1717, the Market Pricing Program Act of 2013, was introduced by Rep. Tom Price (R-Ga.) and Rep. John Larson (D-Conn.), and it needs support. The bill will repeal the current competitive bidding program that is causing a variety of problems for Medicare beneficiaries and replace it with the Market Pricing Program (MPP). The MPP will create better access to medical equipment and service. Read more about the Market Pricing Program.

Please take a moment to email your representative now and ask them to sign the bill. It's as easy as 1-2-3.

1. Click on this link.
2. Review the letter and add your own opinions if you like.
3. Add your personal information and send.

Reprinted with permission from People for Quality Care.

With the holiday season upon us and 2013 quickly approaching, we want to take this opportunity to address an important insurance issue that a new calendar year always brings. Whether you have an individual or employer-sponsored Health Insurance plan, there are certain things to keep in mind as we close out 2012 and usher in 2013.

There are many qualifications and limitations regarding what health insurance covers and to what extent. Certain requirements must be satisfied by the insured before the insurance company will begin paying benefits. A deductible is a fixed dollar amount that the policy holder must pay out-of-pocket for eligible services before the insurance company will make payment for covered medical expenses. For example, if your policy has a $500 deductible, you are responsible to pay $500 worth of healthcare expenses before your insurance will start paying out.

For most policies, the medical plan's deductible is based on a calendar year regardless of when your coverage became effective. All calendar year deductibles will therefore be renewed on January 1, 2013. If you are unsure about your policy, please contact your insurance carrier for more information.

It's always a good idea to keep yourself as informed as possible when it comes to your insurance policy. It's just as important to keep our office up-to-date on any changes that may take place. Many insurance policies renew, change, or terminate at the end of the year. This could mean changes in your financial responsibility.

In most cases, this may be the one chance you have to make a change to your health and prescription drug coverage for 2013. This is the second year the fall Open Enrollment Period dates are earlier. The dates have changed to give you more time if you want to chose and join a Medicare health or prescription drug plan.

Mark your calendar with these important dates!

October 1-15, 2012: Compare your coverage with other available options to see if there's a better choice for you.

October 15-December 7, 2012: Open Enrollment. You can change your Medicare health or prescription drug coverage for 2013.

January 1, 2013: New coverage begins if you switched or joined a new plan. New costs and benefit changes also begin if you kept your existing Medicare health or prescription drug coverage and your plan made changes.

Here are eight things to consider when choosing or changing your coverage:

1. Coverage: Does the plan cover all of the services you need?
2. Your other coverage: If you have other types of health or prescription drug coverage, make sure you understand how that coverage works with Medicare. If you have employment-related coverage or get your health care from an Indian Health or Tribal Health Program, talk to your benefits administrator or insurer before making any changes.
3. Costs: How much are your premiums, deductibles, and other costs? How much do you pay for services like hospital stays or doctor visits? Is there a yearly limit on what you could pay out-of-pocket for medical services? Make sure you understand any coverage rules that may affect your costs.
4. Doctor and hospital choice: Do your doctors accept the coverage? Are the doctors you want to see accepting new patients? Do you have to choose your hospital and health care providers from a network? Do you need to get referrals?
5. Prescription drugs: Do you need to join a Medicare Prescription Drug Plan? Do you already have creditable prescription drug coverage? Will you pay a penalty if you join a drug plan later? What will your prescription drugs cost under each plan? Are your drugs covered under the plan's formulary? Are there any coverage rules that apply to your prescriptions? Is the pharmacy you use in the plan's network?
6. Quality of care: Are you satisfied with your medical care? The quality of care and services given by plans and other health care providers can vary. Get help comparing plans and providers.
7. Convenience: Where are the doctor's offices? What are their hours? Which pharmacies can you use? Can you get your prescriptions by mail? Do the doctors use electronic health records (EHRs) or E-prescribe?
8. Travel: Will the plan cover you if you travel to another state or outside the United States?

If you need help making your decision, you can contact Medicare toll free at 800.633.4277 or you can get personalized health insurance counseling from Med Care Navigators at 716.667.7600.


Source: Medicare.gov The official U.S. Government Site for Medicare Retrieved September 17, 2012 from http://medicare.gov/

According to DME MAC A, the Medicare Administrative Contractor for Durable Medical Equipment, more than two-thirds of all claims denied in their latest audit were denied because of issues with face-to-face clinical evaluation documentation.

DME MAC A reviewed claims processed between November 2011 and January 2012 for CPAP devices. Of claims that were denied, almost half (46.5%) were missing the required clinical documentation and medical records to support the medical necessity of the device.

"These claims had no Face to Face clinical evaluations from the beneficiaries' medical records. Included in these were no Face to Face evaluations conducted by the treating physicians where the beneficiaries were seeking PAP replacement following the 5 year RUL or when requiring coverage of a replacement PAP upon entering FFS Medicare."

About 20% of the claims that were denied had insufficient clinical documentation to support the medical necessity of the device, such as:

- No detailed narrative describing the presenting symptoms of sleep disordered breathing, daytime sleepiness/fatigue, observed apneas, choking/gasping during sleep; duration of symptoms; or Epworth Sleepiness Scale scores
- The face-to-face clinical re-evaluation failed to demonstrate an improvement in obstructive sleep apnea (OSA) symptoms and that the patient continued to benefit from PAP therapy
- Insufficient clinical documentation for face-to-face evaluations where the patient is seeking PAP replacement or when requesting coverage of a replacement PAP upon entering FFS Medicare

Finally, just over 6% of denied claims were missing the signature and/or date on the face-to-face evaluation and a handful had illegible documents.


Source: Results of Widespread Prepayment Review of Claims for HCPCS E0601, (Continuous Positive Airway Pressure Devices). NHIC, Corp. Retrieved August 20, 2012 from http://www.medicarenhic.com/dme/medical_review/mr_bulletins/mr_bulletin_pca/042012_cpap.pdf

You may have heard that Congress has changed the way Medicare determines who can and can’t furnish certain durable medical equipment and supplies. This new program is known as Competitive Bidding. It's already in place in nine metropolitan areas across the United States and will be implemented in the Buffalo-Niagara metropolitan area in July 2013.

Traditionally, Medicare has contracted with multiple home medical equipment (HME) providers throughout the country. However, the Competitive Bidding program will decrease the number of providers available to supply equipment and services. After July 1, 2013, only suppliers that are awarded a contract can provide equipment and supplies to people with Medicare in the Buffalo-Niagara area.

Pro2 has submitted a bid to become a Medicare contract supplier in the Buffalo-Niagara metropolitan area. Contracts for the Buffalo-Niagara area will not be awarded until the spring of 2013.

Competitive Bidding will affect you as a Medicare recipient in several ways:

-You may be required to change providers if your current provider is not awarded a contract.
-You may be required to use multiple suppliers to obtain the different products or equipment you need.

For more information on how you may be affected by this program, please visit peopleforqualitycare.org.