Funding Focus

Nebulizers… Where Are We When It Comes to Medicare Coverage?

• By Claudia Amortegui
• Sep 01, 2006

These days it seems like most people are talking about competitive bidding, accreditation, the Deficit Reduction Act and power mobility devices. What has happened to some of the smaller respiratory items such as nebulizers?

A couple of months ago, we saw the draft, but not much more has been said since then. I can promise you it is still being talked about within the Centers for Medicare and Medicaid Services (CMS). Therefore, you need to be certain you understand what you may be facing.

It comes down to exactly what we all fear most: lower reimbursements and the elimination of coverage for specific items. Not only will this hurt you, the provider, but it will also hurt end-users. More importantly, it can adversely affect end-users by forcing the dispensing of a more generic drug than what the physician prescribed.

To start with a bit of history, the DMERCs (now DMACs) have had a Local Coverage Determination (LCD) or medical policy for nebulizers since the transition back in 1993. There have been some revisions throughout the years, but nothing like what they proposed in the spring. As noted in some of the comments against the draft LCD, Medicare has created a way to make some drugs “non-covered” by only paying for the “least costly alternative.” Medicare’s stance is that specific drugs have not been proved to be better than others. Interestingly enough, many physicians do not agree; they see the medical need when it comes to specific patients. This change could force a change in the preferred method of treatment for a Medicare beneficiary. Even worse, because many of the other funding sources are mimicking Medicare guidelines, it may end up affecting many other patients.

Of even bigger concern is the fact that it seems as if CMS is attempting to tie payment methodology and coverage criteria together. These are two completely separate items. If this is allowed to happen, it could set the precedent for similar changes in other product categories. CMS is attempting to justify the change by saying it will save the program money by paying for certain drugs at the same rate of less expensive, generic drugs.

Another worry is that the draft creates the inability to review specific claims on a case-by-case method. If CMS states that specific items are “non-covered,” beneficiaries lose any chance of having their case reviewed as an exception. We all know that although certain practices may not be used in the majority of cases, there are always instances in which it may be the only solution. It does not mean that the door has to be opened wide; it just means it should not be slammed shut and bolted. By doing this, CMS slows down or may even eliminate the possibilities of new techniques in science. Again, CMS can easily state that it will individually review those cases that may be considered rarely medically necessary. This would at least leave the door open for those exceptions.

The comment period for the draft ended May 8. Nothing has been published since that time. Do not think that just because it is quiet, the battle is over. The question you need to ask yourself is, “Did my company submit comments?” If the answer is “no,” then you need to look in the mirror if your business is hurt by any future changes. So many people within our industry leave the fighting to the “big guys” or to specific associations. That is only one small part of the battle.

As providers you need to be sure you are not just waiting for things to happen. You need to take the appropriate steps in reviewing your business. This is truly a practice you should perform with your company on a regular basis. Do you know what drugs and products make up the majority of your business? Who do the majority of these orders come from? Look at creating some “top lists”—the top drugs/medications dispensed, the top referrals and the top salespeople getting the business. By knowing these facts, in addition to others, you will be able to develop a strategic plan for your business, no matter the changes.

Be sure to stay informed with what is happening, involved in making changes and engaged in understanding your entire business.

This article originally appeared in the Respiratory Management Sept/Oct 2006 issue of HME Business.