Editor's Note

Defining the New Normal

Bidding and audits aren't going away, but that doesn't mean 'game over.'

• By David Kopf
• Jan 01, 2016

There’s a phrase that entered the American lexicon several years ago, “the new normal,” that kind of drives me nuts. I can’t remember if the expression was spawned by life under terrorist threats, or mass shootings, or something else, but the idiom incorporates a level of fatalism that I just can’t accept.

Why does something that we don’t like have to be normal? The whole point of living in a representative democracy is that citizens and their elected officials have the power to change the “new normal;” they never have to accept the unacceptable.

That said, they might have to get creative. Sometimes you have to take something that is unpalatable and slowly turn it into what you want. I used to hate Brussels sprouts until I started roasting them, and now I can’t get enough of them — same with my kids. Those strange balls of cruciferous leaves are still Brussels sprouts, and I’d still detest them if you served them to me steamed, but here I am gobbling them up.

(Okay, I admit that finally being a big boy and eating my veggies isn’t exactly an “adult” example of how public policy can be creatively altered for the better while retaining its moniker, but I think it illustrates my point.)

Bidding By Any Other Name …

From the day CMS first launched the notion of implementing competitive bidding, the die for that program being a reality for DMEPOS providers was pretty much cast. Who would argue with a program that aims to get the best medical equipment possible at the lowest price — especially when the taxpayers are footing the bill?

At last May’s Washington Conference, Sen. John Hoeven (R-N.D.) astutely observed the following about battling competitive bidding: “It’s tough when you’re fighting a euphemism.” He’s absolutely right. In name alone, competitive bidding sounds great, and for many people that’s enough.

Of course HME providers know different. They know that the program jeopardizes their businesses and the care they provide for their patients. HME professionals know that the DMEPOS benefit actually saves Medicare countless sums by preventing costly hospital stays and improving patient outcomes. And above all, everyone in this industry knows that CMS’s program is anything but competitive.

But that name, competitive bidding, and the “savings” that CMS touts to Congress mean that, at least as a concept, CMS’s bid program isn’t going anywhere soon.

This means the program needs to be altered. And we’re starting to see that happen. First, the industry successfully lobbied Congress to pass the binding bids legislation. Next, it is trying to reform the nationwide expansion of the program (read “News, Trends & Analysis,” page 8 and “Big Ten,” page 15 to learn more about that effort). The next step lies in advancing the industry’s market pricing program so that we can ultimately get a fair system in place. In fact, I’ll go one step further and say that CMS can keep the “competitive bidding” name.

Why? Because it’s a win-win. CMS would save face and get to keep a bidding program in name, but that would actually be a “competitive” bidding program that creates a real market pricing dynamic to ensure that taxpayers, patients and providers are treated fairly, and that care is properly provisioned.

And that’s just one example. Audits similarly represent an unpalatable program that can be fixed for the better. As I mentioned in my last column, CMS’s audit program for Medicare claims seems as though it was built to fail.

The poor design in a nutshell: Audit contractors are awarded for recoupments before the appeals process concludes, which only incentivizes the contractors to recoup on technicalities, which forces providers to appeal, which has backed up the number of claims that are waiting to be assigned an Administrative Law Judge is, by most estimates, now skirting 1 million, and the turnaround time is more than 700 days (read this month’s “Big Ten,” page 15, to read more about how audits will impact the industry over 2016).

But audits can also be reformed to be reasonable. No member of the industry or CMS wants to see taxpayer money wasted, but a broken audit system is just as likely to waste taxpayer money by rewarding capricious recoupments, then having to repay those recoupments and adding a massive, unnecessary bureaucracy in the process. Just like competitive biding, reasonable reform can create a program providers find palatable. We wind up liking our Brussels sprouts.

This article originally appeared in the January 2016 issue of HME Business.