Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

CMA Alert – Medicare Trustees Report; Fixing Part D; DME Prior Authorization Expansion; Center Testifies Before Congress On SNF Care

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  1. Medicare Trustees Report: Stop Overpaying Private Plans & Underfunding Medicare
  2. The Right Way to Lower Medicare Prescription Drug Costs
  3. Medicare Prior Authorization Requirement for Power Wheelchairs Expanding Nationwide Effective September 1, 2018
  4. Center for Medicare Advocacy Emphasizes Need to Protect Nursing Home Residents at Congressional Briefing

Medicare Trustees Report: Stop Overpaying Private Plans & Underfunding Medicare

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How has Medicare, Medicaid or the Affordable Care Act (ACA) helped you or your family?  Your stories about the value of Medicare, Medicaid and the ACA help us advocate for the health care programs we all rely on.

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The Medicare trustees estimate the Part A Trust Fund will be insolvent in 2026, three years sooner than last year’s projection. The good news is this is about nine years later than it would have been without the Affordable Care Act.  The bad news is the projection reflects recent, ill-advised laws and policies – including the recent tax cut, increased enrollment in and inflated payments to private Medicare Advantage plans, and increased spending, particularly for prescription drugs.

The Trustees projection should not be used as an excuse to cut Medicare benefits for older and disabled people. Instead, the Administration and Congress should negotiate drug prices for the whole Medicare program, stop Medicare Advantage overpayments, and end efforts to repeal the Affordable Care Act.

More information:

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The Right Way to Lower Medicare Prescription Drug Costs

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Robert Pear wrote last week in the New York Times (“Trump Plan to Lower Drug Prices Could Increase Costs for Some Patients”) that the President’s plan to “inject more competition into the market” and switch coverage of some expensive drugs from Medicare Part B Medicare Part D could significantly increase out-of-pocket costs for some of the sickest people on Medicare.

To truly lower drug costs for Medicare beneficiaries, the Medicare program, and taxpayers, the administration should negotiate prices overall, not one plan at a time. As every big box company knows, that's how to drive down costs. Health economists and Medicare beneficiary advocates have called for overall negotiations since Part D was passed in 2003. Mr. Trump said he would do so during the campaign. At best, these other approaches only whittle away at the edges of the cost problem. It's high time to negotiate drug prices on behalf of all 60 million Medicare beneficiaries.

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Medicare Prior Authorization Requirement for Power Wheelchairs Expanding Nationwide Effective September 1, 2018

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Thirty-one new items of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) will join two existing items of DMEPOS on the Center for Medicare and Medicaid Services (CMS) Master List of Items Frequently Subject to Unnecessary Utilization, requiring prior authorization as a condition of payment. All these 33 DMEPOS items are types of power wheelchairs.

In a June 5, 2018, Federal Register announcement, CMS stated the goal of prior authorization is to reduce fraud, waste, and abuse, while protecting access to care.[1] In previous Federal Register postings, however, CMS stated that 92% of the DMEPOS improper payment rate is attributed to “insufficient documentation”[2] rather than fraud, waste, and abuse. Insufficient documentation is often a simple mistake in the process of documenting the need for the equipment – a doctor leaves off a date, or the therapist does not complete a field. These are clerical errors, not fraud.

For CMS to state that simple mistakes in paperwork result in “unnecessary utilization” of wheelchairs by individuals who legitimately require them for access to mobility is unconscionable. Characterization of the “Master List” as “Items Frequently Subject to Unnecessary Utilization” portends that beneficiaries should engage in proactive measures to ward off prior denial, rather than to assume prior authorization will be approved.

Beneficiaries should be aware of the pros and cons of prior authorization and be fully prepared in order to avoid prior denials.

Possible Benefits of Prior Authorization:  

  • Beneficiaries may have greater confidence of coverage before the item is ordered.
  • Questionable billing practices may be prevented.
  • There are specified review timeframes (ten business days for initial review, twenty business days for resubmissions).
  • The system may be made more efficient for all by encouraging careful and correct legitimate requests for coverage.

Possible Problems with Prior Authorization:

  • Beneficiaries may see delays in access, and/or unfair denials of access, to services and equipment.
  • The time to review may be doubled for re-review, even for a simple clerical error.
  • There is no appeals process.
  • Beneficiaries may be dependent upon providers and suppliers to ensure the paperwork is correct and error-free.

How to Minimize/Avoid Denials:

  • Understand which items will be subject to prior authorization, effective September 1, 2018. The list is located at https://federalregister.gov/d/2018-11953.[3]
  • Ensure sufficient documentation. Evidence must include information that the item complies with all applicable Medicare coverage, coding, and payment rules. The paperwork must be error-free, legible, and complete. Whenever possible, have the prior authorization request reviewed by multiple people before submitting it.
  • Monitor the maximum prior authorization timeframes established by the rule[4]. The timeframes are ten business days for initial review, twenty business days for re-submissions. There are unlimited re-submissions, but, unfortunately, no appeal rights.
  • Know that there is a process for an expedited request for prior authorization. Documentation must be submitted with the request that indicates how the life or health of the beneficiary will be seriously jeopardized without an expedited review.

If a beneficiary encounters difficulties with the prior authorization process, please inform the Center for Medicare Advocacy. Please email your stories or comments to DMEPOS@MedicareAdvocacy.org.

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Center for Medicare Advocacy Emphasizes Need to Protect Nursing Home Residents at Congressional Briefing

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On June 4, 2018, the House of Representatives Democratic Caucus Seniors Task Force held a briefing on “Protecting Seniors by Improving – Not Eroding – Nursing Home Quality Standards.” The Center for Medicare Advocacy, led by Senior Policy Attorney Toby Edelman, presented on the enforcement of the nursing home standards, as well as the current crisis in nursing home ownership and management.

Ms. Edelman highlighted that enforcement of the nursing home standards has been historically weak in this Administration, which has resulted in most deficiencies (95+ percent) being cited as “no harm.” As she explained, “no harm” citations mean that facilities are not financially penalized for violations of resident rights and protections. Ms. Edelman also illustrated recent changes made by the Administration, including efforts to rollback nursing home resident protections. Ms. Edelman ended her presentation by examining changes in the industry as a result of insufficient state and federal oversight of nursing home ownership and management.

The Long Term Care Community Coalition (LTCCC), National Consumer Voice for Quality Long-Term Care (Consumer Voice), California Advocates for Nursing Home Reform (CANHR), as well as a Professor from the University of California-San Francisco, also presented on key issues of concern facing nursing home residents. Janet Wells, Consultant for CANHR, provided background on the Nursing Home Reform Law and a look at a recent example of resident abuse. Richard Mollot, Executive Director of LTCCC, spoke about nursing home quality and oversight, focusing on the inappropriate use of antipsychotic drugs, pressure ulcers, and inadequate staffing. Charlene Harrington, Professor at UCSF, discussed nursing home financial and accountability issues, highlighting Medicare’s high reimbursement rates and hidden nursing home profits. Lastly, Robyn Grant, Director of Public Policy and Advocacy at Consumer Voice, provided policy recommendations for addressing the issues raised during the briefing, including ways to strengthen enforcement and increase staffing.

The presenting organizations plan to conduct a webinar based on the information provided at the briefing. We will provide additional information about the date and how to register for the webinar when it becomes available.

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