Alliance of Wound Care Stakeholders Advocacy Update: Q3 2018


The 3 "C's" of Q3: CMS, Commercial Payers & Capitol Hill
Each year, CMS's proposed annual updates to the Physician Fee Schedule and Hospital Outpatient Prospective Payment System (HOPPS) demand significant time and resources to understand the specific impacts to wound care providers and patients. This year, our comments were not just "comments as usual," they were in several cases a call to arms. For example:

  • We took aim at the proposed payment methodologies related to the packaging of cellular and tissue based products for skin wounds (CTPs) in the HOPPS. Following a series of calls and discussions, we submitted aligned comments that outlined specific unintended consequences and provided detailed alternative solutions.
  • We voiced our strong opposition to the Physician Fee Schedule's proposed consolidation of Evaluation and Management codes and the corresponding reduction in payment for E/M services for those that provide the most complex care. Together, we stood up to the "singling out" of podiatric physicians in the Schedule's proposed creation of separate E/M codes and reimbursement for these specialists.
  • We mobilized both our clinical associations and manufacturer members to take action on the commercial payer front when insurance giant United Healthcare issued a policy that removed coverage for most CTPs. While the policy had no formal comment mechanism, we quickly convened a workgroup, brought in a former commercial payer medical director to give guidance, and sent  a letter and meeting request to UHC.
  • We turned attention to Capitol Hill, and built consensus to submit a letter of support for the Lymphedema Treatment Act (S. 498, H.R. 930), which would grant CMS the statutory authority to cover compression bandages for lymphedema under the Medicare benefit.

Looking ahead, expect more of our attention on Capitol Hill on an issue near and dear to us: LCD transparency.

On Sept.23, the U.S. House of Representatives passed the Local Coverage Determination Clarification Act (H.R. 3635). The Act revises the process by which Medicare Administrative Contractors issue and reconsider local coverage determinations (LCDs). While we support this legislation, we don't believe it goes far enough and are exploring an advocacy path forward for policy articles to also be included.We've already seen that MACs are more liberally using policy articles, which don't require the notice-and-comment procedure of LCDs. Many of these policy articles are providing much more than clarification, they are oftentimes setting new policy. 

While the legislation likely won't be moved to the Senate this year, we are hopeful the legislation can have a path forward in 2019. We'll keep you up to date on its progress and our advocacy.

Q3 Submitted Comments: Ensuring Alliance's Clinical Expert Perspective is Heard

United Healthcare CTP Policy 
The Alliance flagged a concerning new policy from UHC that removed coverage for most CTPs. Despite there being no formal comment process to UHC policies, the Alliance convened a member work group, hired a former commercial payer medical director to guide our strategy, held a series of discussions, and submitted a September letter to UHC medical directors. The letter outlined the policy's unintended consequences and patient care interruptions and requested UHC to reconsider and delay the scheduled Oct. 1st implementation of its "Commercial Medical Policy 2018T0592A, Skin and Soft Tissue Substitutes." The Alliance requested a meeting with UHC for a more in-depth discussion on the policy and its patient care impacts.

CY2019 Hospital Outpatient PPS
The Alliance submitted comments to CMS in response to its proposed CY 2019 Hospital Outpatient Prospective Payment System (PPS). Following a series of conference call discussions, the Alliance focused its comments on provisions related to: CTP packaging and payment methodology, pass through status for CTPs, methods to control unnecessary increases in the volume of outpatient services, ways to control unnecessary costs, and price transparency.

Physician Fee Schedule 
The Alliance submitted comments to the proposed CY 2019 Physician Fee Schedule, voicing opposition to the proposed consolidation of Evaluation and Management codes and the corresponding reduction in payment for E/M services for those that provide the most complex care. Commented included specific examples of unintended consequences that the proposal would create. The Alliance also opposed the "singling out" of podiatric physicians in the rule. The Alliance joined many other clinical associations expressing their concern by also signing on to an American College of Rheumatology letter to the House of Representatives.

CMS Demonstration Project for Home Health Services 
The Alliance submitted comments to CMS in response regarding its "Pre-Claim Review Demonstration for Home Health Services." While the Alliance acknowledged support to address issues of fraud and abuse, comments expressed concern that the policy would create a significant administrative burden on home health agencies. 

AmeriHealth Caritas HBOT Policy
The Alliance submitted August comments addressing the AmeriHealth Caritas Clinical Policy on Full-body Hyperbaric Oxygen Therapy. The Alliance identified clinically inaccurate and/or unsubstantiated information within the policy to be addressed.

Lymphedema Treatment Act 
The Alliance submitted a letter to Congress supporting the Lymphedema Treatment Act (S. 498, H.R. 930). The Alliance recommended that Congress grant CMS the statutory authority to cover compression bandages and garments for lymphedema as durable medical equipment under the Medicare benefit.

Key Q3 Meetings & In-Person Advocacy

  • Health Care Payment Learning & Action Nework Summit: The Alliance attended and alerted membership to this Oct. 22 LAN meeting in Northern Virginia as a terrific opportunity to network with CMS and private payer staff while focusing on "Partnering for the Future" to improve patient outcomes and bend the cost curve.
  • Physician Fee Schedule call: Alliance leadership participated on a July 12 conference call with CMS Administrator Seema Verma and her staff as they summarized the Physician Fee Schedule proposed rule relating to documentation requirements and payment for E/M visits and advancing virtual care. A copy of the CMS presentation was circulated to membership.
  • OPPS Advisory Panel Meeting: The Alliance alerted membership to, attended and spoke at the Aug. 20 meeting of CMS' Advisory Panel on Hospital Outpatient Payment, an expert outside advisory panel that provides to CMS technical advice regarding the clinical integrity of the Ambulatory Payment Classification (APC) groups, relative payment weights, and supervision levels.
  • CMS Home Health Open Door Forum: Alerted members to July CMS forum featuring Hillary Loeffler, Director, Division of Home Health & Hospice at CMS.
  • Member conferences:
    • APWCA: Alliance leadership attended and spoke at the APWCA meeting Sept.6-8 in Baltimore.
    • APMA: Alliance leadership attended the July APMA annual meeting, and had a "guest speaker" slot at the APMA booth to speak about the Value in Health study.
    • Amputee Coalition: hosted its annual meeting July 12-14 in Tucson.
  • UPCOMING: Fall SAWC - Join the Alliance at our in-person meeting at the Fall SAWC on Friday, Nov. 2nd, 10:30am-12:30pm PT. A call-in number is also available. Contact Marcia Nusgart to participate.

Recent Publications & Policies Relevant to Alliance

  • CMS Inpatient PPS Final Rule issued in August. The Alliance circulated a summary comparing our submitted comments to the final rule.
  • APMA issue brief: The Alliance circulated an American Podiatric Medical Association "issue brief" on how the proposed Physician Fee Schedule specifically impacts podiatrists. They make many points relevant to wound care. 
  • DMEPOS Competitive Bidding: CMS published in July its End-Stage Renal Disease Prospective Payment System, which also covers the competitive bidding program for DMEPOS. The proposed rule was circulated to Alliance members; submission of comments was managed by our colleagues at the Coalition of Wound Care Manufacturers.
  • MLN Matters article published in August on Recent and Upcoming Improvements In Hospice Billing and Claims Processing