US COPD Coalition

Insurers follow Medicare’s lead on vents


Insurers follow Medicare’s lead on vents | HME News

YARMOUTH, Maine – Commercial payers have wasted no time drastically reducing reimbursement for non-invasive ventilators, HME providers say. 

In March, provider Bill Hart learned that both Allstate and State Farm were reducing reimbursement for the product category. “We found out when we were doing the billing and got their proposed discounted rate,” said Hart, director of clinical services for Auburn Hills, Mich.-based Advent Home Medical. “It’s half of what we usually get.” 

It’s exactly what industry stakeholders feared would happen after CMS announced plans to overhaul the product category, by reducing the number of codes from five to two, and reducing reimbursement by about 33%. These Medicare changes just went into effect in January. 

“So goes Medicare, so goes the private insurers,” said Gregory LoPresti, CEO of Syracuse, N.Y.-based Upstate Home Care. When provider Ron Jenkins recently got word of reduced reimbursement rates from both UnitedHealthcare and Aetna, he thought it was a mistake. “They took 50% off of Medicare,” said Jenkins, CEO of Longwood, Fla.-based Respitec Medical. “I thought it was miscoded—I thought they were using the bipap rates.”

At that rate, Jenkins says he won’t be able to offer certain products, like the Philips Trilogy, to members of those plans. But overall, he says, other payers still have “decent” reimbursement rates. LoPresti says he’s avoided draconian cuts so far, by working to educate insurers about the value of home care. “I have personally been very successful in showing how decisions made in a distant vacuum by Medicare do not work in our backyard,” he said. “It cannot always be about not wanting a rate cut; it’s about value.” 

In light of reimbursement rates being reduced on both sides of the aisle—Medicare and commercial payers—providers say they have some hard decisions to make, including whether or not to make layoffs or restrict who they serve. “If we have to lay people off, people are not going to get the kind of care that they are getting currently,” said Hart. “And, it’s so much more expensive to keep them in the hospital or a facility and then, while they are there, they are subject
to infection and other risks.”