Meet the Team: Sue Mairena, Chief Operations Officer

Sue Mairena is the chief operating officer (COO) of AAHomecare. She joined the team in the summer of 2003.

Sue has more than 25 years of financial and managerial experience in a variety of industries.

As COO, Sue manages AAHomecare's day-to-day operations, human resources, accounting, monthly financials and yearly audit, tax return and budget. In addition, each year she evaluates the Association's existing structure, and makes recommendations to the President and Executive Committee.

Sue is a certified public accountant (CPA). Up until she joined AAHomecare in 2003, she served as Supervisor of Accounting Outsourcing for Raffa and Associates, P.C., in Washington, D.C. In this role, her clients included The Washington National Cathedral and the American Dental Education Association, both large non-profit organizations in our nation's capitol. Mairena also served as Vice President of Finance and Administration for Bantu, Inc., a Web-based instant communications company in Washington, D.C.

Fun Facts

• Sue has an affinity for music from the 80’s, with the moves to prove it. Her fond memories include “dancing like crazy to the tunes of” Paula Abdul, Bananarama, Fine Young Cannibals, Gloria Estefan, Kool & The Gang, Michael Jackson, Sheila E and Vanessa.
  
  
• Sue is a certified French fry connoisseur – and touts Dogfish Head Alehouse as having the best!
  
  
• Sue is a decorator at heart – in her next life she will accessorize your home and outfits for every occasion. “Deck the halls with boughs of holly” is taken to a new level at Sue’s house, always a warm and welcoming place.

More Support for H.R. 1041

While Congressional support for H.R. 1041 continues to grow, with 143 co-sponsors currently on board, AAHomecare also continues to generate support from patient advocacy, consumer, and healthcare groups across the country, including this recent message from the California Federation for Independent Living Centers. That message, as well as the complete list of groups supporting H.R. 1041 may be useful in your efforts to educate similar groups your area about competitive bidding, and enlist their support for H.R. 1041.

Meet the Team: Tyler Wilson, President and CEO

Tyler J. Wilson is the president and CEO of AAHomecare. He joined the team in Fall 2006, with his first week on the job taking him to Medtrade.

Working with the AAHomecare board of directors (a mix of large and small HME providers and manufacturers), Tyler leads the team in developing and implementing organization strategies on the Hill and at CMS, with the homecare industry’s best interests always the top priority.

Tyler is an attorney with an undergraduate degree in economics from Georgetown University. He has spent the last decade serving as chief executive of organizations that advocate for better policies under Medicare Part B. Among other positions in Washington DC, Wilson served as an attorney for legislative and regulatory affairs at the U.S. Chamber of Commerce.

Fun Facts

• Tyler can reference show tunes from as early as the 1940s with Cole Porter and, more recently, Stephen Sondheim being two of his favorites. He’s a great teammate in trivia games.
  
  
• Among the AAHomecare staff, only Tyler will eat anchovies.
  
  
• Tyler collects presidential campaign memorabilia, with his earliest items being from the election of 1896.

Misleading OIG Report Fails to Blame Flawed CMS Documentation Process

The Inspector General’s Office (OIG) of the U.S. Department of Health and Human Services issued a report last week concluding that 61 percent of power wheelchairs provided to Medicare beneficiaries in the first half of 2007 “were medically unnecessary or had claims that lacked sufficient documentation to determine medical necessity.” But their report clearly indicated that medical necessity was actually only questioned on nine percent of the claims.

The OIG report reaffirmed that the major problem is not mobility equipment going to Medicare beneficiaries who don’t need it, but the government’s failure to establish a process that fairly and adequately documents a Medicare beneficiary’s medical necessity for a power wheelchair. In fact, the vast majority of claims cited in the OIG report were flagged as improper because information was missing in the medical records of the patients that received power wheelchairs.

The fact that the OIG concluded that information was missing in 52 percent of the claims underscores that the government needs to fix the documentation process for determining the medical necessity for power wheelchairs. Despite the repeated pleadings of stakeholders — providers, physicians, clinicians, Medicare beneficiaries, consumer advocates and others — the Centers for Medicare and Medicaid Services (CMS) continues to utilize a flawed system that leaves physicians, providers and Medicare beneficiaries confused about what documentation is needed to satisfy their requirements.

Moreover, the flawed documentation system has become the basis for OIG reports and audits that unfairly create the perception that home medical equipment providers acted improperly and Medicare patients have received equipment that they don’t need. It’s unfortunate that these misconceptions are damaging the image of the Medicare program, providers and beneficiaries at a time when Congress is searching for ways to cut spending to address the nation’s escalating budget deficit.

“Stakeholders have asked CMS to improve the documentation process for years,” said Tyler Wilson, president of the American Association for Homecare. “CMS must focus on establishing a process that works for the government, providers, physicians and Medicare beneficiaries. This should include a template that can assist the prescribing physicians in providing the extensive patient medical information that is being required. And CMS needs to adequately educate providers and physicians on what exactly is required, and how that information must be presented.”

Read AAHomecare's full Mobility Matters article.

OIG Report on Power Wheelchairs Shows that CMS Must Do More to Educate Physicians

A study released yesterday by the Office of Inspector General (OIG) at the Department of Health and Human Services illustrates the pressing need for the Centers for Medicare and Medicaid Services (CMS) to give physicians concrete direction to meet policy and compliance mandates. The report found that more than half of Medicare power wheelchair claims submitted in the first half of 2007 did not meet medical necessity requirements. However, the vast majority of audited claims that were considered improper were the result of a lack of full documentation by the prescribing physician in the patient’s medical record. The report validates what the American Association for Homecare (AAHomecare) has been advocating for years: lawmakers need to hold CMS accountable to establish clear and objective guidance to the physician community in the power mobility benefit.

AAHomecare President Tyler Wilson noted that the OIG report, “Most Power Wheelchairs in the Medicare Program Did Not Meet Medical Necessity Guidelines” (OEI-04-09-00260, July 2011) does not focus enough attention on the real problem—CMS has an expectation of documentation in the medical record without providing a tool for all levels of prescribing physicians to follow. And the report highlights the fact that suppliers are lacking understanding with respect to when the medical documentation meets policy requirements.”

Walter Gorski, AAHomecare Vice President of Government Relations, added, “power wheelchair providers are being put into a position of educating physicians on a very complex policy and then judging the physician’s medical record competency. This should not be the power wheelchair provider’s role. The home medical equipment provider needs to feel confident that the physician is documenting everything CMS expects to see within the medical record and the physician needs to feel assured that the information they are recording in the medical record meets policy requirements, guaranteeing coverage for their patients.”

Gorski added that “this problem could be solved very quickly if CMS were to create a mandatory comprehensive medical necessity assessment template for use by physicians to document proof that the power wheelchair is medically required.”

It is also worth noting that the study takes a snapshot picture in time when confusion about what was required of suppliers and physicians was at its peak. The OIG study looked at power wheelchair claims immediately after CMS had completely overhauled the power mobility benefit in late 2006 (including coverage criteria and coding) and then immediately began issuing clarifications and bulletins, which led to a high level of confusion in the power wheelchair provider community. As a result, auditing of these claims was very subjective, leading to misleading conclusions. Moreover, the OIG report in no way implies that power wheelchair providers are participating in any form of unscrupulous or fraudulent behavior. Since the OIG study was undertaken, power wheelchair providers must be accredited and comply with much more stringent quality and operational standards.

OIG Report: Most Medicare Power Wheelchairs Fail Medical Necessity Guidelines

The Office of Inspector General (OIG) released a report stating they found that 61 percent of power wheelchairs provided to Medicare beneficiaries in the first half of 2007 were medically unnecessary or had claims that lacked sufficient documentation to determine medical necessity. These power wheelchairs accounted for $95 million of the $189 million that Medicare allowed for power wheelchairs during this period.

Recommendations to the Centers for Medicare and Medicaid Services (CMS), based on the OIG’s findings, included:
1. enhanced reenrollment screening standards for current suppliers of durable medical equipment, prosthetics, orthotics, and supplies;

2. reviewing records from sources in addition to the supplier, such as the prescribing physician, to determine whether power wheelchairs are medically necessary;

3. continuing to educate power wheelchair suppliers and prescribing physicians to ensure compliance with clinical coverage criteria; and

4. reviewing suppliers that submitted sampled claims we found to be in error.
After reviewing the report and recommendations, CMS agreed to all of the OIG’s recommendations except for enhanced reenrollment screening standards for current suppliers of DMEPOS.

AAHomecare’s Vice President of Government Relations, Walter Gorski, said, “Not only is the OIG report misleading, the OIG continues to draw the wrong conclusions from the results of the study. Government bureaucrats are overturning physicians’ medical judgment more than six out of every ten times. When the so-called error rate does not decrease despite continued efforts to educate providers over a period of several years, CMS and the OIG must look to simplify the coverage policy and inject common sense back into the auditing process.”

The American Association for Homecare’s Complex Rehab Power and Mobility Council is reviewing this report. To learn more, contact Alex Bennewith at 703-535-1891.

Proposed Rule Issued on Home Health Face-to-Face Requirement

On July 5, 2011, CMS issued a proposed rule that would require a physician who is ordering home health services under Medicaid to document that a face-to-face exam with the patient has occurred. The proposal, called for by the Patient Protection and Affordable Care Act (ACA), requires a face-to-face exam with a physician for home health and durable medical equipment (DME) under both Medicare and Medicaid.

Beginning on April 1, 2011, CMS has required a face-to-face exam prior to certification for Medicare home health for patients, and it has been subject to push back from Congress and the homecare and physician communities. Yesterday’s proposed rule expands this requirement to patients who require home health services under Medicaid as well as clarifies the definition of “medical supplies, equipment and appliances,” which is the term used for DME under the Medicaid home health services benefit.

CMS has not yet issued a rule to apply the face-to-face exam requirement to DME patients under the Medicare program. However, the proposed rule indicates the items that will be subject to the DME face-to-face exam requirement for Medicare will also require a face-to-face exam prior to ordering the items under Medicaid.

Learn more about this homecare issue (AAHomecare members-only)

What CMS is Not Saying About the Competitive Bidding Program

In contrast to CMS reports that there have been no changes in beneficiary health outcomes resulting from the Medicare competitive bidding program for durable medical equipment, AAHomecare and other members of the homecare community are hearing a markedly different story from patients and providers affected by the program.

People for Quality Care has captured a particularly appalling story from Jim Kokenge, president and CEO of PAX Medical Supply, a DME provider in Cincinnati, Ohio. Jim's story illustrates the impact that the confusing and poorly-implemented bidding program is having on patients -- and clearly shows a wide discrepancy between the picture painted by CMS and the reality of this bidding program.

"I am offended when I hear CMS putting out statements that there are no problems when we're getting calls on a weekly basis, daily actually, from therapists who we had dealt with as referral sources who don't know who to go to," says Kokenge.

Watch the video

While there's plenty in this story that causes alarm, we're especially struck by the primary concern of the higher-level CMS staffer who Jim talks about in the latter stages of the video.

Legislation to repeal the bidding program, H.R. 1041, was introduced after hundreds of patients and providers reported problems with the program in the wake of its January 1 implementation. As designed by CMS, the bidding program severely and arbitrarily restricts the number of companies that are allowed to provide commonly used medical equipment and services. Since the program began, patients, clinicians, and homecare providers have reported:

• Difficulty finding a local equipment or service provider;
• Delays in obtaining medically required equipment and services;
• Longer than necessary hospital stays due to trouble discharging patients to home-based care;
• Far fewer choices for patients when selecting equipment or providers;
• Reduced quality; and
• Confusing or incorrect information provided by Medicare.

The legislation has strong bipartisan support in the House, with over 130 cosponsors. AAHomecare would like to thank those members of Congress who have cosponsored H.R. 1041, which will protect Medicare patients' access to home medical equipment.

Medicare’s Audit Process Hampers Access to At-Home Care

Over-reaching by federal audit contractors in Medicare is restricting the ability of legitimate providers to supply medically required care and equipment to patients. The American Association for Homecare is working with policy makers to ensure that fraud prevention efforts are effective at stopping fraud without limiting access to care.

At a June fraud prevention summit conducted by the U.S. Department of Health and Human Services and the Justice Department, the administrator of the federal Centers for Medicare and Medicaid Services (CMS) admitted that audits designed to detect fraud are a “blunt instrument.” After hearing several complaints from healthcare providers participating in the fraud prevention summit, another CMS official stated that federal officials will conduct an “audit audit” to ensure that audit contractors do not needlessly hamper legitimate providers.

“The current auditing strategy is expensive, inefficient, and distorts the Medicare claims error rate for at-home care products,” said Tyler Wilson, president of the American Association for Homecare. “The burdensome process disrupts the service and care provided to patients in need of these at-home services and severely taxes providers’ resources.”

To read the full article, visit the AAHomecare Newsroom.