Article IV: Furnishing of Items

Transcription

1 PALMETTO GBA June 12, 2015 Authorized Official Home Care Company, Inc. 123 Main St. City, ST Re: Termination for Contract Number: Dear Authorized Official: This letter is to notify you that the Centers for Medicare & Medicaid Services (CMS) is terminating Home Care Company, Inc.'s entire Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) competitive bidding program Round 2 contract for all competitively bid items in all competitive bidding areas (CBAs) for which Home Care Company, Inc. has been awarded a contract. Through our monitoring and enforcement of the DMEPOS competitive bidding program, we determined that Home Care Company, Inc. is in breach of Articles IV and VII of the DMEPOS competitive bidding contract for refusing to furnish all items in your contract throughout the CBA and failing to cooperate fully with CMS and the Competitive Bidding Implementation Contractor (CBIC) to resolve issues that pertain to Home Care Company, Inc.'s performance under the contract. The specific Round 2 competitive bidding contract articles that have been breached by Home Care Company, Inc. are listed below. Article IV: Furnishing of Items A. General The Contract Supplier shall furnish all items described in Attachment A throughout the entire CBA(s) listed in Attachment A in accordance with 42 CFR and CBAs are defined by ZIP codes. For a complete list of the ZIP codes included in each CBA, please visit the (CBIC) website at ZIP codes are established by the United States Postal Service and are subject to change. CMS will attempt to minimize the effect of any ZIP code changes within the CBAs. On a quarterly basis, CMS will post updated ZIP code files on the CBIC website, which will be effective as indicated by CMS. CMS may institute additional notification methods as it deems appropriate. CMS reserves the right to make ZIP code updates more frequently than quarterly and will provide notice to suppliers. Page 1 of 15

2 B. Furnishing of a Particular Brand or Mode of Delivery As described in 42 CFR (b), if a physician or treating practitioner, as those terms are defined in 42 CFR , prescribes a particular brand of an item or mode of delivery, the Contract Supplier shall (1) furnish the particular brand or mode of delivery as prescribed by the physician or treating practitioner; (2) consult with the physician or treating practitioner to find an appropriate alternative brand of item or mode of delivery for the beneficiary and obtain a revised written prescription from the physician or treating practitioner; or (3) assist the beneficiary in locating a contract supplier that can furnish the particular brand or mode of delivery prescribed by the physician or treating practitioner. Article VII: Cooperation The Contract Supplier shall cooperate fully with CMS and the CBIC to promptly resolve issues or questions identified by CMS or the CBIC that pertain to the Contract Supplier's performance under this Contract. Specifically, CMS has determined that Home Care Company, Inc. is in breach of Article IV.A of the Round 2 contract by not furnishing all competitively bid items throughout the entire CBA, which is listed in Attachment A of the Round 2 contract. In addition, we have determined that Home Care Company, Inc. is in breach of Article VII of the Round 2 contract by failing to promptly resolve the contract performance issues CMS and the CBIC identified in prior communications and for repeatedly indicating that Home Care Company, Inc. will not or cannot fully perform under the contract. Appendices A, B, and C of this letter summarize details concerning the underlying violations. Appeal Rights Under 42 C.F.R , CMS established an appeals process for all suppliers that receive a notice of contract termination. Under this process, CMS is allowing you the option to submit a corrective action plan (CAP) as set forth in 42 C.F.R (d). If you choose to submit a CAP, it must include the following: A plan to eliminate all the deficiencies identified in this notification Timeframe(s) by which the components of the CAP will be implemented (e.g., timeframes for appealing National Supplier Clearinghouse decision/reactivating PTANs and servicing beneficiaries in all CBAs). If CMS determines the CAP is acceptable and is appropriately implemented to correct the breaches under the contract, Home Care Company, Inc.'s contract will not be terminated. If CMS determines that the CAP is not acceptable or Home Care Company, Inc. does not implement an Page 2 of 9

3 acceptable CAP, Home Care Company, Inc. will receive a subsequent notice that its contract will be terminated within 45 calendar days of the date on that notice. You may also request a hearing, as set forth in 42 C.F.R (d), before an independent hearing officer who was not involved with the original recommendation to terminate Home Care Company, Inc.'s contract. A hearing may be requested when a contract supplier receives either: (1) A notice of termination, or (2) A notice that the CAP is not acceptable. Therefore, given this termination notice, an authorized official for Home Care Company, Inc. must submit either (1) a CAP or (2) a written request for a hearing (in lieu of a CAP), to the CBIC within 30 calendar days from the date of this termination letter to the following address: Palmetto GBA Attn: Contract Appeal 2743 Perimeter Pkwy Ste Penalties of Termination Pursuant to 42 C.F.R , CMS is providing notice that it will terminate Home Care Company, Inc.'s Round 2 contract effective July 27, 2015, unless a corrective action plan (CAP) or a hearing request is received within 30 calendar days of the date of this letter. If Home Care Company, Inc.'s contract is terminated, Medicare will not reimburse Home Care Company, Inc. for furnishing any competitively bid items in any CBA for which it is awarded a Round 2 contract for dates of service on or after the date the contract is terminated. For that reason, if Home Care Company, Inc.'s contract is terminated 42 C.F.R (1)(2) requires you to inform affected beneficiaries who currently rent or purchase these items that Home Care Company, Inc. is no longer a contract supplier and that the beneficiaries must obtain the items from a contract supplier in order for Medicare to pay. Unless you are appealing this termination, i.e., submitting a CAP or a hearing request, Home Care Company, Inc.'s notification to beneficiaries must be completed within 15 calendar days of termination as set forth in regulation. If Home Care Company, Inc. is picking up rental equipment, the pick-up and delivery must be coordinated with the beneficiary and the new contract supplier, and should occur on or after the anniversary date of the initial delivery (see the "Transitioning a Competitive Bidding Beneficiary to a Contract Supplier after Program Implementation" fact sheet in Appendix D for more information). Page 3 of 9

4 If you have any questions, please call the CBIC customer service center toll-free at between 9 a.m. and 5:30p.m. prevailing Eastern Time, Monday through Friday. Sincerely, Elaine Garrick Program Manager Enclosure(s): Appendix A: Home Care Company, Inc.'s Secret Shopper Call (SSC) Results Appendix B: Home Care Company, Inc. s Authorized Official (AO) Contact Log Appendix C: Home Care Company, Inc.'s Authorized Official (AO) Contact Log Appendix D: Fact Sheet Page 4 of 9

5 Appendix A: Home Care Company, Inc.'s Secret Shopper Call (SSC) Results Date SSC Type PTAN CBAIPC Findings Contract Violation(s) 8/27/2014 Initial Round 2 CBA/ Standard Wheelchairs, Scooters, and Accessories Issue 1: Do they provide a wheelchair? Findings: Yes. Issue 2: Do they provide deliver to the beneficiary's zip-code? Findings: No. Issue 3: Do the) offer to take your information to deliver to you in-person or via shipment? Findings: No. Issue 4: Do they bill Medicare? Findings: Yes. Article IV.A Violation -Does not service entire CBA 09/09/2014 Follow- Up Round 2 CBA/ Standard Wheelchairs, Scooters, and Accessories Issue 5: Do they offer to assist in locating a supplier who can provide your brand? Findings: The customer service representative (CSR) stated they didn't Issue I: Do they provide a Scooter? Findings: No, the CSR stated they do not provide Scooters. The CSR stated they provide standard wheelchairs. Nebulizers, NPWT, but they do not provide scooters. Caller advised that Medicare stated they were a provider and that scooters are part of the category they arc contracted to provide. Article IV.A Violation Does not furnish item Issue 2: Do they provide (deliver) to your relatives ZIP code? Findings: N/A Issue 3: Do they offer to take your information to deliver to you either inperson or via shipment? Findings: N/A Issue 4: Do they file claims to Medicare? Findings: N/A Page 5 of 9

6 Appendix B: Home Care Company, Inc.'s Authorized Official (AO) Contact Log Date/Time Call Summary Call Details 08/28/2014 CBL contacted AO and left message regarding the SSC findings. On August 28,2014, the Competitive Bidding Liaison (CBL) contacted Home Care Company, Inc.'s AO, John Doe regarding a non-compliant secret shopper call. The CBL left a voice message as Mr. Doe was not available. The CBL immediately followed up the voic with an (see Appendix C). 08/29/2014 AO contacted CBL. Per AO request, CBL contacted Compliance Officer to discuss SSC findings. On August 29, 2014, the CBL received call requesting they contact the Compliance Officer, Mr. Smith. The CBL contacted Mr. Smith and provided the SSC details and the non-compliant findings. The CBL also educated on the Supplier and Quality Standards, in which contract suppliers are required to deliver all items in the product category to which they have been awarded a contract to the entire CBA where they won a bid. In addition, the CBL addressed that if they were unable to assist, they should be able to recommend the beneficiary to another contract supplier who can provide the equipment to the beneficiary. Mr. Smith understood and stated he would take care of the issue. Page 6 of 9

7 Appendix C: Home Care Company, Inc.'s Authorized Official (AO) Contact Log From: DMEPOS (CBIC) Sent: Thursday, August 28, :40 PM To: Subject: Competitive Bidding program Non-compliance finding Good Afternoon Mr. Doe, This is a follow up to the voice message I left you in regards to the non-compliance findings for your Round 2 CBA Competitive Bidding Area location for the product category: Hospital Beds and Accessories. On August 26, 2014, I conducted a Secret Shopper call, as part of CMS's monitoring program to your location and requested a Hospital Bed. Your office was found to be non-compliant. Under Article IV, Part A of your contract; The Contract Supplier shall furnish all items in the product category indicated in Attachment A throughout the entire CBA(s) listed in Attachment A in accordance with 42 CFR and Please see the attached documents which outline the guidelines for your contract with CMS. Please let me know if I can be of further assistance. Thank you, DMEPOS (CBIC) CBIC Liaison- Round 2 CBA #1 Round 2 CBA #2 (800) (T) (800) (F) RCBICcontractor@PalmettoGBA.com Page 7 of 9

8 Appendix D: Fact Sheet Guidance: Transitioning a Beneficiary with Rented Equipment who Resides in a Competitive Bidding Area to a Contract Supplier A beneficiary who is renting durable medical equipment or oxygen equipment may switch to a contract supplier at any time during the competitive bidding program contract period. For example, the switch may be the result of: Beneficiary or caregiver's decision to change suppliers Beneficiary moves and must change suppliers Current supplier no longer in business Termination of a supplier's competitive bidding contract Beneficiary changes from a Medicare Advantage plan to Original Medicare Current supplier was not awarded a contract for the competitive bidding program and decided not to become a grandfathered supplier In the event a beneficiary changes suppliers for any of the other reasons stated above, the current supplier who is transitioning the beneficiary to a contract supplier should coordinate the pick-up of its existing rental equipment and the delivery of the new rented equipment with the new contract supplier and beneficiary. The pick-up and delivery of such equipment should occur on or after the anniversary date of the initial delivery, which i's explained in further detail below. Service to the beneficiary should not be disrupted. A supplier should pick-up its rented equipment after making arrangements with the new contract supplier for the delivery of the new equipment. Suppliers should be sure that these arrangements meet the beneficiary's needs. The current supplier should assist the beneficiary in locating a contract supplier, if necessary. The contract supplier is obligated by the terms of the contract to accept the Medicare beneficiary as a customer. Pick-Up and Delivery Process The pick-up of the existing rental equipment and delivery of the new equipment with the new contract supplier should occur on the anniversary date of when the item was first delivered to the beneficiary by the current supplier or another date agreed upon by the beneficiary. The anniversary date is the date when a new monthly rental period begins. For example, if the anniversary date is March 27 th, the current supplier would pick-up its equipment on April 27th and the new contract supplier would deliver equipment on April 27th. Billing and Documentation Guidelines Medical documentation requirements apply when transitioning a beneficiary to another supplier. The new contract supplier should acquire all supporting documentation, such as the physician order or the certificate of medical necessity form, when applicable, from the current supplier. Please see Chapter 5 of CMS' Program Integrity Manual or contact your DME MAC for specific guidance. Page 8 of 9

9 Transitioning from a grand fathered supplier to a contract supplier Beneficiaries who are receiving their rented competitive bid item from a grandfathered supplier may choose to transition to a contract supplier at any time. In these situations, the contract supplier may be entitled to additional payments depending on the type of equipment. For more information, please refer to the ''Grandfathering for Rented DME" or the "Grandfathering for Oxygen and Oxygen Equipment" fact sheets on the CBIC website under Educational Information. Page 9 of 9