OIG Issues Fraud Alert for Rental Space

March 2, 2000
A February 24th Federal Register gives notice of a recently issued Office of the Inspector General (OIG) Special Fraud Alert. The alert concerns rental of space in physicians’ offices by persons or entities that provide health care items or services to patients that are referred either directly or indirectly by the physician-landlord. Generally, OIG Special Fraud Alerts address national trends in health care fraud, including potential violations of the anti-kickback statute for Federal health care programs. This Special Fraud Alert specifically highlights questionable or suspect rental arrangements for space in physicians’ and other practitioners’ offices, and how the space rental safe harbor can protect legitimate arrangments.

For a complete copy of the Fraud Alert visit the Web site or call Julie Kass, Office of Counsel to the Inspector General, 202-619-0335.

Pulse Oximetry Code Changes Cause Concern for RTs

February 8, 2000
A Medicare revised CPT-4 coding regulation is causing concern for respiratory therapists who provide pulse oximetry testing in pulmonary rehabilitation programs through Independent Diagnostic Testing Facilities (IDTFs) and other diagnostic or clinical sites.

On Nov. 2 1999, the Health Care Financing Administration (HCFA) released its annual physician fee schedule update. HCFA chose to discontinue separate payments for CPT codes 94760 and 94761 (pulse oximetry). These codes are now bundled as part of the standard physician office visit payment. Pulse oximetry with continuous overnight monitoring was exempt from the bundling and is still paid separately.

The AARC submitted comments in November raising concerns that physicians would be reluctant to perform services or procedures for which they would no longer receive separate payment. Our concern, as well as the concern of other associations, focused on the physician office, which, in essence, was the area that these regulations addressed.

Respiratory therapists also raised concerns that the regulations did not clarify that the new bundling provisions for pulse oximetry codes were only for the physicians' office and that the provisions would also be applicable to other sites where pulse oximetry was provided.

The AARC submitted a second set of comments in late December 1999 asking for exemptions for pulmonary rehabilitation services IDTFs and other clinical settings where pulse oximetry was being provided.

In late January HCFA staff issued both a Program Memorandum and a verbal clarification regarding the bundling policy. The clarification made to the AARC is: The bundling provisions are applicable only under Medicare Part B. Pulmonary rehabilitation programs bill for their services with Medicare Part A; thus pulse oximetry bundling provisions will not affect these services.

HCFA also issued a Carrier Program Memorandum (Transmittal B-00-03), which in a convoluted manner addresses the concerns we and others have had regarding pulse oximetry provided by IDTFs. HCFA is changing the procedures status of CPT codes 94760 and 94761 to a "T" status. HCFA regulations for the "T" procedure status state:

"T" = Injections. There are RVUs for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the service(s) for which payment is made." (HCFA also states within Transmittal B-00-03 that it will soon amend the definition of "T" status to include more than injections.)

Basically, HCFA is giving IDTFs a way around the pulse oximetry bundling provision. As long as pulse oximetry is the only service provided on a single day (date), the service will be paid.

While this is not a perfect solution, this amendment does provide independent diagnostic testing facilities some leeway around the pulse oximetry bundling provision. We will keep you posted if and when further developments arise on this issue.

AARC Joins in "Coalition to Fix Medicare Now"

August 18, 1999
The AARC has joined with other health professional groups and consumer advocates to form the Coalition to Fix Medicare Now. The goal is to fight for adequate medical services for Medicare beneficiaries by convincing Congress and the President to reverse the damaging cuts that were made as a part of the 1997 Balanced Budget Act.

At the first meeting of the Coalition, members outlined their founding principles:

Founding members of the Coalition to Save Medicare Now are:
American Association for Respiratory Care
American Health Care Association
American Occupational Therapy Association
American Society of Consultant Pharmacists
Jewish Federation of Aging Services
Lutheran Services of America
National Association for the Support of LTC
National Association of DON Administration
National Subacute Care Association
The Seniors Coalition
United Jewish Communities

HHS Expands "Senior Patrol" Grants

August 4, 1999
The Department of Health and Human Services (HHS) has announced that 41 grants totaling $7 million will be dedicated to expanding a program that recruits and trains retired professionals to identify waste, fraud and abuse in the Medicare and Medicaid programs.

HHS Secretary Donna Shalala and US Senator Tom Harkin (D-Iowa) are pleased to have further empowered the Senior Medicare Patrol Project with the grants, 29 new and 12 renewed, which will be distributed among 38 states including Washington DC and Puerto Rico. The HHS Administration on Aging administers the grants which will provide funds to teach volunteer retired professionals such as doctors, nurses, accountants, investigators, law enforcement personnel, attorneys, teachers and others how to work with Medicare and Medicaid beneficiaries. The volunteers will work in their own communities and in local senior centers to help identify deceptive health care practices like over billing, overcharging, or providing unnecessary or inappropriate services.

In 1997 Senator Harkin authored the Senior Medicare Patrol Project grants, originally called the Health Care Anti-Fraud, Waste and Abuse Community Volunteers Demonstration Projects. The current projects have tested different models and in the past 18 months have trained more than 6,000 retired volunteers to serve as resources and educators for older persons in their communities. The trainees have gone on to educate more than 70,000 Medicare beneficiaries on how to spot problems. The newly announced projects should result in the training of another 15,000 volunteers who will in turn educate 250,000 more beneficiaries.

AARC Applauds Intro of Medicare Benefits Improvement Act

June 8, 1999
The American Association for Respiratory Care, a member of the National Association for the Support of Long Term Care (NASL), commends Congressman Burr (R-NC) along with Congressman McCrery (R-LA), Congressman Cardin (D-MD) and Congressman Pallone (D-NJ) for the introduction of bipartisan legislation which would serve to help those Medicare beneficiaries who would be otherwise limited in their ability to obtain medically necessary rehabilitaiton services.

NASL issued a formal statement recently following the introduction of the legislation. Peter Clendenin, the organization's executive vice-president, called the measure "crucial" and said it "will go a long way in ensuring that no senior will have to forgo medically necessary services or be put in the excruciating position of having to choose between walking or talking."

As you probably know, the Balanced Budget Act of 1997 imposed on Medicare beneficiaries a $1,500 annual cap for the reimbursement of occupational therapy and one for physical therapy and speech-language pathology services combined. An analysis based on actual Part B claims for the first four months following the implementation of the limitation indicates that the number of beneficiaries affected by the therapy cap continues to rise.

The AARC will continue to support NASL in its efforts to stand against the therapy cap for Medicare beneficiaries and will keep you informed as new information is available.

AARC Meets With HHS About PPS Concerns

April 21, 1999
The American Association for Respiratory Care met last week with representatives from the Urban Institute and the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services (HHS) to discuss how the Balanced Budget Act of 1997's (BBA) prospective payment system has impacted respiratory therapy.

AARC Executive Director Sam Giordano, Director of Government Affairs Cheryl West and Director of State Government Affairs Jill Eicher met with Jennie Harvell of HHS and Korbin Liu and Barbara Gage from the Urban Institute (a Washington, D.C.-based think tank). Participating in the meeting by conference call were AARC members Scott Bartow, MS, RRT of Ventilatory Care Management, Kevin Cornish, RRT of Ernst & Young, and Patrick Dunne, MEd, RRT of Southwest Medical Emporium.

The Office of the Assistant Secretary for Planning and Evaluation at HHS has contracted with the Urban Institute to study trends and issues in Medicare's post-acute care benefits. The first section of a two-part report on this study was published in January 1999. The report chronicled the evolution in costs and utilization of Medicare's post-acute care benefits over a ten-year period from 1986 through 1996. The second half of this study will focus on post-acute trends after the implementation of the BBA. The BBA mandated the development of a prospective payment system (PPS) for skilled nursing facilities (SNFs), outpatient department (OPD) services, home health care, rehabilitation hospitals and units, and long-term care hospitals.

The AARC and its members took advantage of this opportunity to discuss the impact SNF PPS has had on respiratory therapy. Our representatives cited concerns with inadequate reimbursements for service intensive patients, such as those on ventilators, and discussed the severe safety risks created by a lack of federally mandated competency standards for health care providers delivering respiratory therapy. The AARC proceeded to review the Association's recommended competency requirements and encouraged HHS representatives to consider adopting similar standards. The Association also reviewed its concerns with inadequate payments and inappropriate classification of respiratory therapy services under the proposed PPS for outpatient services. And because "real life" examples of compromised care make such a strong impact, AARC conference call participants took advantage of the opportunity to educate HHS and Urban Institute staff about how federal Medicare policy is affecting the daily delivery of respiratory therapy services.

This meeting allowed the AARC to pinpoint and clarify inadequacies in coverage of respiratory therapy services under the Medicare program, such as the lack of respiratory therapy coverage under Medicare's home health care and outpatient rehabilitation benefits. As part of the AARC's continuing effort to educate federal policymakers on the role of respiratory therapy, this latest meeting has taken us a step closer to initiating changes in federal policy regarding coverage of respiratory therapy services and competency requirements for health care providers rendering respiratory care.

AARC Continues to Fight Denial Rulings

March 23, 1999
In an ongoing exchange between the AARC and HCFA about respiratory claim denials in the northwestern states, we are finding the government agency cannot support their decisions with medical justification and clinical evidence. We provided background information on this issue in January soon after we had made contact with Ruiz. Following is our latest response to HCFA in which you will also find links to earlier exchanges we have had with the agency. The AARC will continue to pursue this issue until we have received a satisfactory response from HCFA.

March 16, 1999

Linda Ruiz
Regional Administrator
Health Care Financing Administration
Region X
M/S RX-40
2201 Sixth Avenue
Seattle, Washington 98121

Dear Ms. Ruiz,

Thank you for your letter dated March 2nd in which you provide a response to my letter of January 20th of this year. As I stated in that letter, the purpose for my contacting you was to gain assurance that respiratory therapy services are provided safely regardless of who provides the service. I posed four questions in order to gain that assurance. After reviewing your response, I find that the two most relevant questions have gone unanswered. They are:

Item #3
"What is the objective evidence and documentation that justifies reclassification of specific respiratory therapy services as routine nursing services?"

Item #4
"What is the objective evidence that documents the competency of persons other than respiratory therapists to provide respiratory therapy services?"

I am, therefore, once again, requesting answers to those questions. I do appreciate that HCFA policy calls for intermediaries to differentiate between respiratory therapy services and routine nursing services. But, what is the basis for such differentiation?

In your letter of March 2nd, you state that "We agree that nurses are not qualified to provide respiratory therapy services without special training." If special training is required in addition to standard nurse training, what mechanism exists to assure that such training leads to the competent and safe provision of the services in question? Moreover, if additional training is needed, how then, can the services in question be considered part of "routine nursing services?"

In your letter, you also indicate that "We do not believe the intermediariesí position is in conflict with the positions taken" in the articles attached to your letter. While you made reference to the American Journal of Critical Care article, the American Society of Anesthesiologists statement, and the American College of Chest Physiciansí section on respiratory care resolution, you did not directly reference the statement authored by the National Association for Medical Direction of Respiratory Care which states:

"The hours of education and the curriculum required for credentialing of respiratory care practitioners should be the standard for all non-physician providers of respiratory care services. Verification of the knowledge and skills acquired through this educational process should be documented by appropriate testing which includes input from physicians who specialize in respiratory medicine in the preparation of certifying examinations."

Since the entire statement from NAMDRC was included as part of the "articles," are you in agreement?

In your response, you offered a quote from a statement made by the American Society of Anesthesiologists (ASA) which refers to the role of respiratory therapists in the provision of respiratory care. You infer, through the use of excerpting a part of a sentence out of context, that respiratory therapists are only needed for ventilator care. Specifically, the quotation you used states "the control of life support equipment in critically ill patients." However, when the statement is placed within the context of the complete sentence in which it was used, it states "The patients under their care frequently include a disproportionately sicker population than is the case with most other allied health practitioners, and RCPs have responsibility for control of life support equipment in critically ill patients." The full sentence does not limit the role of respiratory therapists to that of management of ventilator patients.

The ASA statement also described a concern over the use of substitute care givers in the area of respiratory care. Indeed it expressed concern that "The standard of care to patients could be compromised unless these other individuals receive the same expensive education, training, and competency testing as required of RCPs." We share this concern, as does the American College of Chest Physicians. Specifically, in their resolution I quote "We are concerned that the quality of these services [relating to respiratory therapy] may be inferior if the health care provider has not had adequate training and experience."

Your letter of March 2nd also indicated that we contend that "Only a registered respiratory therapist can perform the services which are listed in the LMRP as routine nursing services." I apologize for not being more clear in my earlier correspondence. My contention is that anyone who undergoes the same education and competency testing equal to that of a credentialed respiratory therapist, can provide the services. We took issue with the Robinson statement because the statement was not preceded with the qualification that nurses, after receiving special training and competency testing, could provide those services. I donít want a genuine concern for patient safety to be spun into a turf issue. My organization wants to provide assurances to consumers that regardless of who provides respiratory therapy within the Medicare program, that these providers have been appropriately trained, and most importantly, have undergone a valid competency examination. I know that HCFA must have objective evidence to support its contentions, since we are required to provide the same, any time we recommend changes to the system.

I am merely asking that that information be made available to us.

Thank you for your consideration. I am sorry to keep bothering you with these same questions. But the answers are important to all of us.

Sincerely,

Sam P. Giordano, MBA, RRT Executive Director

SG/bd

cc: Thomas Hoyer, CO, HCFA Senator Ted Stevens Senator Frank Murkowski Senator Gordon Smith Senator Ron Wyden Senator Patty Murray Senator Slade Gorton Evelyn McChesney, Asst. Regional Counsel, OGC Janet Russell, Premera Barbara Riley, Premera

Appeal to Re-examine Medicare Payment Decision Denied

March 19, 1999
Federal regulators won a legal battle recently when the U.S. Supreme Court ruled that health care providers cannot appeal a fiscal intermediaryŐs refusal to re-examine a Medicare payment decision after the initial time period for such appeals is exhausted, according to the March 1 issue of Modern Healthcare. Under current law, providers have 180 days to appeal an unfavorable payment decision to the Health Care Financing AdministrationŐs Provider Reimbursement Review Board, and another 60 days to appeal the BoardŐs ruling to a federal court.

The decision came in a case involving a Knoxville, TN-based home care company, which in 1994 had asked its fiscal intermediary, Blue Cross and Blue Shield of South Carolina, to reopen its Medicare cost report for 1989, saying that it had new information showing that it was being paid less than a competing nursing service.

HCFA Coaches Medicare Providers on Y2K

March 10, 1999
The Health Care Financing Administration (HCFA) recently mailed the following letter to over a million of its health care partners and provider related associations regarding the Y2K issue. The message is that HCFA will be ready to process and pay all acceptable claims by January 1, 2000 and that providers must take steps to ensure their own readiness in order to be paid promptly. Further, the Y2K problem has implications for patient care. Providers should take steps to assure that beneficiaries receive the same quality of care that is provided to them today. The letter includes a checklist that providers can use as a tool to assess their Y2K readiness.

Medicare providers were to begin submitting claims with 8-digit date formats no later than January 1,1999. However, it was recognized that many providers needed additional time to modify and test their own billing systems and, therefore, claims without 8-digit date formats would continue to be accepted until further notice by HCFA. On January 13,1999, we notified Medicare contractors that, beginning April 5,1999, claims will be returned to providers if they are not submitted in the Y2K format. To assist providers with Y2K readiness efforts, Medicare contractors offer free or minimal cost Y2K compliant billing software. Changing formats and using appropriately modified billing software are just two of the important steps that providers must take to assure that they are ready for the Year 2000.

The letter to health care partners is part of an extensive outreach effort being conducted by HCFA to promote Y2K self-assessment and readiness among all providers engaged in delivering health care services to beneficiaries of Medicare, Medicaid and the Children's Health Insurance Programs. HCFA has assumed a lead role in addressing Y2K readiness in the health care sector and holds regular meetings and discussions with a variety of industry groups. HCFA has strongly encouraged health care industry associations to accelerate efforts to assess the readiness of their provider members and to foster remediation initiatives.

In addition to this letter to providers and the resource information on its web site, www.hcfa.gov, HCFA has established a Y2K Speakers Bureau and is prepared to make speakers available to health care provider organizations that wish more detailed information about Y2K readiness and the implications of the millennium change for the industry.

FOR FURTHER INFORMATION CONTACT: Joe Broseker 410-786-1950 or Anita Shalit 202-690-7179. (Catalog of Federal Domestic Assistance Program No. 93.778, Medical Assistance Program) (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare-Hospital Insurance; and Program No. 93.774, Medicare-Supplementary Medical Insurance Program)

AARC Pursues Denial Rulings Through HCFA

January 26, 1999
Problems with reimbursement for services in the northwestern states continue to plague respiratory therapy. AARC has recently contacted both the local intermediary and the HCFA Regional Administrator to harshly voice concerns about their handling of recent policy implementations.

Last September, AARC wrote to the Alaska fiscal intermediary because they had implemented a policy of denying routine respiratory therapy services when provided by respiratory therapists. A December response from the intermediary noted that this policy was not just a local policy, but apparently was a regional HCFA directive affecting Washington, Idaho, and Oregon as well.

Last week, AARC fired off a response to that intermediary demanding to know about the comment period and, more importantly, the medical justifications and clinical evidence for their decisions.

Problems with reimbursement have been especially rampant in this area of the U.S. primarily due to the opinions and decisions of one individual. AARC's campaign to fight these decisions is extending to the entire HCFA region, as we have additionally written to Linda Ruiz, the regional administrator of HCFA for that area.

"It is disconcerting to have the welfare of respiratory patients and, indeed, the welfare of this profession, reside with one person," said Cheryl West, AARC Director of Government Affairs. "But the reality is that is what is happening. We will make an all-out effort to reverse these decisions."

IDTF Enrollment Deadline Nears

December 16, 1998
If you work for an Independent Physiological Laboratory (IPL), you are probably aware that IPLs must enroll with the Health Care Financing Administration as an Independent Diagnostic Testing Facility (IDTF) by January 15, 1999. Any diagnostic procedure performed after that date by a facility not recognized as an IDTF will not be covered by Medicare.

HCFA recently published the final regulations regarding IDTF enrollment requirements and conversion procedures. This document is available here for your review. Please ensure that your IPL has met the outlined requirements to avoid potential problems and reimbursement denials.

Office of Inspector General Issues Final Compliance Program Guidance for Hospitals

March 11, 1998
On February 23, the Office of Inspector General (OIG) of the Department of Heatlth and Human Services (HHS) published in the Federal Register its final Compliance Program Guidance for Hospitals. The document also appears on the OIG's Web Page at: www.dhhs.gov/progorg/oig.

This is the second formal OIG effort to promote voluntary development and implementation of compliance programs for the health care industry. The first, called the "Model Compliance Plan for Clinical Laboratories," was published last March in the Federal Register.

HCFA Delays Medicare Changes

June 30, 1998
Several of the Medicare changes outlined in last year's balanced budget act (BBA) might have to be delayed according to HCFA administrator Nancy-Ann DeParle.

In an internal memo written by DeParle, she says the "year 2000" computer problems may cause HCFA to postpone implementation of some of the BBA required changes. The agency might have to ask Congress to let it delay implementation of the prospective payment system for home health agencies (HHAs) and outpatient facilities.

HCFA may also seek to postpone payment increases for doctors and hospitals. HCFA says they will develop a contingency plan to allow for steady payments to doctors and hospitals. HCFA officials have said, for example, that the agency could advance money to doctors and hospitals in 1999 to cover the first few months of 2000 or it could continue to pay them at current rates and then make up any shortcoming after the computers were reprogrammed.

Other developments in HCFA's handling of the Medicare modifications include the agency's agreement to drop the antifraud surety bond rule. HHAs had been required by the new law to obtain by July 31 surety bonds of $50,000 or %15 of annual billings, whichever was greater. After strong protests from HHAs and threats from Congress to repeal the rule, HCFA decided to suspend the rule pending a General Accounting Office review. Future bond rules may not go into effect until February 15 next year.

New Executive Order May Give RCPs Access to Patients

March 16, 1998
The AARC is investigating how the new federal "Health Care Consumer Bill of Rights" may assure a patient's access to a respiratory care practitioner.

The new executive order, signed by Clinton at the end of February, includes guarantees that patients will have access to accurate and easy-to-understand information, access to emergency care and specialists when they need it, the right to participate in their treatment decisions, confidentiality of medical information, and grievance and appeals procedures to resolve difference with their health plans and providers.

There guarantees are for those citizens who receive health care coverage through Medicare, Medicaid, the Federal Employees Health Benefits Plan, military personnel, and veterans.

The AARC will use the language assuring access to specialists as leverage to help ensure that patients will receive the care of respiratory care practitioners when they need it.

AARC Comments on Conditions of Participation

February 5, 1998
In our continuing effort to champion the cause of respiratory care, the AARC has sent comments to HCFA regarding its proposed rule for hospital conditions of participation. There are several issues in particular which will impact the profession, and AARC President Cindy Molle has addressed each one and provided HCFA with suggestions for the necessary revisions. The complete proposed rule was published in the Federal Register December 19.

Following is the final draft of the AARC's comments to HCFA.

Dear Madam Secretary:

The American Association for Respiratory Care (AARC) welcomes the opportunity to comment on the proposed rule for the Medicare and Medicaid Programs; Hospital Conditions of Participation; Provider Agreements and Supplier Approval.

The AARC supports the intention of HCFA to shift the focus of Medicare in the direction of patient outcomes and away from procedures and process requirements. With these proposed regulatory revisions, the Health Care Financing Administration (HCFA) brings the Hospital Conditions of Participation (HCOP) into alignment with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation requirements. We are aware that only 1,500 of the nation's 6,700 hospitals use HCOP rather than accreditation by either JCAHO or the American Osteopathic Association (AOA). These 1,500 facilities choose, for a variety of reasons, not to undergo what we believe to be a more detailed and comprehensive accreditation review than is currently required, or will be required under the Medicare HCOP. To ensure that Medicare beneficiaries receive health care services in non-JCAHO accredited facilities that is of equal quality, Medicare's HCOP must be as rigorous as those of the other accrediting bodies. We are particularly concerned with Sec. 482.125 (Condition of Participation: Human Resources) of the proposed rule.

This section of the proposed rule cedes the current Medicare HCOP authority over personnel qualifications to either state licensure laws or qualification standards developed by each hospital. If these proposed regulations become final, HCFA will have dissolved national personnel standards and ushered in an inconsistent, disjointed system of personnel requirements. We believe this will threaten quality of services to Medicare beneficiaries. HCFA must recognize the need for minimum personnel qualifications criteria, which must be implemented in every hospital.

The elimination of federal personnel requirements and reliance solely on state law will be detrimental to the quality of care Medicare patients receive. State licensing laws vary from state to state in terms of competency testing, continuing education requirements, and scope of practice. In the case of respiratory care, 35 states, the District of Columbia, and Puerto Rico have licensure laws, seven states have certification laws or laws that protect the use of a title, and 8 states do not regulate the respiratory care profession. These concerns notwithstanding, states with licensure still have minimum personnel standards in terms of education, credentialing, competency testing, scope of practice, and medical direction. In many instances, licensure has been the only safeguard standing between the Medicare beneficiary and care from an incompetent provider. What standards will assure that providers are competent in states without licensure? In lieu of licensure, HCFA must develop minimum personnel criteria which can serve as a proxy in states without comprehensive licensure of health care professionals.

State and federal regulations have been the cornerstone for maintaining personnel qualifications within hospitals and other health care facilities. We believe that HCFA cannot assure quality health care by relying on the development of personnel qualifications on a hospital-by-hospital basis without the benefit of any federal oversight. In the absence of state licensure, Medicare HCOP must stipulate in far greater detail than is currently proposed the personnel qualification requirements that a hospital must meet if the institution chooses to develop its own set of standards.

The Joint Commission standards for personnel qualifications are extremely detailed. We believe HCFA must develop a similar mechanism to ensure quality health care. HCFA must include extensive personnel requirements with the HCOP.

The use of the National Practitioner Data Bank in aiding a hospital in acquiring and maintaining qualified staff may be helpful in selecting physicians and some other health care practitioners but respiratory care is currently not included in the system. HCFA should not depend upon this mechanism as it is still in its formative stages and does not include all health care providers.

HCFA's proposal to allow individual hospitals to determine their own personnel requirements or in lieu of licensure will create a patchwork of differing requirements across the U.S. One of the recommendations of the 1995 PEW Commission's Task Force on Health Care Workforce Regulations was that states use uniform language in regulating health care personnel. Clearly, the PEW task force sees the benefits of uniform and standardized policies in regulating health personnel.

We would ask that HCFA identify the organizations it received professional input from (P. 66727, col. 1, #4). Because the proposed rule significantly alters the current HCOP, we believe it is in the public's best interest for HCFA to acknowledge their sources of input.

We also ask for clarification on Sec. 482.35 (b) (6) Drug Management Procedures. You state in the preamble to the regulations (page 66739, col 3) that individuals who bring their own medications when admitted to the hospital must have these medications positively identified. The regulation states "...a pharmacist or someone with similar drug identification skills must make sure that the drugs brought to the facility are in fact the same drug that the label represents." Metered dose inhalers (MDI) are an obvious example of the type of drug that a pulmonary patient would bring to a hospital. We assume respiratory care practitioners, given their expertise in various aerosol drugs, would meet HCFA's requirement as being one who has drug identification skills.

The AARC acknowledges the rapid evolution of the health care system and its subsequent changes effecting the delivery of health care. However, despite these changes, patients have a right to expect their health providers to be educated and tested for competency in their areas of expertise at the patient's bedside. There can be no substitutions for qualified health care professionals without endangering the health and the safety of the patient. The AARC recommends federal personnel standards be developed as part of the revised Medicare Hospital Conditions of Participation.

Sincerely,


Cynthia J. Molle, RCP, RRT, BS President

AARC Reviewing Proposed Regulation for New Conditions of Participation

January 15,1998
Medicare has issued a proposed regulation which will completely revise the current Hospital Medicare Conditions of Participation (HCOPs). Medicare intends to bring its accreditation process in line with the reforms that have been instituted by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the American Osteopathic Association (AOA). Several years ago, these private accreditation organizations shifted their focus toward patient outcomes and away from procedural and process requirements. AARC is reviewing the proposed regulations, published in the December 19, 1997 Federal Register. We are concerned that personnel qualifications will rely either on state licensure laws or, if not state licensed, by individual hospital personnel standards. While the Joint Commission also allows hospitals to develop internal personnel qualifications, there are extensive and precise requirements a hospital must meet under this accreditation process. The proposed Medicare rule lacks this detail and therefore is of great concern to the Association.

In order to participate in the Medicare Medicaid program, a hospital must be accredited either by JCAHO, AOA or the Medicare HCOPs. Currently Medicare certifies only 1,500 out of the country's 6,700 hospitals.

Rehabilitation Agencies and Services

The Balanced Budget Amendment has had a significant impact on the reimbursement for physical therapy (PT), occupational therapy (OT), and speech therapy (ST). With the exception of hospital-based outpatient therapy services, therapy reimbursement is limited to $1,500 per beneficiary per year. To make matters worse, PT and ST must share the $1,500 allowance, while OT has the full $1,500.

Furthermore, the laws would exclude from Medicare coverage outpatient PT and OT services furnished as "incident to physician services" that did not meet the standards required for outpatient PT services provided in a clinic, rehab agency, or public health agency.

While the focus was specifically on physical, occupational, and speech therapy services, with no mention of respiratory care, it is wise to take note of the changes that are happening to other therapies, as it might foreshadow what will happen to respiratory.

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