Exercising the Wound Care Provider’s Right to Ensure Care Quality

Editor’s Note: The author of this article is co-chair of the AAWC regulatory committee.   Have you ever questioned a new coverage policy or a new regulation issued by a payer, Congress, or the Centers for Medicare & Medicaid Services (CMS)? Have you ever thought, “This doesn’t seem right for patients, but what does it matter what I have to say?” or “I’m only one voice in a sea of noise; no one is going to care or listen to me”? Well, despite the challenges that may exist in making one’s presence felt, what you have to say can and could make a difference in the lives of your patients if you take it to a higher power. So, whenever you find yourself asking these questions or making these generalizations, consider the following scenario, as it may encourage you to voice any and every opinion or concern you may have the rest of your healthcare career.

How One Nurse Practitioner May Initiate Big Change

  It all started this past May when a nurse practitioner (NP) who specializes in wound care was perplexed by the pending activation of statute “Public Law 111-148, 124 STAT, Sec 6407,” better known as the “physician only” requirement to document that a face-to-face encounter occurred within six months, by a physician or a non-physician practitioner, before durable medical equipment (DME) can be ordered for a Medicare patient. An NP who practices in Tennessee and is a newly elected board member of the Association for the Advancement of Wound Care (AAWC), as well as a new volunteer member of the AAWC’s regulatory committee, was confused by the statute, which was to be enacted by CMS July 1 but is being delayed until Oct. 1. Specifically, she struggled to find the logic behind the new rule mandating that non-physician providers (NPPs), particularly nurse practitioners, who can evaluate and treat patients in most states with or without physician supervision, must seek out a physician to sign a form documenting that a patient visit occurred within six months of ordering DME. Citing an existing shortage of primary care physicians, the NP was concerned that the stipulation would negatively impact her patients by delaying their release from a hospital or skilled nursing facility to home health (or home in general) while waiting for DME orders to be cleared.    “This regulation goes against all that CMS has been doing to promote the use of NPPs to help expand patient access to care,” the nurse practitioner said.   Her inquiry began a chain of events that has led an AAWC subgroup of physicians, NPs, and nurses to participate in a meeting with the House Ways & Means Committee’s Subcommittee on Health in late August. Their interchange has lead to a future meeting with the Senate Finance Committee, whose members were instrumental in drafting the legislation in question, later this September.

Making One’s Voice Heard

  So, what did it take to go from having this complaint to essentially requesting a personal conference? For starters, a quick phone call by the NP to Marilyn Tavenner, BSN, MHA, the administrator and chief operating officer at CMS, to discuss her opinions “nurse to nurse” regarding the new mandate went a long way. By taking this type of initiative, the voices of the NP and AAWC committee members have been considered by CMS officials and resulted in an invitation to discuss the matter further with CMS staff. In the weeks that have followed the scheduling of the discussion with CMS, the AAWC committee prepared an “issues and impact” document identifying its concerns related to the mandate from both a patient care and financial standpoint. (Its contents are too lengthy to list here.) AAWC then conducted a conference call with a group of staff members from CMS’ compliance group in its Office of Financial Management. Through this process, the group learned that CMS actually shared the same concerns — that the pending statute would not be advantageous for patients. While administrative limitations prevent CMS from changing regulations passed by Congress, AAWC received guidance on how best to approach the Ways & Means Subcommittee on Health to attempt to reverse the mandate that requires physician-only signatures. AAWC also addressed with CMS the added annual costs to reimburse physicians to document that a visit occurred, based on the assumptions CMS used to determine how much DME is written by NPPs. AAWC argued to CMS and Ways & Means that the mandate “adds absolutely no benefit to the patient and does nothing to reduce fraud and abuse of DME.” The reality remains that the documenting physician, if not already the patient’s doctor, does not have to see the patient, review the patient’s chart, evaluate if the correct DME has been ordered by the NPP, or even know the patient. The only requirement is to document a visit with a physician or NPP has occurred within six months of the DME order, and that concerned us. Our group also went a step further by preparing recommendations for the actual statute language modifications we believe is needed to “correct” the regulation, using clinical knowhow and a passion for patient advocacy as motivation to achieve our goal of securing one-on-one time with Ways & Means. Regardless of the ultimate outcome of what the initiative brings, we are confident that our drive to have our opinions and concerns formally addressed will entice others to speak up whenever questioning a policy or regulation by contacting their local public office and/or sending communication to the payer, CMS, or Congress to inform them of the issue(s) of contention. After all, who knows what’s best for patients more than the practitioners who care directly for them? Peggy Dotson may be reached at peggy_dotson1@yahoo.com.