Home Health & Hospice Week

Wheelchair forum barely scratches the surface of suppliers' concerns.

Five hundred people called into the March 31 special Open Door Forum on wheelchair issues, and not one of them got to speak a word.

The dialog between the in-person attendees of the Baltimore forum and Centers for Medicare & Medicaid Services and durable medical equipment regional carrier officials was so contentious, it took up the 1.5 hours allotted for the forum, plus an extra 25 minutes tacked on.

"This issue is obviously not going away," said beneficiary advocate and former CMS employee Henry Claypool. "There are 500 people on the phone."

The main point of contention was the definition of "non-ambulatory" and "bed- or chair-confined" for coverage purposes, including whether there were any so-called bright lines in the definitions.

"This is not a matter of counting steps," said a CMS official of the coverage criteria. The agency can't give bright line guidance on the definition, because it doesn't exist, CMS insisted.

But former Region C Medical Director Paul Metzger disagreed. "Contrary to that statement, since 1995 there have been very bright lines established by all four DMERCs," said Metzger, now with The Scooter Store based in New Braunfels, TX. And those bright lines were reversed in the December DMERC article that CMS now has retracted.

As proof of the bright lines, Metzger offered up the 1993 revision to the certificate of medical necessity and the supporting Office of Management and Budget documentation for the change. The CMN went from asking "is the patient otherwise bed or chair confined" to "does the patient need and use the power wheelchair to move around within the residence."

Why is CMS asking physicians to fill out the question "if it is not and never has been relevant?" Metzger demanded of the CMS officials.

CMS responded that the CMN is just one piece of documentation used to establish wheelchair eligibility and doesn't furnish bright lines.

Further, CMS claimed throughout the forum that the DMERC article, though retracted, was never a change in wheelchair policy and reflected policy as it has been since the mid-1980s. CMS said it pulled back the so-called clarification, which the industry "misconstrued or misinterpreted," only because it seemed to cause more confusion.

"I would also like to ask you how you people sleep at night," Metzger blasted. He called CMS' reasons for rescinding the article "lame" and "laughable." And he said the facts didn't square with CMS' "revisionist history" of the wheelchair coverage policy.

Although Metzger's comments were the most scathing, numerous in-person forum attendees echoed the question of bright lines. Without them, CMS is using a mere "rule of thumb" to decide eligibility on a whim, said Peter Thomas with the ITEM Coalition.

CMS argued that setting specific guidelines could unnecessarily exclude beneficiaries from the benefit.

But without such guidelines, suppliers have no idea whether patients qualify or not, and must eat high costs as a result, attendees maintained.

CMS wouldn't confirm whether the coverage criteria require beneficiaries to be "totally non-ambulatory" or "usually totally non-ambulatory." Such terms aren't in the national coverage policy and are set by DMERCs, officials demurred.

When Doug Harrison of The Scooter Store said leaving coverage as a gray area and letting DMERCs define policy meant the most restrictive criteria would be used, CMS denied it.

CMS also insisted that despite supplier complaints, the "vast majority" of wheelchair claims are being paid on time. Claims that aren't being paid quickly are usually due to the supplier failing to furnish required documentation, officials said.

Tip: CMS stressed that suppliers striving to en-sure complete documentation should be sure medical records, particularly doctors' progress notes, are "contemporaneous" or "simultaneous" with the ordering of the wheelchair.

After nearly two hours elapsed, CMS promised to hold future meetings on the topic.