Advanced Search

Home Health & Hospice Week

Coverage:

Wheelchair Changes Increase Medicare Costs, Industry Says

Published on Thu Feb 05, 2004

The power mobility industry has a host of complaints against Medicare's recent so-called clarification to wheelchair coverage policy (see story, "Coverage: New Coalition...."). Here are some of their major beefs:

  • Non-ambulatory definition changed. Medicare covers wheelchairs for beneficiaries who are non-ambulatory, but under the new policy the definition of non-ambulatory appears to have changed, notes the Power Mobility Coalition in a Dec. 23 letter to the Centers for Medicare & Medicaid Services.

    For about eight years, durable medical equipment regional carriers have covered wheelchairs for beneficiaries who needed them to complete activities of daily living (ADLs), notes former DMERC Medical Director Dr. Paul Metzger, now executive vice president of medical affairs for The Scooter Store in New Braunfels, TX.

    Medicare's certificate of medical necessity (CMN) for wheelchairs reflects that interpretation, with a question on whether the patient needs a wheelchair to conduct ADLs within the home, the PMC notes.

    The new policy indicates that beneficiaries will be considered non-ambulatory, and thus eligible for a wheelchair, only if they are completely confined to the bed or chair. That change means tens of thousands of Medicare beneficiaries will lose access to power mobility equipment, the Restore Access to Mobility Partnership says in a release.

  • Neuro and cardio patients excluded. The new definition of non-ambulatory means that patients who are technically able to be mobile based on limb strength, but shouldn't move for cardiopulmonary reasons, also aren't covered for wheelchairs under Medicare, Metzger says. And patients whose mobility waxes and wanes, such as those with multiple sclerosis, wouldn't be covered either, RAMP notes.

  • Extra costs to follow. Besides depriving beneficiaries of mobility, the new policy change also is likely to result in increased costs, RAMP says. Beneficiaries who can't get around in their homes will be forced into nursing homes. And those who want to try to stay in their homes anyway are more likely to suffer falls and fractures without mobility equipment.

  • CMS sidestepped notice procedure. What has suppliers and consumer groups most up in arms is the way CMS went about effecting this change. Instead of issuing a local medical review policy or other type of notice and soliciting comments, CMS is pretending that the drastic change is merely a "clarification" of existing policy. They are "in absolute disregard of the due process established by CMS and the DMERCs themselves for changing medical review policies," Metzger insists.

    "They claim to be 'clarifying' existing policy in order to avoid the essential opportunity for [suppliers] to offer comments to the clinical advisability of policy restriction," Metzger says in the letter.

    The so-called clarification is actually "a coverage restriction," judges Invacare's Cara Bachenheimer.

  • Retroactivity. Because CMS is casting the change as only a clarification, it is retroactive. The change "is a clarification of national policy," CMS and the DMERCs said in the December notice. "All DMERCs are strictly enforcing these coverage criteria and applying them to all claims reviewed regardless of the date of service or date of submission." That means even if a beneficiary qualified for the wheelchair at the time, your claims may now be denied based on the new criteria.

  • Physicians, paperwork devalued. The policy change also seems to take the decision-making out of physicians' hands and puts it squarely in medical reviewers' purview, the PMC says in its comments. Likewise, the physician filling out the CMN seems to have no bearing on the new policy, the PMC complains.

  • Real fraud and abuse left untouched. While the change is likely to keep suppliers from furnishing wheelchairs to thousands of beneficiaries who need them, it won't do much to keep true fraudsters from billing for equipment they never deliver and conducting other scams. "This new policy does little to impact bad players and much to harm innocent beneficiaries who need power wheelchairs to maintain their independence and quality of life," RAMP says.

    • Other Articles in this issue of

    Home Health & Hospice Week

    View All