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Medicare Compliance & Reimbursement

DME:

IR Review A Certainty For Operation Wheeler Dealer

Published on Thu Oct 02, 2003

Power wheelchair use should be on the rise, disability advocates say. 

The double threat of reduced reimbursement and more restrictive coverage guidelines hangs over medical suppliers' heads as the feds gear up for Operation Wheeler Dealer.

Dealers and manufacturers hoping to glean more details about the fraud-fighting initiative targeting power wheelchairs and scooters were sorely disappointed by a Sept. 11 special open door forum on the issue. The Centers for Medicare & Medicaid Services briefly reviewed the astronomical spending increases for the mobility devices, then took comments only on the rather vague 10-point plan to tackle power wheelchair fraud it issued the previous week. CMS officials declined to answer questions about the project.

In a brief appearance on the call, CMS chief Tom Scully did say there was no doubt that wheelchairs would be at the top of the list for inherent reasonableness review. "It's not optional," Scully told listeners.

But cuts are not guaranteed. Based on the review, CMS may keep reimbursement levels the same or even add to them if warranted, Scully noted.

Scully was responding to several meeting attendees who insisted that IR cuts to wheelchair and scooter rates would have little to no effect on fraud and abuse of the items. "The only people you're going to hurt by that are the honest legitimate people that are left" in the wheelchair industry, insisted Doug Harrison, founder and president of The Scooter Store, representing the Power Mobility Coalition.

Fraudsters who furnish no equipment when billing for expensive chairs or furnish low-end equipment at high-end prices will still see huge profits even if Medicare reduces power wheelchair payment rates by 15 percent, Harrison said. Honest, law-abiding providers' businesses would be slammed down to "near non-existent profit margins."

The current reimbursement rate goes to cover services such as evaluations by occupational therapists and other clinical services, pointed out Meir Raskas of Advanced Medical Concepts, a Baltimore, MD supplier. Raskas implored CMS not to take a "shotgun approach" to wheelchair pricing that would harm legitimate suppliers. It's crucial "that the reimbursement and the good apples in our industry are not affected by the clean-up," Raskas maintained.

Hard Line Could Lead to Hard Time 

CMS stressed that the agency is taking a hard line on fraud and abuse of these mobility products, but assured listeners that compliant suppliers had nothing to fear from the crackdown. Honest businessmen "have no reason to be concerned about these measures we're taking," one CMS official said.

Commenters both attending the meeting in person in Baltimore and calling into the conference were less sure of the initiative's unintended consequences, however. In addition to IR cuts, restrictive coverage guidelines and medical review policies could harm legitimate providers' businesses, participants said.

"I hope that CMS does not paint this with a broad brush," Tom Kruse, president and CEO of Hoveround Corp., told officials. Kruse asked CMS to resist making new rules, based solely on fraudulent suppliers' practices, which would restrict access to mobility products for beneficiaries who need and qualify for them.

"If CMS really knows who these [fraudulent providers] are, why the blanket tactics?" asks health care attorney Elizabeth Hogue. The 10-step plan outlined by CMS and the HHS Office of Inspector General "will definitely adversely impact a number of ethical providers in terms of payment delays and suspensions," Hogue says.

Other issues of concern included:

  • Utilization limits. CMS expressed shock that utilization of power wheelchairs shot from 55,000 Medicare beneficiaries with power wheelchair claims in 1999 to 159,000 in 2002. But a good deal of that increase may be legitimate, and Medicare shouldn't shut the door on beneficiaries acquiring needed equipment, participants said.

    Mobility equipment has become much more practical and useful in the home setting, with smaller sizes and higher levels of maneuverability, said Dan Meuser, President of Exeter, PA-based manufacturer Pride Mobility Products Corp. New products since 1997 "truly change the paradigm of mobility" due to these advances, Meuser said.

    And initiatives to move people out of institutions and into the home and community setting, in compliance with the U.S. Supreme Court's Olmstead decision, also have sparked increases in mobility product sales, said Laura Williams, president of Californians for Disability Rights.

    "Don't be throwing the baby out with the bathwater," Williams told CMS. The agency should expect mobility utilization to increase as beneficiaries move settings.

  • Provider number freeze. CMS is putting a halt to issuing new supplier provider numbers as it beefs up the screening process for new applications. Durable medical equipment regional carrier Palmetto GBA confirms on its Web site that the freeze until early 2004 applies to all suppliers, not just those furnishing power wheelchairs and scooters.

    Additionally, "until further notice from CMS, this hold on issuing supplier numbers applies to all applications," Palmetto says. That means both new applications and those potential suppliers already have submitted are suspended.

    That suspension could unfairly penalize legitimate providers, especially those that are in the process of acquiring new locations and continuing service to those locations' customers, said Kim-berlie Rogers-Bowers of Lake Forest, CA-based Apria Healthcare Group Inc. Holding up provider numbers for such organizations could put a "tremendous strain" on them, she warned.

    "It seems unfair to applicants who may have a lot of money riding on their ability to start billing Medicare according to their business plan," Hogue adds.

  • Physician and beneficiary education. Suppliers certainly agreed with CMS that physicians and beneficiaries need to understand the rules regarding Medicare payment for mobility equipment. A caller from Wheelchairs Plus in Jacksonville, FL cited instances where beneficiaries walk into the store with a prescription for a wheelchair, but obviously do not qualify. "It makes us the bad guys" to tell them Medicare won't cover the equipment, the caller said.

    "From the perspective of many dealers, physicians and beneficiaries are the problem," Hogue maintains. "They often don't understand the rules, don't care about the rules and just want patients to have what they 'need.'"

    In fact, "if physicians and patients were in charge, CMS would see what overutilization is really all about," Hogue exclaims.

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