Medicare Compliance & Reimbursement

Feds vow to crack down on those who are riding away with Medicare's money. 

The feds are on the warpath over power wheelchair fraud, and it's law-abiding suppliers who could get caught in the crossfire.

In addition to implementing a 10-point plan to curb fraud and abuse of the Medicare program regarding power wheelchairs and scooters, the HHS Office of Inspector General is investigating "the proliferation of durable medical equipment (DME) fraud cases involving inflated billings to Medicare, charges for equipment and supplies not delivered, and the falsification of documents to qualify beneficiaries for wheelchairs and other equipment that they often did not need."

Offers of free equipment, as well as other enticements to beneficiaries and physicians, feature prominently in the "fraudulent schemes" for DME, says Acting Principal Deputy Inspector General Dara Corrigan. Corrigan threatens fraudsters with fines, jail time and exclusion from the Medicare program.

Medicare motorized wheelchair payments skyrocketed from $289 million in 1999 to $845 million in 2002. That figure is projected to shoot to $1.2 billion in 2003. And the number of Medicare beneficiaries with at least one claim for a motorized wheelchair surged from 55,000 in 1999 to 159,000 in 2002.

The Centers for Medicare & Medicaid Services' "nationwide clean-up campaign" will start in the Houston area, where widespread improper wheelchair spending has been uncovered, the feds say.

Here's the plan:

1. CMS will immediately begin scrutinizing all new applications for supplier numbers, freezing any new supplier numbers until early 2004.

2. CMS will publish regulations beefing up the supplier application screening process. The regs will give CMS more time to review applications and set out sanctions against suppliers abusing the enrollment process.

3. CMS staff on a special task force will personally and individually approve all payments for motorized wheelchairs in the Harris County, TX area.

4. All wheelchair suppliers in Harris Coun-ty, TX must attend mandatory training on wheelchair coverage and medical review policies.

5. CMS, DME regional carriers (DMERCs), and law enforcement agencies will collaborate to process fraud cases and assure aggressive, timely application of sanctions, and civil or criminal prosecutions. CMS will use payment suspensions "to stop the improper hemorrhaging of Medicare dollars."

6. CMS will finalize regulations revising the coverage policy for motorized wheelchairs and scooters. This policy will require, for the first time, that the medical provider see the patient before prescribing a wheelchair or scooter.

However, the medical provider may prescribe either a motorized wheelchair or a power-operated vehicle. Under existing policy, only a specialist may prescribe a POV.

7. DMERCs will immediately adopt Local Medical Review Policies (LMRP) that accurately portray the clinical conditions for which mobility products are reasonable and necessary.

8. The DMERCs will adopt a consistent approach to medical review so national billing problems are resolved in a consistent manner.

9. CMS will develop inherent reasonableness review guidelines, with motorized wheelchairs set as the first item analyzed for potential IR cuts.

10. CMS will work with physicians to clarify their prescribing responsibilities, and with beneficiaries to explain their role and Medicare coverage criteria.

Editor's Note: The announcement of the initiative and the full language of the 10-point plan are at http://oig.hhs.gov/publications/docs/press/2003/090903release.pdf.