Wednesday, August 8, 2012

Prior Authorization To Be Required for Power Wheelchairs in NC

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The Center for Medicare and Medicaid Services has announced a controversial power wheelchair prior authorization demonstration on September 1.  North Carolina is one of seven states where the demonstration will be held. CMS has chosen North Carolina because of the strong history of fraud and improper payments for power mobility devices.  In September 2009, four Raleigh Individuals were charged with more than 12 million in Medicare fraud for motorized scooters, powered wheelchairs and other medical equipment claims since 2007. The prior authorization hopes to encourage either suppliers or physicians to submit documentation and a written order for the item to Durable Medical Equipment Medicare Administrative Contractors or face lower reimbursement. CMS aims to stop people like the four Raleigh residents from committing fraud again. However, there are still many industry stake holders that believe the demonstration could make wheelchairs less accessible to those that need them.
The American Association for Homecare believes that the demonstration’s design could make wheelchair access difficult, because CMS did not include a clinical necessity template for doctors to properly and consistently document patient need. The Association continuously urged CMS to adopt a template, but CMS maintained that the current documentation these states used had a “92 percent error rate for power wheelchairs that did not meet Medicare coverage requirements” according to their 2010 Comprehensive Error Testing Program Report. The American Association for Homecare does not believe that the absence of a template will fix the problem and conversely, this absence could make it more difficult for those who need wheelchairs to obtain them. However, CMS has opted to continue the demonstration without the template.
CMS hopes to provide a more accurate assessment through an expedited authorization process and resubmission process. Under the demonstration, CMS will provide expedited 48 hour authorization, if the doctor says the current timeframe of 10 days could jeopardize the patient’s health.  If a claim is denied the supplier or doctor is free to resubmit the claim within 20 business days of the prior decision. 
To insure that suppliers comply with the demonstration, after the first three months, a supplier with an approved claim for a wheelchair but did not go through prior authorization will face a 25 percent payment cut. The claim will also be subject to medical necessity review. This cut cannot be appealed and will not be passed on to the consumer.
CMS’ expectations for the demonstration include improved methods for the investigation of fraud, lower payments for those in need of power chairs and the reduction of the claim error rate. To find more information on CMS demonstration, see the CMS website directed at addressing questions concerning the demonstration.  

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