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.
