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Mobility Providers Ask White House to Address Gross Mismanagement of Mobility Benefit

Author: American Association for Home-care

Published: 2011-02-10

Synopsis and Key Points:

Attention must be focused on the Centers for Medicare and Medicaid Services supervision of the Medicare power mobility benefit.

Main Digest

As the Obama administration embarks on improving the efficiency of government agencies, attention must be focused on the Centers for Medicare & Medicaid Services' (CMS) supervision of the Medicare power mobility benefit. The White House would be hard pressed to find a government operation more outdated, mismanaged and wasteful of taxpayer dollars.

In fact, recent audits by the government's own contractors demonstrate the extent to which CMS has failed to provide proper administration of this important benefit.

Power wheelchairs save taxpayer funds by curtailing emergency room visits caused by fall-related injuries, while also allowing Medicare patients to age at home rather than being admitted into costly nursing homes. Yet, CMS policies and guidelines continue to make it more difficult, rather than easier, for seniors and people living with disabilities to obtain mobility assistance.

While problems associated with competitive bidding and ending the first-month purchase option for beneficiaries have dominated headlines over the last few months, other issues also plague providers, physicians and beneficiaries: the process for documenting a Medicare beneficiary's medical necessity for a power wheelchair and the claim approval process remain in total disarray.

The most frustrating part for stakeholders is that these problems are not new. Over the last decade, CMS has failed to design a system that adequately documents the medical need for senior citizens and people living with disabilities to receive power wheelchairs. CMS has continuously tinkered with the process, but each change has resulted in more confusion and headaches for the stakeholders - providers, physicians and beneficiaries.

At question is what method should be utilized to document medical necessity. The second, and related issue, is what criteria CMS contractors should use when reviewing reimbursement claims presented by medical equipment providers after delivering power wheelchairs to Medicare patients.

With the level of technology available today, neither of these objectives should be major hurdles. Unfortunately, the government hasn't delivered workable solutions. In fact, recent audit reports by their Durable Medical Equipment Medicare Administrative Contractors (DME MACs) demonstrate not only the extent to which the government has failed to provide a reasonable process, but also call into question the competency of Medicare's payment system for medical equipment providers.

From December 2008 until November 2010, the DME MACs, who administer Medicare claims for CMS, conducted 11 industry-wide audits of reimbursement claims from their four geographical regions. The results were astounding. In their published reports, the DME MACs said that out of 7,309 claims, 5,977 were denied for an error rate of 82 percent.

In a November 2009 executive summary of an improper payments report, CMS specifically stated that the error rates are not related to fraud, but "may be an indication of a program weakness that requires more oversight and diligence by CMS." That is a gross understatement. The reimbursement process for the mobility benefit is so riddled with subjectivity and confusion that providers and physicians don't know how to comply with the criteria that is established, and frequently changed. The long history of the documentation and audit issues clearly pinpoint CMS as the culprit, while providers, physicians and beneficiaries have been the victims.

The denial rate for claims has been high not just in DME MAC audits, but also for most audits conducted on mobility assistance providers, such as those conducted by the U.S. Department of Health and Human Services' Office of Inspector General. At times, CMS has introduced new criteria for submitting claims and then absurdly applied the changes retroactively to deny previously approved reimbursements for power wheelchairs delivered before the new standards were even applied.

Another key indicator of how poorly the claims are processed is that providers are often successful when appealing denials to Administrative Law judges, allowing providers to eventually be paid. But this has created cash flow nightmares for providers, who now face severe financial ramifications from the controversial competitive bidding program, as well as the end of the first-month purchase option. As a result, some providers are no longer selling standard power wheelchairs or going out of business, making it more difficult for Medicare beneficiaries, especially those in rural areas, to obtain the medical equipment prescribed by their physicians.

At the heart of the issue is the role of physicians. CMS has requested that doctors make handwritten progress notes on their patients, documenting over time the increasing need for mobility assistance. This documentation must be presented to prove medical necessity. But physicians vary widely in what they write on patient progress notes, leading to broad discrepancies over what patient chart notes will be available in individual cases. While health care reform is supposed to give patients better access to physicians, as well as better care, the CMS claims process creates an unhealthy environment where claim review contractors are overruling the clinical assessments made by physicians. Doctors prescribe power wheelchairs after mandated face-to-face examinations of their patients, yet CMS treats the doctors as if they don't know what they are doing.

Even more absurd is that many claims are denied, not because of questions related to medical necessity, but because the physician documentation was presented in a format deemed undesirable by CMS. For instance, physicians are encouraged not to submit prepared forms to help describe why their patient needs a power wheelchair to ambulate in their home, despite the fact that such forms are universally used in medicine. Physicians must "write" their prescriptions and not even a beneficiary's name can be pre-printed. Claims are also being denied if the physician's signature is not legible. More importantly, CMS has ordered that "clinical inference" can't be considered by claim reviewers, meaning that physicians must document every specific element of the algorithm in patient clinical records or claims will be denied. This change, as well as the others cited, are being applied retroactively during audits and are contributing to the high number of denials.

The entire claim review process is far too subjective, when objectivity is needed. Physicians are not trained to document information the way that CMS is requesting it, they aren't compelled to change and what CMS is asking is contrary to their common practices. Furthermore, the rules of the game keep changing, and mobility providers, Medicare beneficiaries and physicians become more and more frustrated with the process. "Instead of helping me in my mission to keep my patients functional at home, CMS or Medicare throws stumbling blocks in my way at every turn it seems," laments Dr. Jerald Winakur, M.D., F.A.C.P., C.M.D., a Clinical Professor of Medicine at the Center for Medical Humanities and Ethics at the University of Texas.

Tyler Wilson, president and CEO of the American Association for Home-care, said that CMS can't expect physicians to follow rules and regulations that they don't understand. "Two things are apparent," Mr. Wilson said. "Some of the things that CMS is asking of the nation's physicians are unreasonable considering the technology that we have available today, and there absolutely must be broader and more effective outreach that educates physicians on how to comply with the rules. The doctors are refusing to buy into a system that doesn't make much sense to them."

Wilson noted that if the White House is serious about reinventing government, reviewing how the power mobility benefit is administered is the place to start.

Mobility Matters is published periodically by the American Association for Home-care to inform Congress, the administration, policymakers, consumer organizations and the media about Medicare's power mobility benefit, and the need to sustain it. To learn more about the Medicare power mobility benefit, go to www.aahomecare.org/mobility.

The American Association for Home-care represents durable medical equipment providers, manufacturers, and other organizations in the home-care community. Members serve the medical needs of millions of Americans who require oxygen equipment and therapy, mobility assistive technologies, medical supplies, inhalation drug therapy, home infusion, and other medical equipment and services in their homes. The Association's members operate more than 3,000 home-care locations in all 50 states. Visit www.aahomecare.org/athome. 2011 Crystal Drive, Suite 725, Arlington, Virginia 22202; 703.836.6263.

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