BALTIMORE--A victory some industry stakeholders thought they had gained turned to disappointment on March 31 at a special CMS Open Door Forum on Medicare power wheelchair policy.
Since Dec. 9, when the DMERCs issued a clarification of power wheelchair coverage, mobility leaders have vigorously opposed the policy. Some claim the clarification represented a change in reimbursement policy and restricted access to beneficiaries who need the equipment. CMS and DMERC officials, however, maintained that the clarification--issued as part of Operation Wheeler Dealer to curb fraud and abuse of the power wheelchair benefit--did not change long-standing policy and gave consistency to the four DMERCs' application of coverage criteria.
A mid-March notice from CMS retracting the DMERC article--stating the agency would continue to pay claims as it had "prior to and following" the clarification--seemed to confirm the industry stance. Some advocates, then, anticipated the Open Door session would provide further explanation and might better define the medical conditions required for power wheelchair coverage.
And though participants said they appreciated last Wednesday's discussion with CMS, many were not happy with the results.
Eight Themes
HME providers, manufacturers, representatives from consumer groups and other interested parties turned out to take part in the session, held at the agency's Baltimore headquarters with the four DMERC medical directors and CMS staff. About 50 people attended in person, while another 667 participated by phone.
The agency announced that its crackdown on power wheelchair fraud has resulted in 150 cases being referred to law enforcement, so far resulting in six convictions and eight indictments. CMS also identified eight major themes gained from the prior listening sessions that deserve attention, including:
1. Confusion over the scope of the DME benefit;
2. Criteria for medical coverage of power wheelchairs;
3. Use of power wheelchairs outside the home;
4. Appropriate beneficiary access;
5. Physicians' judgment in ordering power chairs;
6. Documentation requirements;
7. Supplier education and training; and
8. Certification of power wheelchair providers, an issue that may be considered as CMS implements provisions in the Medicare Modernization Act that require supplier accreditation. (See "CMS Prepares to Form DME Advisory Committee.")
But central discussion in the two-hour forum focused squarely on interpretation of national policy language and whether the beneficiary is "bed- or chair-confined."
"I'm sure you feel we've been a bit obtuse," said Richard Lawlor, director of CMS' Open Door Initiative. "We've spent the last couple of months distilling [all the] feedback we've gotten," he said, referring to information gained from two listening sessions on the issue held Feb. 24 and March 3.
But according to the officials at the meeting, CMS cannot give a more specific definition of its policy language. "Being more specific than the national policy, by definition, will take control away from physicians," said Timothy Hill, director of CMS' Office of Financial Management. "A more precise definition ... will make the circle [of those who qualify for a power wheelchair] smaller and smaller."
CMS staff members said that physicians "have the right to order whatever [they] want for the beneficiary," but added that the agency has the "fiduciary responsibility" to review the order to determine whether it meets Medicare coverage criteria.
As for documentation, physician notes will continue to be an important part of the process, the agency's representatives said. HME supplier documentation must corroborate physician documents and medical records, CMS staff added, explaining that although at times CMS does talk to the beneficiary directly, "from our viewpoint, the supplier accepts payment for these services" and so should ensure all documentation requirements are met.
CMS also believes the current power chair policy provides appropriate beneficiary access to such equipment. If providers have had specific instances that would prove otherwise, "we need to hear about it. We want to hear specific occurrences," said one official.
When a provider at the session said that the DMERC clarification had created access problems, Hill responded: "Evidence belies that statement. There has been a 300-percent increase in the last three years [of power wheelchair utilization]. Over any period of time, 90 to 95 percent [of those claims] are paid." If there were a beneficiary access problem, Hill continued, "those numbers wouldn't be what those numbers are."
As for the DMERC clarification, CMS' Lawlor stated that it did not represent a change in policy and added that the Dec. 9 article had been retracted only because the confusion it caused became "counterproductive" to understanding Medicare's power wheelchair coverage.
Industry Reaction
According to an April 1 report on the meeting from the Alexandria, Va.-based American Association for Homecare, the association "had hoped that the meeting would provide some clarity to the issues since CMS' statement to Congress on March 18 indicated that the [DMERC] article had been retracted."
The report continued, "AAHomecare is disappointed that CMS did not provide any information to indicate that the restriction of access to power wheelchairs has been resolved. In their words, the retraction of the clarification was simply a retraction of an article intended strictly for educational purposes of provider and Medicare beneficiaries and in no way changed the pre-existing medical coverage policy."
Having no clear answer defining coverage leaves "tremendous uncertainty" for providers, said Cara Bachenheimer, vice president of government relations for Elyria, Ohio-based Invacare. "[The meeting] was extremely disappointing. CMS is maintaining the same position as it has from day one," she said.
"I walked away with a realization that there are probably more questions than there are answers," said Rita Hostak, vice president of government relations for Sunrise Medical and president of NCART (National Coalition for Assistive and Rehab Technology). "We need some kind of clear policy that indicates what patients are covered."
Having no clear definition of coverage criteria could cause "any claim to be denied for any reason because of the lack of guidance," said Eric Sokol, president of the Washington, D.C.-based Power Mobility Coalition. "Now, coverage policy is inconsistent, unpredictable and unfair. [CMS is] totally disregarding a standard part of the CMN [asking if the beneficiary] needs the use of the chair to perform activities of daily living in his residence. The agency is reverting back to a 1985 provision [requiring power wheelchair beneficiaries to be bed- or chair-confined], but they can't define what that really means."
Bachenheimer said the root of the problem lies with CMS' strict interpretation of policy language. A short-term goal, she said, is to communicate that "bed- or chair-confined" should be construed to mean "functional nonambulation," where the user's ability to perform activities of daily living in the residence is restricted. A long-term goal, she said, is to change the K0011 national coverage policy itself.
Hostak agreed, pointing out that the process for such changes could take 18 months or more. "The industry can't take this lack of understanding for that long," she said. "We need to push for some interim clarification of the policy that ensures access."
Lawlor said CMS is planning a future Open Door Forum to be held in Washington, D.C., specifically to hear from beneficiaries impacted by the DMERC article. Because of the many comments from those who attended last week's session in person, phone participants did not have the opportunity to ask any questions.
Comments to CMS from beneficiaries and physicians could help, said Seth Johnson, AAHomecare's director of public policy, pointing out that many of the 600-plus participants on the phone were consumers and physicians.
"Just the number of people on phone speaks volumes on the impact this DMERC article is having," Johnson said. "Clearly, there is an access problem."
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