Kevin Lyons

About six of every 10 power wheelchairs provided to Medicare beneficiaries were medically unnecessary or lacked enough medical documentation to prove they were needed, according to a report from the Office of the Inspector General (OIG) at the U.S. Department of Health and Human Services.

An executive at the American Association for Homecare, whose members include companies that sell power wheelchairs, calls the report “misleading.” Walt Gorski, vice president of the trade group, says the OIG findings include paperwork errors made by medical professionals who were coping with a Medicare payment system that had undergone a massive overhaul several months earlier.

Power wheelchairs are advertised heavily on TV; the ads typically stress that the equipment is covered by Medicare.

Because of lack of medical need or lack of proper paperwork, about six of every 10 power wheelchairs that went to Medicare recipients should not have been approved, according to a federal review of claims from 2007.

The federal Medicare program provides health insurance to about 46 million Americans.

OIG: $95 million spent on ‘wrong’ equipment

OIG investigators — acting as watchdogs within the Department of Health and Human Services — reviewed 375 claims for power wheelchairs that were supplied to Medicare recipients in the first half of 2007. The OIG determined 9 percent of power wheelchairs were medically unnecessary; another 52 percent of claims for power wheelchairs lacked enough medical documentation to prove the equipment was needed.

In total, Medicare paid about $189 million for power wheelchairs during the first half of 2007, but $95 million went toward power wheelchairs that weren’t needed, according to the OIG report. Medicare reimburses most of its suppliers $5,000 to $10,000 for each power wheelchair, according to the report.

“Regardless of whether a more expensive or less expensive power wheelchair was needed, Medicare paid for the wrong equipment to meet these beneficiaries’ needs,” the OIG report says.

Industry representative: Simplify payment process

Gorski says Medicare’s approach to assigning billing codes to power wheelchairs is so complex that errors are likely to be made.

“The power wheelchair coverage policy is the most complicated policy of all from the durable medical equipment segment. There are so many facets, and it can be so subjective that a claims reviewer could deny any claim for power mobility based on his or her mood,” Gorski tells InsuranceQuotes.com.

Gorski says the OIG and the federal Centers for Medicare & Medicaid Services “must look to simplify the coverage policy and inject common sense back into the auditing process.”

In its report, the OIG says it didn’t try to determine whether claims were given correct billing codes or whether they met “non-clinical documentation requirements,” although it has acknowledged previously that nearly one of every 10 power wheelchair claims was miscoded, and 60 percent didn’t meet documentation requirements.

Necessary or unnecessary?

Before providing a patient with a power wheelchair, a supplier must receive medical evidence from a doctor. The suppliers then bill Medicare for reimbursement. Power wheelchairs are covered if they are medically necessary for a patient to perform everyday activities that they otherwise wouldn’t be able to do with a cane, walker, manually operated wheelchair or mobility scooter.

The OIG provided several examples of power wheelchair claims that it considered unnecessary.

In one instance, a supplier of a power wheelchair provided a letter from a physician stating, among other things, that a patient was recovering from knee replacement surgery, was obese, was unable to walk safely with a cane or walker, was unable to propel a manual wheelchair because of severe pain, had severe osteoarthritis, had a history of brain surgery and had poor balance.

But the physician’s records about that patient noted the Medicare recipient had adequately recovered from knee replacement surgery and would need only a cane or a walker. Still, this patient received a power wheelchair, the OIG report says.

Recommendations for improvement

The OIG made several recommendations for the Centers for Medicare & Medicaid Services (CMS), such as:

• Enhance Medicare screening standards for current suppliers of durable medical equipment (such as power wheelchairs), prosthetics, orthotics and related supplies.

• Review records from sources other than suppliers, such as prescribing physicians, to determine whether power wheelchairs are medically necessary.

• Beef up continuing education for power wheelchair suppliers and prescribing physicians.

In a written response, CMS agreed with the OIG on all but the first recommendation, saying it already has tools for improved screening of its current suppliers.

“The CMS continues to support efforts to reduce improper power wheelchair payments, including increased prepayment reviews of power wheelchairs,” wrote Donald Berwick, administrator of CMS. “Moreover, CMS plans to pursue additional provider and supplier education to ensure suppliers and prescribing physicians understand Medicare’s coverage and documentation requirements for power wheelchairs.”

Follow Kevin Lyons on Twitter: twitter.com/stakingaclaim.

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