WASHINGTON — More than half of power wheelchairs provided to Medicare beneficiaries in the first half of 2007 had claims that lacked sufficient documentation to determine medical necessity, the Department of Health and Human Services Office of Inspector General said July 7.
Based on its review of a 375-claim sample, an OIG report showed 9 percent of the PWCs were medically unnecessary, and another 52 percent had claims that were insufficiently documented.
The report, "Most Power Wheelchairs in the Medicare Program Did Not Meet Medical Necessity Guidelines," is the OIG's latest based on the same 2007 sample. Two previous OIG reports found problems with PWC claims coding and documentation.
"Across all three reports, 80 percent of claims for power wheelchairs supplied to beneficiaries in the first half of 2007 did not meet Medicare requirements," the OIG stated.
But that was in 2007, HME advocates point out, immediately following CMS' overhaul of the power mobility benefit, which in turn was followed by a raft of clarifications that left mobility providers waiting on additional guidance about exactly what documentation was required to support power mobility claims.
They're still waiting, said The MED Group's Tim Pederson, former chair of the American Association for Homecare's Complex Rehab and Mobility Council.
"There was a lot of confusion in the industry then, and I think there still is today," Pederson said. "The report says half of the claims in 2007 didn't meet medical necessity requirements, but if you look into the detail of it, the lack of documentation by the physician in the patient's medical record is by and large the biggest culprit, and we still have a lot of questions about what is acceptable documentation.
"We don't have any more clear guidelines about documentation now than we did then," he said.
According to the OIG report: "Seventy-eight percent of claims without supplier-record errors were not supported by records provided by physicians who prescribed the power wheelchairs. That is, while suppliers' records indicated that power wheelchairs were medically necessary, physicians' records indicated that they were medically unnecessary, or physicians' records provided insufficient documentation or no documentation of medical necessity. In most cases, physicians' records had insufficient documentation to support the medical necessity of power wheelchairs."
"We can't help but fail because they are measuring the wrong stuff," said Pederson, who recently sold South Dakota-based WestMed Rehab and now heads MED's O&P network. "What they should be looking at is what kind of effort CMS is making to educate physicians …
"Until that gets addressed, we are going to see these reports and audits look really, really bad."
The OIG report also noted that "although CMS has taken steps since 2007 to decrease errors among suppliers of power wheelchairs and other DME, Medicare has paid significantly more in recent years for power wheelchairs than it did in 2007. These increases may indicate that CMS continues to pay for power wheelchairs that are not medically necessary and/or that have claims that do not meet documentation requirements."
As a result, the OIG made four recommendations, one being enhanced reenrollment screening for current DME suppliers.
"Federal regulations place new DMEPOS suppliers at a risk level of 'high,' whereas currently enrolled DMEPOS suppliers are placed at a risk level of 'moderate,'" the report said. "We believe that currently enrolled DMEPOS suppliers should be subject to the same enrollment screening standards as newly enrolling DMEPOS suppliers and should also be placed at the risk level of 'high.'"
CMS disagreed, noting that it has other tools that allow increased scrutiny of current suppliers. But the agency agreed with the OIG's additional recommendations that it should:
- review records from sources in addition to the supplier, such as the prescribing physician, to determine whether power wheelchairs are medically necessary;
- continue to educate power wheelchair suppliers and prescribing physicians to ensure compliance with clinical coverage criteria; and
- review suppliers that submitted sampled claims we found to be in error.
AAHomecare, which has long argued that Medicare documentation requirements for PWCs are confusing, inconsistent and too complex, had a quick reaction to the report.
"Not only is the OIG report misleading, the OIG continues to draw the wrong conclusions from the results of the study," said the association's Walt Gorski, vice president of government relations, in a statement issued Thursday afternoon. "Government bureaucrats are overturning physicians' medical judgment more than six out of every 10 times. When the so-called error rate does not decrease despite continued efforts to educate providers over a period of several years, CMS and the OIG must look to simplify the coverage policy and inject common sense back into the auditing process."
In a following blog, Gorski added that "power wheelchair providers are being put into a position of educating physicians on a very complex policy and then judging the physician's medical record competency. This should not be the power wheelchair provider's role."
The report validates what AAHomecare has been advocating for years, the blog said: "Lawmakers need to hold CMS accountable to establish clear and objective guidance to the physician community in the power mobility benefit."
But Sen. Thomas Carper, D-Del., also issued a statement about the OIG report that shows another view.
"When we see that more than half of Medicare's payments for power wheelchairs in a given time failed to meet the appropriate standards required for reimbursement, we know that something is very wrong and that the federal government can and must do better," Carper said.
Last month, Carper and Sen. Tom Coburn, R-Okla., introduced the Medicare and Medicaid Fighting Fraud and Abuse to Save Taxpayers Dollars Act (S. 1251), or the FAST Act, which includes a provision that requires increased screening for Medicare providers. It also requires prepayment screening for all power wheelchairs and other DME "susceptible to fraud."
On July 12 (Tuesday), the Senate Subcommittee on Federal Financial Management, which Carper chairs, will hold a hearing on Medicare fraud and abuse.
Download a PDF of the 55-page OIG report.
Read Carper's full statement.