The data is from 2007 and the trouble rests with physician education, HME advocates say, but will government officials care about that?

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;
  • 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

"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 target="_blank">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 target="_blank">AAHomecare's blog on the report.

Read target="_blank">Carper's full statement.