Open Door Session Opens Power Mobility Can of Worms

BALTIMORE–HME stakeholders and CMS officials engaged in a
heated discussion about the agency’s overhaul of Medicare’s
mobility benefit at a special Open Door Forum on Tuesday.

More than 500 callers jammed the phone lines and 45 to 55
appeared in person at the three-hour session, which focused on an
interim final rule released last month that eliminates the current
power mobility CMN. Instead, the proposed rule requires providers
to submit a physician’s prescription with their reimbursement
claims–and, if asked, to supply documentation from the prescribing
practitioner about the patient’s condition that supports medical
necessity for the equipment. (See HomeCare
Monday, Aug. 29).

With a number of other new mobility policies set to take
effect–including the implementation of new codes and pricing on
Jan. 1–some meeting attendees said CMS is rushing the rule, which
is currently scheduled to become effective Oct. 25.

Implementation should be delayed until at least April 1, 2006,
according to Dan Meuser, president of Exeter, Pa.-based Pride USA.
“Folks, providers cannot adapt to this rapid change in this time
period,” Meuser told CMS officials, citing provider concerns about
retooling billing systems to the new requirements, concerns the
DMERCs will not be able to adjust their own claims processing
systems and a widespread lack of education in the medical community
about physicians’ new role in the process. “We need for you to
truly consider a delay so we transition again in an orderly way as
opposed to a rush to disorder,” Meuser said.

CMS’ Richard Lawler said the agency is “listening” to that
request.

Another forum attendee said it is inappropriate to require
equipment providers who are not medically trained to gather patient
medical records from physicians, and then to hold providers
responsible for deciding whether the prescription and documentation
physicians supply is appropriate.

As “laymen,” non-clinician suppliers are not qualified to make
these medical evaluations, said Doug Harrison, president of The
Scooter Store, New Braunfels, Texas, the nation’s largest power
mobility supplier. “Imagine the outcome if pharmacists first
requested physician’s chart notes from a patient, then analyzed
those notes, and finally, refused to fill the prescription based
upon his or her reading of the chart notes,” he said. “Neither the
patients nor doctors would tolerate that outcome at a pharmacy, nor
should they in the instance of the prescription of power mobility
devices.”

But Lawler responded that the agency has no intention of
changing the requirement. “We’re not asking the supplier to make a
diagnostic information or to write the prescription,” he said. “But
you do have to find between the time the prescription is made and
it is supplied an ability to translate that prescription into a
physical piece of equipment. That’s your business that you’re
in.”

John Warren of CMS also noted that there are no plans to perform
random medical reviews, but they will be conducted by the DMERCs in
response to “billing anomalies.” He said he had no estimate as to
what percentage of power mobility claims would be reviewed.

Others at the meeting were concerned that the role of clinicians
is not addressed in the policy language, leaving the burden on
physicians who may–or may not–have the training necessary to
prescribe appropriate equipment.

“It’s not been my experience that there are a lot of physicians
who feel confident to provide the detailed prescription that’s
necessary. They neither have the time nor the expertise in the MAE
that’s necessary in order to have the whole thing turn out right
for the beneficiary in the end,” commented Ginger Walls, outpatient
clinic director at National Rehab Hospital in Washington, D.C.
“It’s been my experience that I’ve had to go back and try to fix
more patients’ problems who had improper devices prescribed for
them.”

Laura Cohen, a clinical research scientist at the Shepherd
Center in Atlanta and co-coordinator for the Clinician Task Force,
said because few physicians document the detailed type of
information necessary to prescribe the right equipment, the rule
should be amended to recognize that it is appropriate for
physicians to refer to independent physical or occupational
therapists who can then evaluate the patient and work with the
supplier to find the appropriate device. “The multi-disciplinary
team isn’t addressed in this [rule]. And knowing when and where to
refer on is not talked about, and I think that that’s a problem
with the system as it is today,” Cohen said.

Steve Furrough of CMS said it would be “appropriate in many
cases” for physicians to refer a beneficiary to someone who can
assist with the evaluation and prescription, but “we don’t feel
that’s an appropriate thing to regulate through a rule.

“Just like in any other health care provision, we expect
providers who are going to order power mobility devices to be
competent in ordering those power mobility devices,” he said. “We
expect [physicians] to do the appropriate evaluation, answering
those questions [as outlined in the NCD], and if they are
uncomfortable doing that, then we certainly expect them to ask for
some assistance.”

To help educate physicians about the changes, the agency is
planning meetings with physician groups, publishing Medlearns and
using DMERCs to get the word out, CMS’ Warren said, adding that
suppliers also should take responsibility for informing their
referral sources about the new rule and its requirements. “This is
a huge educational campaign, and I would expect that as suppliers
that you have relationships with the physicians that you deal with,
and part of that relationship would be educating [them] on what
their responsibilities are,” he said.

Still other forum participants, such as Phil DiLernia, president
of Flemington, N.J.-based Cornell Healthcare Corp., said the
interim final rule does not provide the clarity necessary for
suppliers to follow its requirements. “All suppliers have asked for
for four years consistently is clarity in the guidelines, no
ambiguity. If you want to reduce fraud and abuse, it seems
ultimately imperative that you make things more clear rather than
less clear. The more clear things are, the more easy it is to go
after fraudulent providers,” he pointed out.

The fact that the equipment prescription is required within 30
days of a face-to-face physician exam also disturbed a number of
stakeholders, who said that it could take a much longer time for
patients to shuttle among doctors, clinicians and an HME provider.
Furrough said that the 30-day clock does not start the first time a
patient sees the physician, but the date the prescription for a
mobility device is written, which may be a date after the initial
exam. Other officials said CMS would have to provide clarification
on this point.

“This is not new medicine, new science,” Furrough said. “It’s
just putting a name on what has always been expected to occur. So
the actual term ‘face-to-face examination’ and the requirement that
a face-to-face examination happened becomes effective the day the
rule … becomes effective. But it should not, in the larger sense,
really change practice. [Physicians] were required by good medical
practice to see patients before they wrote a prescription. That
doesn’t change.”

CMS officials at the forum said they will take the comments they
heard into consideration before the final rule is issued.

To view the interim final rule, click
here.

To comment on the policy, click
here.

To participate in HomeCare’s monthly Web poll on CMS’ new
interim final rule for power mobility equipment, visit www.homecaremag.com.