Similar Policy, Same Result

I am writing this column just prior to Medtrade, a time during which we are spending considerable resources to convince CMS to suspend the Oct. 1, implementation date of the new power wheelchair codes and fee schedules until CMS fixes their fundamental flaws. As the PSCs’ Local Coverage Determination issued Aug. 15 stands today, those who have a need for a power mobility device after Oct. 1 will have serious problems obtaining the medically appropriate chair.

If, in the time between writing this and when you read this, CMS has rectified these issues, then we can all breathe a collective sigh of relief.

Just prior to a critical election for Republicans, the Bush Administration is taking a far-reaching approach, under the guise of preventing fraud and abuse, that will prevent many U.S. citizens from obtaining the clinically appropriate power mobility device.

The LCD issued in mid-August clearly will limit coverage of motorized wheelchairs and scooters to the cheapest and lowest-powered models. These Group 1 devices are not designed to be used by someone for more than two hours per day, are not designed for use on anything other than smooth surfaces and, in some cases, cannot even push up and over a door threshold.

The LCD also creates an even more meager benefit compared to one that has never been characterized as generous. Previously, Medicare did not pay for a power mobility device unless it was required for use indoors to eat, dress or use the bathroom. Despite those limits, the wheelchairs and scooters Medicare covered had the power and durability to be functional outdoors as well.

In the name of fighting fraud, CMS decided nearly three years ago to limit access to power wheelchairs and scooters to Medicare beneficiaries who could not walk a single step in their homes. An outcry from the public, and eventually Congress, pressured CMS to rescind this directive. Through various pricing, code and coverage changes over the past three years, CMS has essentially enacted a similar policy, taking a different route, with the same results: a downward trend in usage of the Medicare mobility benefit, resulting in a reduction in costs.

The technical changes scheduled to take effect Oct. 1 will mean that beneficiaries with mobility impairments will have to pay for an upgrade, which many can not afford. Otherwise, these consumers will be stuck with a wheelchair not designed to get them outside for any number of ordinary reasons, such as going to the mailbox, visiting a doctor, shopping for groceries or worshipping.

More distressing is the potential inability of a consumer to escape a household emergency and be able to safely leave the home. If they do dare venture outdoors in the equipment, the consumer could be at of risk of serious injury if an uneven surface upsets the vehicle. Or a battery life as short as an hour-and-a-half could leave them stranded away home.

A new standard requires a beneficiary be unable to stand and pivot to get into the seat of a wheelchair or scooter to be eligible for the best of the low-power models that CMS will allow. Some people with multiple sclerosis, Parkinson’s disease and cerebral palsy will end up in a clinically inappropriate wheelchair as their conditions worsen, with the rough rides contributing to the deterioration of their condition.

Federal agencies have a responsibility to crack down on fraud and abuse (which we all wish to eradicate), but CMS is using the coding, coverage and payment process instead of using its enforcement resources. As usual, these policies will punish the compliant provider, making it easier for physicians to do business with providers that are not interested in obtaining sufficient supporting documentation.

At the end of the day, it is the six million disabled people under 65 who receive Medicare and the elderly beneficiaries who need power wheelchairs and scooters who will bear the brunt.

A specialist in health care legislation, regulations and government relations, Cara C. Bachenheimer is vice president, government relations, for Invacare Corp., Elyria, Ohio. Bachenheimer previously worked at the law firm of Epstein, Becker & Green in Washington, D.C., and at the American Association for Homecare and the Health Industry Distributors Association. You can reach her by phone at 440/329-6226 or by e-mail at [email protected].