An Issue of Access

The situation is not exactly what HME providers projected during the last quarter of 2003 when they responded to HomeCare’s annual survey on purchase intentions for the New Year. Then, there seemed to be no obstacles to growth in the power mobility market. Indeed, 48.9 percent of surveyed providers said power wheelchairs would be the fastest-growing product for their companies. And 17.8 percent were banking on power wheelchairs to account for their largest percentage of revenue growth in 2004.

But then, along came the government’s “Operation Wheeler Dealer” and a clarification notice involving Medicare-covered power wheelchair and scooter claims. In the few months since, the unexpected turn of events has led the industry to a fight for beneficiary access — and business. New Braunfels, Texas-based The Scooter Store, the nation’s largest provider of power wheelchairs and scooters, laid off 200 employees, blaming the move on the clarification notice. As payments in some areas slow, smaller providers are mulling their options.

Seeking relief, manufacturers, providers and industry organizations are clamoring for audiences with government entities. And just about everyone is asking, “What’s the future for the power mobility industry and its beneficiaries?”

“It’s hard to say what effect this will have on the mobility market. There’s a lot of [concern] right now,” says Cara Bachenheimer, vice president of government relations for Invacare, Elyria, Ohio.

“The mobility market is in for a change,” predicts Sandra Hoskins, owner of American Medical Equipment Company in Houston.

“Power wheelchairs are profitable, there’s no doubt about that,” states D. Rexford Maxey, president of Penn York Medical Supplies, Binghamton, N.Y. Nevertheless, he says, “we’ve had the discussion that we need to look at other things.”

FRAUD TAKES A TOLL

Circumstances changed almost overnight for HME dealers when the Centers for Medicare and Medicaid Services, in conjunction with Health and Human Services’ Office of Inspector General, issued a 10-point initiative designed to curb fraud and abuse in the power mobility market. The nationwide crackdown came after reports surfaced of “rampant fraud and abuse” in the Houston area. Medicare paid for more than 31,000 claims for power wheelchairs in Texas in 2002, compared to 3,000 in 2001.

“Spending on power wheelchairs has increased nearly 450 percent over the last four years [nationally], an unprecedented growth in this benefit,” said then-CMS Administrator Tom Scully in announcing “Operation Wheeler Dealer” last September. “While many of these wheelchairs are provided by ethical suppliers and go to beneficiaries in need, we know that a great number of unscrupulous suppliers are promising free wheelchairs to beneficiaries who don’t need them.”

The vast majority of power wheelchair manufacturers and providers — who have long complained about unscrupulous physicians writing power wheelchair prescriptions for busloads of Medicare beneficiaries, and providers who promise free scooters or wheelchairs in TV ads — applauded the intent of the initiative. But it set in motion a series of actions that have since outraged industry stakeholders, and that, some say, may prevent many people who need power wheelchairs from having them.

Among its 10 points, CMS suspended issuance of new provider numbers; required all payments for motorized wheelchairs in Harris County, Texas, to be scrutinized and approved by CMS staff on a special task force; required the medical provider to see the patient before prescribing a wheelchair or scooter; and targeted power wheelchairs as the “first item analyzed for potential inherent reasonableness adjustments.” It also required the four durable medical equipment regional carriers to “adopt a consistent approach to medical review.”

Accordingly, in December the DMERCs issued a clarification notice regarding criteria for power wheelchair claims. And therein, say industry players, lies the real rub.

ABOUT THE CLARIFICATION

“We view the recent clarification as a change in policy,” says Kevin Quaglia, general manager, reimbursement services, government affairs for Exeter, Pa.-based Pride Mobility Products. “We do not support a change in policy masked in the guise of a clarification.”

The issue is the DMERCs’ definition of the word “nonambulatory.” Medicare policy states that a power wheelchair or power-operated vehicle is covered “if the patient’s condition is such that without the use of a wheelchair he would otherwise be bed- or chair-confined” and if “the patient is unable to operate the wheelchair manually.”

The clarification adds that power wheelchairs and POVs are covered only for patients considered nonambulatory — that is, “if a patient can only bear weight to transfer from a bed to a chair or a wheelchair.” However, it continues, “if the patient is able to walk either without any assistance or with the assistance of an ambulatory aid, such as a walker, the power wheelchair is denied as not medically necessary.”

And that definition, say those involved, will greatly reduce the number of people qualifying for power wheelchairs.

“We are extremely concerned about the DMERC bulletins,” says Invacare’s Bachenheimer. “We believe [the clarification] is intended to be a significant restriction so that seniors who would previously qualify and need [power wheelchairs] to get around their homes won’t qualify because they can walk two steps and then collapse.”

The Washington, D.C.-based Power Mobility Coalition, a nationwide group of providers and manufacturers, agrees. “The real problem,” says PMC Director Eric Sokol, “is that under the clarification you could have the following: a certificate of medical necessity completed by a treating physician; a letter on the doctor’s letterhead on why they are prescribing [a power wheelchair]; a physical therapist’s report also signed by the doctor. You could submit all that to Medicare and, under this clarification, all of that could be thrown out by someone at the DMERC. That’s not combating fraud; that’s taking services and equipment from beneficiaries with legitimate needs.”

It also, according to the PMC, effectively removes power from the treating physician. “You have someone at a DMERC, who has never seen the patient, deciding what that patient needs,” Sokol says.

There is another issue as well, says Rita Hostak, vice president of government relations for Longmont, Colo.-based Sunrise Medical and president and chairman of the board of NCART (National Coalition for Assistive and Rehab Technology), an independent coalition of high-end rehab professionals.

“Sunrise believes that considering someone ambulatory without consideration for safety or function is inappropriate and must be challenged,” she says. “Medicare beneficiaries should be provided necessary equipment to allow them to function in the full range of their daily activities. If only those people who meet the definition of nonambulatory, as it is contained in the clarification, receive mobility products, a very large number of Medicare beneficiaries will experience a loss of access to equipment they must have to remain independent in their homes.”

If it appears to be a change in policy, it also appears to some as a departure from CMS procedure.

“The DMERCs failed to issue a draft medical review policy, as well as post the drafts on their respective Web sites,” says Kay Cox, president of the American Association for Homecare in Alexandria, Va. “They didn’t solicit comments from the various industry groups or the general public.”

CMS AND THE DMERCS

The concern over the clarification notice has prompted manufacturers, providers and industry organizations to appeal to CMS and the DMERCs for meetings to discuss the clarification, and some have even asked CMS to rescind the clarification. While CMS has scheduled a “listening session” for late February with the American Association for Homecare on the issue (see “RAMP to Fight Power Wheelchair Policy”), at press time, no move had been made to rescind or revise the clarification.

That could be because, according to a spokesman who specializes in medical policy for CMS and who asked not to be named, the clarification is not a change in policy and thus didn’t warrant a draft medical review policy or solicitation of comments. “The rules haven’t changed,” he says. “The coverage criteria haven’t changed. They have been the same since 1995, if not before that.”

Robert D. Hoover, Jr., M.D., medical director for Region D DMERC, agrees there has “been no change in the written language of the policy.” The clarification was needed, he says, because “in some regions there have been different [applications].”

“No one is trying to hide behind unpublished criteria,” he notes. “It’s not to our advantage to do that.”

Indeed, Hoover says, the clarification notice also was an attempt to standardize what documentation is needed, something the industry itself has sought. “They want to know what documents are needed and what we are looking for,” he says.

Because of the Paperwork Reduction Act, however, Hoover says the DMERCs are hampered from saying what exactly they need. “We can’t put it into the policy in black and white terms because of the Paperwork Reduction Act,” he says.

“Our goal is not to deny claims,” he adds. “It is to educate providers so they have the information to submit claims properly and they go through the first time. A denied claim costs us money and the provider money.”

Hoover says that, as a physician, he understands the conflict between what might be medically appropriate and what Medicare approves. “The conflict is between what may be medically appropriate with the patient and what is clinically appropriate,” he says. “By clinically appropriate, I mean the statutory limits we are bound by to only provide things in their home.”

There’s such a thing as “powered endurance,” he says. A person, he explains, can be fine within the confines of his or her home and can move from the bedroom to the kitchen or the den. “But when they start moving outside their home to the grocery store or the mall or the baseball field to watch their grandchildren play, they need powered endurance. And as a physician, it would be appropriate to provide something like that for them. But as we look at it, as the statutes are written, we can’t cover it.”

LOOKING BACK — WAY BACK

Another bone of contention, industry leaders say, is that in the clarification the DMERCs reserved the right to review claims submitted, and approved, years ago.

“They say it is retroactive seven years, which we think is illegal,” says Bachenheimer. “And CMS hasn’t issued any statement otherwise.”

That has providers imagining horror stories like being forced to go to a beneficiary’s home and retrieve a power wheelchair because CMS has decided the claim should not have been approved.

“They shouldn’t get to do that,” says Joan Cross, president of the Florida Association for Medical Equipment Services and co-owner of C&C Homecare in Bradenton. Cross got out of the power wheelchair market a few years ago, but her old claims could come up for scrutiny, she says. “The rules were in place at that point, and that was what the payment schedule was about. You don’t get to change the rules [retroactively]. You’ve got to be fair with this industry.

“What are the beneficiaries going to say when you call them up and say, ‘I have to come and get your wheelchair because Medicare says you didn’t need it three years ago, even though three years ago they said you did?’ she asks. “I have no intention of taking the brunt of this one, because I think it is unreasonable.”

“It’s outrageous,” states Bob Achermann, executive director of the California Association of Medical Product Suppliers. “If you go through the approval process and they approve it, what right do they have to come back and rethink their own process? And how do you ever budget for that eventuality?”

American Medical Equipment’s Hoskins has already had the experience of picking up a wheelchair — ironically, because of fraudulent providers. “I’d get a notice that I had to pick up my standard wheelchair, and when I got there, the people were in tears because someone had dropped off a power wheelchair and they couldn’t even get it in the door. I’ve left I don’t know how many because I couldn’t leave the people without ambulation. I’ve just written [the wheelchairs] off.”

But, she adds, Medicare has the upper hand because “if they want their money back and you don’t pay, they can hold up future payments.”

Hoover does not dispute the retroactivity feature, though he does question the period of time. “There are provisions in the appeals rights on how the DMERCs are to conduct their prepayment and postpayment reviews,” says the Region D medical director.

“The breakpoints, I believe, are one year and four years. Seven years is not one that sticks in my mind. However, if there is fraud, there is no limit.”

And the CMS spokesman notes that contractors can only reopen claims for “good cause — if we suspect fraud, an error on the claim. We do not apply policy retroactively. So even if the rules did change — which they didn’t — we would not be able to go back seven years and deny them.”

THE RESULTING STAND-OFF

While HME manufacturers and providers are eager to weed out the unscrupulous companies that give everyone in the industry a black eye, they believe the CMS actions are unlikely to curb fraud and abuse. However, they say, the agency may be successful in cutting the amount Medicare spends on power wheelchairs.

“They are aiming at stopping fraud and abuse, but they are applying it to medical necessity — and fraud and abuse is not medical necessity,” Quaglia contends. “It is blatant abuse of rules and regulations. You don’t want to make it impossible for someone to qualify for a product. That’s not stopping the people who are blatantly doing it wrong, who are not delivering equipment but who are billing for it.”

“It won’t have any real effect or deterrent effect on the bad companies,” says Bachenheimer. “If you look at some of these places in Houston, some of these companies came in and set up an operation for a day just for the site inspection, and they actually passed the site inspection. So obviously something is wrong … CMS should be able to differentiate between legitimate companies and those who are not.”

“It won’t have any effect on fraud and abuse,” says Margaret McGuckin, executive vice president of marketing for The Scooter Store. “If [CMS] wanted to control fraud and abuse, they would put into place the internal audit capabilities that would identify [it]. They can do things like audit how many CMNs are coming from a specific physician in a specific period of time, how many supplier numbers are coming out of a single address. If they had done either of those things, the fraud in Houston could have been avoided.”

What will happen, Bachenheimer and others say, is that more beneficiaries will be denied power wheelchairs. Some legitimate providers, particularly in Texas, could simply close. “They’ve completely shut down payments for wheelchairs [in Texas],” says Bachenheimer. “Most of the providers there are small companies. They can’t continue to operate if they aren’t paid.”

And, since inherent reasonableness regarding power wheelchairs is part of the CMS initiative, industry-watchers also believe reimbursement could be cut. That would save CMS even more money but, again, would not help curb fraud and abuse.

“I would imagine they are going to check out the cost on power chairs and probably reduce the allowable,” says Hoskins of American Medical Equipment.

For Maxey of Penn York, the situation echoes that of seat-lift chairs 20 years ago. “There was total abuse of the code for seat-lift chairs, and it sounded the death knell for reimbursement on seat-lift chairs,” he says, adding that he worries the same could happen to power wheelchairs. “Certainly reimbursement can be reduced. There’s room for it to be lowered.

“But my concern is for the beneficiary,” he continues. “What’s going to happen is that either the reimbursement is going to be reduced to a level [where] providers are not willing to take a risk, or the qualifications for this equipment are going to be so difficult to meet [that] very few are going to qualify.

“And then … the beneficiaries will have to pay up front for [the wheelchairs] and hope they can get reimbursed. It’s really going to limit the ability of the beneficiaries who require the equipment.

“I’ve been in the business for 29 years,” he adds. “I want to make a profit, but the fact of the matter is, the people who are going to be really hurt by this are the beneficiaries.”

RAMP to Fight Power Wheelchair Policy

In late January, an industry power mobility coalition called RAMP — the Restore Access to Mobility Partnership — launched a campaign to fight the DMERC clarification on Medicare power wheelchair coverage.

RAMP members include the American Association for Homecare, Alexandria, Va.; Invacare Corp., Elyria, Ohio; The MED Group, Lubbock, Texas; Mobility Products Unlimited LLC, Holly Hill, Fla.; Pride Mobility, Exeter, Pa.; The Scooter Store, New Braunfels, Texas; and Sunrise Medical, Longmont, Colo.

Joining with other senior, disability, consumer, clinical and medical organizations, RAMP is “calling on the White House, Congress and the Department of Health and Human Services to persuade the Centers for Medicare and Medicaid Services (CMS) to rescind the new policy,” according to the coalition.

The organizations working with RAMP include Advancing Independence, the American Association of People with Disabilities, Paralyzed Veterans of America (PVA) and World Institute on Disability (WID). All are members of Independence Through Enhancement of Medicare and Medicaid (ITEM), a coalition of more than 70 disability, aging, consumer, labor and voluntary health associations.

“The December policy change will have a major impact on our nation’s seniors and people with disabilities,” said WID Executive Director Deborah Kaplan. “This is a severe blow to our citizens as tens of thousands of Medicare beneficiaries could lose access to power wheelchairs … Just as many seniors and disabled people are beginning to realize that a power wheelchair can allow them to function independently, this decision could instead deprive many of basic mobility. It must be changed.”

“We are going to work with groups representing people with disabilities, senior citizens, clinicians, physicians, consumers and others to put this important issue on the national agenda,” said Mal Mixon, chairman and CEO of Invacare. “This new policy creates a situation where millions of people whose quality of life could be vastly improved are denied a better existence.”