CMS Considers Changes To Wheelchair Coverage Policy

Washington

This year, HME industry advocates and the Centers for Medicare and Medicaid Services (CMS) have volleyed back and forth in a K0011 coverage debate that may end with vigilant payment oversight, pricing changes or even changes to national coverage policy for wheelchairs.

Since a DMERC clarification of power wheelchair policy was issued in December, industry stakeholders have spoken out against CMS’ strict interpretation of policy language, voicing concerns regarding beneficiary access to medically necessary power equipment and provider payments. Although CMS retracted the clarification in mid-March, some advocates say access questions remain.

At a March 31 Open Door session on the issue, CMS officials said the agency cannot give a more specific definition of its policy language. “Being more specific than the national policy, by definition, will take control away from physicians,” said Timothy Hill, director of CMS’ Office of Financial Management. “A more precise definition … will make the circle [of those who qualify for a power wheelchair] smaller and smaller.”

In an Associated Press article published last month, Hill said he does not believe that more K0011 claims have been rejected due to the Medicare policy, adding that “much of what we have seen in the increase in the last few years is a direct result of consumer marketing in the industry, which creates the appearance the benefit is broader than it is.” According to CMS, the years from 1999 to 2003 saw a 300 percent increase in Medicare power wheelchair payments, while overall Medicare spending increased only 11 percent during the same period.

In mid-April, the debate took a twist when the agency announced it is considering making changes to the wheelchair national coverage policy itself. According to Kimberly Brandt, acting director of CMS’ Program Integrity Group, “[The national policy] is something that has been widely debated.

Because it dates back to 1985, it’s something that may need to be revisited. Our consideration of that will also allow for changes of the local coverage policy.” The CMS official made the comments at an Open Door Forum the agency held April 14 for the disabled community.

Noting that the agency’s staff has discussed wheelchair policy changes internally, Richard Lawlor, director of CMS’ Open Door initiative, added, “What would the questions be that we would ask legislators to provide for us to get out of individual confinements in our statutes? You have to be careful what you ask for on one hand, and then you have to be concerned about the trust fund and how we pay for the overall Medicare program. The realistic ability to make a coverage change may require legislative input.”

Along with possible changes in national coverage policy, Brandt named changes to wheelchair pricing and “especially vigilant” oversight of payments among a number of options CMS is currently considering.

She also addressed issues regarding the K0011 controversy. Responding to a drastic increase in K0011 payments and to a massive power wheelchair billing scheme uncovered in Houston, last fall CMS launched its Operation Wheeler Dealer initiative in an effort to curb fraud and abuse of the Medicare power wheelchair benefit. As a result, Brandt said, spending levels for power wheelchairs are down to what they were in 2000 and 2001. “This is a very positive [effect of] this initiative. [CMS is] getting closer to paying what we should be,” she said.

Brandt stressed that CMS wants “to make sure we’re preserving access to wheelchairs” for beneficiaries with genuine need. “We encourage all of you, if you know of somebody who legitimately needed a wheelchair and had their claim denied to contact us … If we don’t know about it, we can’t make sure the claim gets appropriately processed.”

Concluded Lawlor, “Beneficiaries with disabilities are the most important people we need to deal with. Clearly, those with disabilities must weigh in on the coverage policy.”

At press time, Senate Finance Committee Chairman Charles Grassley, R-Iowa, had scheduled an April 28 hearing on power wheelchair fraud and abuse.

CMS WANTS TO HEAR FROM YOU — AND YOUR PATIENTS

CMS wants to hear from providers who feel their power wheelchair claims have been wrongly denied. You can contact the agency about such claims at the following e-mail address: [email protected]. The agency is also looking for input from consumers about K0011 issues. Beneficiaries may contact the agency through its consumer Web site, www.medicare.gov.

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