CMS Launches New Power Wheelchair Initiative, To Split K0011 Code

Washington

The Centers for Medicare and Medicaid Services (CMS) has launched an aggressive three-pronged initiative focusing on power wheelchair coverage, payment and quality controls for suppliers.

The campaign was announced by recently appointed CMS Administrator Mark McClellan on April 28, and outlined by Herbert Kuhn, director of CMS’ Center for Medicare Management, during a Senate Finance Committee hearing on power wheelchair fraud and abuse held the same day. The committee oversees the Medicare program and has been investigating the reasons for a dramatic increase in power wheelchair claims.

“CMS has cracked down on fraud and abuse in the wheelchair market, including the launch of Operation Wheeler Dealer last fall in collaboration with the [Department of Health and Human Services] Office of the Inspector General,” said McClellan. “Now we are moving to the next stage in strengthening our policies for power mobility devices.”

For starters, CMS plans to develop more coverage guidance on power wheelchair policy. The agency’s chief medical officer will bring together clinicians from across HHS and other government agencies to refine and describe the conditions that are associated with the current coverage definition and to develop draft guidance for determining whether a patient meets the definition of “bed or chair confined.”

CMS also will address ordering requirements for mobility equipment through a proposed regulation that will, in part, implement provisions in the Medicare Modernization Act (MMA).

The second part of the plan addresses billing and payment. CMS will work with a national panel to establish a new set of codes accounting for the variety of power wheelchairs now available, with accurate individual payment ceilings to be developed for each of the new codes. Currently, most power wheelchairs are billed through the single K0011 code.

In the third part of the campaign, which deals with quality controls for suppliers, CMS will revise the supplier standards for enrolling in Medicare to include quality measures as required by MMA — revisions the agency plans to finalize in the fall of 2005. Working through the National Supplier Clearinghouse (NSC), CMS will continue to ensure thorough review of all applications for enrollment so that only qualified suppliers are allowed to bill the Medicare program.

In addition, CMS will also develop a proposal for an accreditation program, as part of its implementation of competitive bidding, to assure that power wheelchair providers meet industry standards. Provisions in MMA require competitive bidding for DME to begin in the nation’s top 10 metropolitan statistical areas (MSAs) in 2007 and phase to the top 80 MSAs in 2009. At that time, the government could expand competitive bidding nationwide.

Government officials at the Senate hearing said such bidding may help CMS align power wheelchair payments with free-market rates. Leslie Aronovitz, director of health care program administration and integrity issues at the General Accounting Office (GAO), said previous DME competitive bidding demonstration projects held in Polk County, Fla., and San Antonio, Texas, showed “promise as a way for CMS to use market forces to set more reasonable payment rates.”

Hearing Reveals Past Mistakes

Testimony at the Senate hearing also revealed that problems with government oversight, policy and coding opened the door for fraud and abuse of Medicare’s K0011 benefit. “Fraudulent schemes have made big money off this program because the equipment is expensive, the government pays more than anyone else and the controls are lax,” said Committee Chairman Charles Grassley, R-Iowa.

HHS’ OIG released two power wheelchair inspection reports at the hearing. One found that, on average, Medicare pays more for power chairs than either suppliers or consumers, allowing reimbursement of $5,297. The second report found that from a random sample of 300 power wheelchair claims, only 13 percent actually met Medicare’s coverage criteria for the mobility equipment.

Other testimony given by the GAO divulged that CMS did nothing to control rising power wheelchair spending despite warnings from the four DMERCs, the NSC and from the agency’s data analysis contractor, the SADMERC. “Although the four contractors that process DME claims identified escalating power wheelchair spending as early as 1997, CMS did not lead a coordinated response until September 2003” when Operation Wheeler Dealer was launched, Aronovitz said.

To remedy the situation, the agency’s new power wheelchair program “sets a very aggressive agenda,” CMS’ Kuhn told the committee, “and I believe this approach will improve access to high-quality power mobility devices for beneficiaries and ensure appropriate coverage through the regulatory process and [DMERC] guidance.”

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