Court: CMN Not Enough for PMD Claims

Baltimore

A certificate of medical necessity alone was insufficient for reimbursement of a provider’s power wheelchair claims, a U.S. district court ruled last month.

MacKenzie Medical Supply has been battling CMS for years over a $500,000 overpayment assessment, issued after it was determined the provider did not include enough documentation with claims to prove medical necessity. The 29 power wheelchair claims in question, filed between 1998 and 1999, all contained a physician-signed CMN.

In its ruling, the U.S. District Court for the District of Maryland rejected MacKenzie’s effort to recover thousands of dollars it paid back to the government. In the process of repaying the money, MacKenzie went out of business.

The court also rejected MacKenzie’s claim that the Paperwork Reduction Act made it unlawful for CMS to request additional medical records.

“Contrary to MacKenzie’s argument, the secretary has not issued an information request ‘to an entire class of individuals.’ Rather, here the audit explicitly targeted MacKenzie because MacKenzie was submitting an unusually high rate of requests for power wheelchairs,” District Judge Andre M. Davis wrote. “In addition, 30 percent of payments from those requests come from a single doctor’s referrals. This request certainly falls under the investigatory exception to the [Paperwork Reduction Act].”