Start Your Engines

I am sure you are familiar with the “Golden Rule.” It goes something like this: “He who has the gold makes the rules.” This is certainly the case with the new policy for mobility assistive equipment that the DMERCs are implementing. Who else would have come up with such a complex procedure to see if a cane or walker or wheelchair is reasonable and necessary?

Prescribing MAE is now based on “an algorithmic approach.” A good analogy would be to think of the questions prescribing physicians or practitioners must answer as the steps you must take to start your car. You must have an engine, gas, keys and a charged battery. If any of the items fail, or are not present, then the car will not start.

The same goes for the qualification of an MAE item. To qualify for a walker, for example, several conditions must exist based on the questions that must be answered about that walker. If, at any point during the qualification process, you end up at “not reasonable and necessary” for your answer, the item that was prescribed will not be covered.

By looking at the stepped MAE questions, you might also determine that a different piece of equipment is required than what the physician ordered. Say, for example, the physician ordered a manual wheelchair, but then he, a physical or occupational therapist or clinician answered Question 6 on the MAE — Does the home environment support the use of wheelchairs? — with a “no.” Since the home does not support the use of a wheelchair, the wheelchair would be considered “not reasonable and necessary.”

Another example would be if a power wheelchair were ordered. The physician may have answered all nine MAE questions, but he indicated that the recipient cannot operate the power wheelchair safely. In this case also, the chair would be considered “not reasonable and necessary.”

There are many points in the new coverage procedure that can “stop” a provider from considering an item ordered to be “reasonable and necessary.” Be sure you follow the MAE and that you have physician notes to back up the answers that are given by the physician, PT, OT or clinician.

I would recommend getting these notes as part of your normal intake process. It will be far easier to get them at intake than months, or even years, later. Nothing is worse than getting an audit letter and then finding out that the doctor has retired and you cannot get the additional medical justification for the item you put out.

I have spent a good amount of time creating a purchase order to cover the new MAE policy with all of its caveats — and it is seven pages long. Granted, only the first five questions need to be filled out by the physician, PT, OT or clinician for a cane or walker, but even those still cover three pages of the PO. I have heard doctors say it would take them all night doing paperwork just to prescribe canes and walkers to their patients. Unless we can find a way to reduce the workload on physicians, then we are going to have a hard time getting the appropriate, DMERC-required paperwork and documentation to be able to provide mobility equipment for beneficiaries.

CMS has also decided to eliminate the CMN for power mobility devices. This change will require a lot of training and education on your part with referring physicians, as they have become familiar with and used to filling out a CMN for these items.

Your physicians will have to be educated on the new MAE policy as well as the “face-to-face” exam requirement and the 30-day time window when ordering power mobility. Also, the fact that any physician can now order power mobility will need to be communicated.

I know this policy is new and confusing. It will take a concerted effort not only on the part of providers but of physicians as well in order to be successful. Let’s not look at this as a step back, however, but as a step forward. I believe this policy goes a long way toward helping qualify and quantify the equipment that is best suited for the beneficiary’s particular condition of the beneficiary. After all, the well being of the beneficiary is our main concern in this industry.

Jane Bunch is vice president, HME consulting, for Atlanta-based CareCentric. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans and serves as a consultant for fraud and abuse cases. She can be reached at 678/264-4495 or via e-mail at [email protected].