FICTION V. FACT

Fiction:  Recently, Medicare’s Office of Inspector General claimed payment for power wheelchairs were excessive and site that Medicare pays, on average, $5,300 per chair yet the same unit can be purchased “off the shelf” for $3,863 and wholesale for as low as $1,550.

Fact: Medicare pays 80 percent of the federally established allowable amount, or $4,240, for a power chair. When Medicare pays a claim for a chair, it is not just paying for the chair. There are many costs associated with providing power mobility to Medicare beneficiaries that are bundled into the Medicare allowable.  These costs include, among other things, paperwork and documentation, fitting people for the appropriate chair, delivering the product, patient assessment, and staff training.

Fiction:  The same OIG review of 300 claims alleged that only 13 percent of claims met the Medicare coverage guidelines for receiving a power wheelchair.

Fact: Every claim reviewed by the OIG included a Certificate of Medical Necessity (CMN) signed and completed by the patients treating physician.  The CMN is defined by Congress, was developed by CMS and the medical community, and was approved by the Office of Management and Budget as the Medicare document of record. In other words, the OIG is ignoring established federal law and policy.

In reviewing the sample claims, not only did the OIG disregard the physician completed and signed CMN, it appears that the OIG never even contacted the treating physician to inquire as to the health condition of the patient.  Instead, the OIG relied on the sole judgment of a medical reviewer who never observed or treated any of the patients. 

Further, the OIG relied on an arbitrary standard in defining who is qualified to receive Medicare assistance in receiving a chair. While Medicare eligibility policy for power wheelchairs says that the patient must be “bed or chair confined,” CMS officials have publicly stated that there is no current definition of “bed or chair confined.”  Thus, there is no clear criteria as to what constitutes the 1985 “bed or chair-confined” standard, thereby making the claim approval process subjective and inconsistent.  Under this directionless criteria applied in an ad hoc manner, it is not surprising that the OIG found that more than 80 percent of power mobility claims failed to meet Medicare coverage requirements.

Fiction: Growth in the power wheelchair benefit is fueled by fraud and needs to be reigned in.

Fact: While any level of fraud is unacceptable, there are a number of legitimate factors that have led to growth in the power wheelchair benefit.  These factors include: technology that has reduced the size of the wheelchairs allowing them to be used in all areas of the home (and therefore, covered by Medicare), the aging of the population, the increase in the number of those suffering from diabetes and other diseases that severely compromise patients ability to use traditional wheelchairs and walkers, and an increase in awareness of power mobility and its benefits.

Fiction: The Medicare power mobility benefit is rife with fraudulent operators and scam artists.

Fact: The vast majority of power mobility suppliers are law-abiding who work hard to play by the rules.  They have a vested interest in ensuring that both Medicare beneficiaries and the taxpayers are being well served by suppliers who provide high quality equipment and services.  In fact, as early as April, 2003 power mobility suppliers notified CMS and the OIG of unusual spikes in the number of claims being filed and chairs being sold in areas around the country. We also accurately suggested that there were possible linkages between this increase and potential fraud by “fly-by-night” operators.  It wasn’t until September 2003 - five-months after they were first notified - that CMS unveiled its 10-point plan to combat fraud in the power mobility benefit. Aside from self-policing, power mobility suppliers support the accreditation and quality standards to be established under the Medicare Modernization Act and look forward to working with CMS to develop such standards.

Fiction: Direct marketing to consumers by power mobility suppliers leads to phantom need and unnecessary utilization.

Fact: Just as the Medicare program is currently underwriting an education campaign directed to its beneficiaries to promote the new drug benefit card, power mobility suppliers are educating beneficiaries about the possible benefit of a power chair. Interestingly, the vast majority of those consumers who respond to advertisements by power mobility suppliers do not even qualify for Medicare coverage according to the pre-screening done by suppliers.

Fiction: There is no viable gatekeeper to oversee the appropriateness of who qualifies for the benefit.

Fact: Both the Congress and power mobility suppliers agree that the physician is in the best position to determine the medical need for power mobility and whether or not the beneficiary meets eligibility standards.  Under current law, Medicare will not pay a power mobility claim unless the treating physician certifies the need as set forth in the CMN.  The CMN is completed and signed by the patient’s treating physician who subjects himself to both civil and criminal penalties concerning the veracity of the information on the document.   CMS, however, has devalued the role of the CMN and the decision making of the physician by leaving the ultimate determination of whether to pay a power mobility claim with a medical reviewer who has never seen, treated or examined the patient.  This runs counter to both the law and Congressional intent that the physician plays the role of the gatekeeper in the power mobility claims process as the new Medicare Modernization Act (MMA) explicitly calls for face-to-face examinations by a health care practitioner prior to submission of a power mobility claim.

Fiction: Power mobility has led to a large increase in government spending.

Fact: The Medicare power mobility benefit is a very small part of the Medicare program with less than one percent of program revenues spent on power wheelchairs and scooters.  Power mobility saves the government money. If not for power mobility equipment, beneficiaries with limited or compromised mobility would have little or no choice but to enter a nursing home or other more costly institution at a cost to taxpayers of $26 billion in addition Medicare expenses. A recent study conducted by health care economists RRC, Inc., examined the Medicare cost savings attributable to power mobility and found that beneficiaries who utilize power mobility save the Medicare program between $5,000 - $6,000 when compared to similarly situated beneficiaries without power mobility over a three-year period.

Fiction: Imposing national competitive bidding on durable medical equipment (DME) like power mobility products and services will result in huge savings to the Medicare program.

Fact: Competitive bidding raises significant concerns, including the fostering of monopolistic markets, loss of quality and service, and the potential negative impact on beneficiary access and choice.  Specifically, competitive bidding for DME supplies, including power mobility:

• Can limit access to appropriate technology by focusing on cost over appropriation of technology and quality;
•  Reduces beneficiary choice by allowing only those suppliers with winning bids to serve Medicare beneficiaries;
•  Reduces quality since, under competitive bidding, price becomes the main buying criteria;
•  Raises costs over the long run by promoting supplier monopolies that reduce competition; and
• Creates beneficiary confusion and additional burdens if the beneficiary is already receiving supplies and service from a supplier who can no longer serve in the area as a result of competitive bidding.

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