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POLICY ISSUES
The Power Mobility Coalition is currenty focusing
on three major policy issues:
Medicare Eligibility
Criteria
A major debate is currently underway over criteria
for defining eligibility for the power wheel chair
benefit under Medicare.
At stake is access to technology offering personal
independence and freedom to millions of Americans
suffering from serious diseases and injuries that
often lead to much more costly institutionalization.
For most of the past decade, in response to
legislation passed by Congress in 1994, a physician-signed
Certificate of Medical Necessity (CMN) has been
the primary tool for determining that a patient
is eligible for the Medicare power wheel chair
benefit.
The Centers for Medicare and Medicaid Services
(CMS) developed the CMN with cooperation from
the physician community, including the American
Medical Association, Practicing Physicians Advisory
Council, and the Medical Directors of the four
Durable Medical Equipment Regional Carriers ("DMERCs").
The CMNs were then subject to a public notice
and comment period prior to final approval in
1996.
The CMN provides clarity and definition to motorized
wheelchair national coverage policy by requiring
the physician to certify that a patient needs
power mobility equipment to move around the residence
and safely complete the essential activities of
daily living. In this way, the CMN has set the
standard for prescribing and providing power wheelchairs
to Medicare beneficiaries since its inception.
Before the CMN became the established tool for
qualifying patients, Medicare participants were
subject to an arbitrary and ill defined standard
as to whether a patient is "bed or chair confined."
In December 2003, in announcing that power mobility
access would be denied to patients able to take
more than a single step or two, CMS and the DMERC's
effectively reverted to the outdated, arbitrary
and sharply restrictive pre-1996 approach. Further,
when challenged to define "bed or chair confined"
CMS officials announced at a March 31, 2004 motorized
wheelchair Open Door Forum that there is no current
definition and that the CMN is merely a billing
document.
The Power Mobility Coalition (PMC) is deeply
concerned that CMS has reverted back to the restrictive
"bed or chair-confined" criteria, has devalued
the CMN, and is now permitting CMS contractors
to second-guess the judgment of trained physicians
in the claims approval process.
Stronger Industry Standards
The PMC seeks to develop an ongoing partnership
with government to reduce fraud and abuse throughout
federal healthcare programs. Power mobility suppliers
and manufacturers are in the best position to
identify fraudulent operators and "fly-by-night"
suppliers who are not abiding by Medicare rules.
The PMC has developed several anti-fraud recommendations,
beyond current Medicare requirements, that would
increase accountability by requiring power mobility
suppliers to comply with more rigid requirements.
These recommendations, which have been previously
presented by the PMC to CMS and the OIG, are listed
in the following chart:
| PMC Proposed Standards
for Medicare Suppliers |
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· Frequent, random and unannounced National
Supplier Clearinghouse visits to supplier
locations to assure that Medicare supplier
standards are being met.
· Suppliers should be required to service
items that they sell as well as rent.
· Suppliers should be accredited by a nationally
recognized accrediting agency or, for smaller
suppliers, a surety bond or increased capitalization
requirement should be imposed in lieu of
accreditation.
· High end rehabilitation suppliers should
be credentialed by a nationally recognized
credentialing agency.
· Advertising should be regulated. Rules
must be clear and bright line tests and
clear guidance should be developed to ensure
acceptable marketing practices.
· Suppliers should adopt a compliance program.
Marketing and billing personnel should be
required to attend company compliance training.
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| Documentation Requirements |
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· Valid Certificate of Medical Necessity
signed by a legally licensed physician containing
a diagnoses code or codes that supports
the need for a motorized wheelchair. The
diagnoses codes would demonstrate a lack
of ambulation and upper extremity weakness.
· Answers to the Certificate of Medical
Necessity questions documented by:
Physician confirmation of coverage criteria
in the form of a document signed by the
treating physician addressing the medical
conditions of his/her patient and why
he/she completed the Certificate of Medical
Necessity, OR Evaluation completed by
a state licensed physical or occupational
therapist, OR Physician chart notes.
· Certification by the beneficiary of lack
of upper and lower body strength and verification
of coverage criteria prior to delivery.
· Formalize proof of delivery (required
on every claim but not OMB approved). Require
make, model, serial number to have something
to use in audits to validate product supplied
versus product billed
· Audit forms/questionnaires aimed at the
physician, supplier and beneficiary should
be implemented and gain OMB approval, thereby
providing the agency with a documented audit
trail.
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| Power Mobility Anti-Fraud
Advisory Board |
| Power mobility suppliers
and manufacturers want to develop an ongoing
partnership with government to assist reducing
fraud and abuse throughout federal health
care programs. This partnership should be
codified by the creation of a National CMS
Power Mobility Advisory Board that would provide
a conduit between the power mobility industry
and CMS for the identification of fraudulent
and abusive practices and suppliers, along
with recommendations for change. |
Reimbursement Levels
Medicare currently 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.
Reimbursement levels must be adequate to permit
Medicare beneficiaries to obtain the mobility
technology that is best suited to meet their needs.
Payment rates must also be sufficient to cover
essential patient assessment, safety training,
and service requirements.
Janet Rehnquist, former Inspector General of the
Department of Health and Human Services, in June
2002 testimony before the Senator Committee on Appropriations
Subcommittee on Labor, HHS, and Education, provided
a summary of 16 products (including motorized wheelchairs)
comparing Medicare prices to the Department of Veterans
Affairs (VA), Medicaid, retail and the Federal Employee
Health Benefit Plan (FEHB) prices. Rehnquist informed
the Subcommittee that the median retail price for
a motorized wheelchair is greater than the median
Medicare price. Further, the difference between
Medicare and FEHB pricing for motorized wheelchairs
was merely 3.28%. Other products cited in the Rehnquist
study were found to have a Medicare allowable of
up to 72% higher than a retail transaction and up
to 22% higher than that of a FEHP transaction. When
taking into account a markup of VA prices (based
on the dramatic difference between a VA and Medicare
transaction), Rehnquist found that the VA price
for motorized wheelchairs was 12.3% lower than that
of Medicare. Other products listed were up to 80%
higher than that of the VA.
The service and cost components involved in
a Medicare power mobility transaction are extensive.
The following are some of the costs that are unique
to the Medicare program.
Paperwork/Documentation
The Medicare program has imposed significant
paperwork and documentation requirements on power
mobility suppliers including submission of the
Certificate of Medical Necessity which must be
signed and completed by the patient's treating
physician. Suppliers obtain from (and submit to)
beneficiaries a wide range of documentation including,
but not limited to, delivery slips, an authorization
of benefits form, patient consent to release records,
rental/purchase agreement, supplier standards,
and co-pay information.
In addition, suppliers are often asked to obtain
additional documentation from physicians, hospitals,
other medical professionals, and beneficiaries.
Such documentation might include a physical therapist
report, a letter from the treating physician,
or the entire set of medical records for a particular
patient. One of our members collected "additional
documentation" primarily consisting of medical
records and chart notes for 283 claims. The total
time associated with this one project required
1334 man-hours, or 4.71 hours per claim.
Service Costs
Suppliers in the Medicare program must deliver
products to beneficiaries and must instruct beneficiaries
on how to use Medicare-covered items safely and
effectively. The Medicare allowable covers this
entire process, including all transportation costs
(and follow up educational costs) associated with
each transaction.
Medicare Appeals Process
Suppliers must undergo a costly Medicare appeals
process for claims that are denied at the carrier
level or denied per the results of an audit. The
appeals process currently includes a carrier review
and fair hearing followed by a hearing before
an Administrative Law Judge. The current system
requires suppliers to repay the government and
then undergo this lengthy appeals process to win
back monies to which they are entitled. It is
not unusual for a supplier to wait one or two
years for a claim to be completely adjudicated.
Staff Training
Suppliers incur significant costs to ensure
that their personnel are compliant with the Medicare
rules and guidelines. This includes compliance
training, attendance at carrier seminars, and
constant dialogue with carrier staff.
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