ABC Affiliate Airs Story on Wheelchair Denial Story

70 year old Chuck Robinson, a 25 year resident of Yucca Valley became wheelchair bound 5 years ago after he suffered a stroke. After losing a leg in a motor cycle accident more than a decade ago, doctors amputated his other leg following the stroke and he lost use of his right hand. If it wasn't for his battery powered wheel chair, Chuck hates to think where he might be. "I'd probably be in a hospital ward; wanting to die." Said Chuck.

Chuck wouldn't be mobile if it hadn't been for Esta Willman. She owns Medi-Source Equipment and Supply. Two years ago she put Chuck in his current wheelchair at the risk she wouldn't see a dime on a $4,500 Medicare claim. That's because Chuck wore out his previous chair too fast. "When we contacted Medicare we learned he had been provided the power chair 3 years before. Medicare has a rule that equipment should be expected to last 5 years. It hadn't been five years." Said Willman.

And if it wasn't bad enough the claim got denied, once Willman filed an appeal, things took a turn for the worse. "Not only that, that the patient that the claim, the case was being referred to the Medicare Program Safeguard contractor for an investigation of patient culpable neglect." Said Willman. In other words, Medicare wanted to see if Chuck mis-used and abused his equipment. Granted he put a strain on it, but it was all about remaining independent. "He's using his chair 24 hours a day. Inside, outside, everywhere, because he has no legs to move him anywhere any other way." Said Willman.

Willman says after repeatedly contacting Medicare she has yet the hear back on the status of the investigation. In the meantime , she's not worried about recouping her money at this point. Chuck has become almost family. "We can't turn our back on him. He's not a charity case, but he's a human being. We live here so we do what we can. Sorry getting all choked up." Said Willman. Chuck added. "She's a sweetheart, a good woman and smart as hell."

News Channel 3 contacted Medicare about this case. We were told Chuck Robinson's claim was denied because the original chair it paid for was so severely damaged it was beyond repair. The good news, Medicare says Chuck Robinson is entitled to a new chair in June.

The story can be found at: http://www.kesq.com/news/23298202/detail.html

Medicare Denies Wheelchair Claim for Elderly Amputee

The American Association for Homecare (AAHomecare) today released a Mobility Matters bulletin documenting the case of a 68-year-old amputee from Yucca Valley, Calif. whose Medicare claim for a power wheelchair was denied by the government.

Mobility Matters, a bimonthly update sent to lawmakers on Capitol Hill, said that two years ago, the man, who was referred to as John, sought a power wheelchair from Medi-Source Equipment & Supply, a home medical equipment provider in rural Yucca Valley. Both his legs had been amputated; after a stroke he had the use of one “good” arm that constantly ached.

“His power wheelchair, battered and broken down, lay crumpled on the side of his caregiver’s garage,” Mobility Matters reported. “At the time, that garage was the place that John called home. Often his power wheelchair served as both his transportation and his bed. But his power chair had seen its last day.”

Under Medicare regulations, power wheelchairs are supposed to last at least five years before being replaced, but John’s had worn out after three years from heavy use.

“His power wheelchair served as his only means of getting around,” said Esta Willman, owner of Medi-Source. “When his caregiver wasn’t available, he literally slept in his wheelchair. He couldn’t get out of it on his own. He came to our place, and we started the process to provide him a new chair, thinking that even if the Medicare claim was initially denied, his extenuating circumstances would allow it to be approved on appeal.”

Tyler Wilson, president of the American Association for Homecare, said the chain of events in this particular case reinforces the need for substantial changes in the way that Medicare claims for homecare equipment are handled by the Centers for Medicare and Medicaid Services (CMS). He said that across the country, small and large providers are outraged over the broken process—claims rejected for Medicare beneficiaries who clearly need power wheelchairs, a high percentage of these denials later overturned in administrative appeals, good providers pushed to the brink of bankruptcy because of delays in getting paid for legitimate claims, and new standards for documenting medical necessity applied retroactively to claims filed long before the new guidelines were established.

“John’s case isn’t about disruptions in the claims process,” Wilson said. “At the core, it is potentially much more serious. It’s about flaws in how people are treated by a government program that President Lyndon Johnson created as a centerpiece of his Great Society. He envisioned health safeguards for the most vulnerable people in America – the elderly and people struggling to live with disabilities. But today, sadly, Medicare is failing people like John.”

Medi-Source fitted John for a new chair, and a short time later, he had a Pride Jazzy 600 wheelchair. Under Medicare regulations, the company provided the wheelchair before filing the reimbursement claim. Medi-Source’s Willman was aware that recovering the $2,400 cost of the chair, as well as reimbursement for the services she provided, would likely take longer than normal because the five-year use period had not expired on his last chair. Medi-Source’s original claim was denied, and Willman appealed, documenting John’s unique situation – he was literally living in his chair, sometimes 24 hours a day, and at the time, was staying in a friend’s garage. His physical handicaps prevented him from doing maintenance on his chair, leading to greater than normal wear and tear. She included pictures of his old wheelchair, showing it beyond repair.

Much to her surprise, not only was the appeal denied, but the case was referred to Medicare’s patient culpable neglect unit – John was being investigated for allegedly abusing his original wheelchair and was in danger of having his Medicare benefits restricted.

“This poor guy was not abusive to the equipment, he just needed to use it more than most,” said Willman. “Maybe I shouldn’t have had faith that they would want him taken care of. But don’t go after him. Without the power wheelchair, he’s in a bed. This is truly appalling. It is stunning that Medicare would deny him a way to even exit in case of fire. He can’t walk; he has no legs and he can’t push a manual wheelchair because his one good arm is killing him all the time. How can he not be qualified for a power wheelchair?”

In September of 2008, the neglect investigation began. Despite letters and telephone calls, Willman has been unable to receive any information about the investigation. The delay has had ramifications for her and the beneficiary, John. Her appeal of the claim denial has stalled because the neglect investigation has not been completed. Like other providers dealing with claim denials, Willman hasn’t taken John’s chair away. But he needs new batteries to keep it running – something that Medicare would cover if the original claim had been approved.

“Patients are being let down by the government all across the country,” said Wilson, of AAHomecare. “Providers, like Medi-Source, are doing the best they can to help them. It is disappointing that the Medicare program creates hurdles for providers, rather than improving service and care options for beneficiaries.”

Impact of Health Reform on People Who Require Wheelchairs, Oxygen, and Other Types of Home Medical Equipment, from Cleveland Plain Dealer April 2, 201

Q: How will the health care reform bill affect the elderly and people with disabilities who use wheelchairs, walkers, oxygen and other medical devices? Will a new medical device tax in the bill make it harder for them to get needed equipment?

A: To help the government raise at least $2 billion yearly to subsidize insurance coverage for those who lack it, the reform bill establishes a new, 2.3 percent excise tax on medical device manufacturers that starts in 2013.

"I have no doubt that manufacturers and importers of medical devices will try to figure out ways to lessen the impact of this tax," says Peter W. Thomas, a Washington, D.C. attorney who specializes in disability and rehabilitation issues and reimbursement. "One of the key ways is to pass the costs onto consumers."

But Thomas predicts manufacturers may have some trouble passing the new tax along to end users because many of the devices are bought by big buyers like Medicare, Medicaid, the Veterans Administration and private insurance companies, that have established fee schedules for the purchases. He said medical equipment suppliers, who act as middlemen between the manufacturers and big buyers, could end up on the hook paying more.

Andrew Imparato, who heads the American Association of People with Disabilities, cautions that the tax could drain money from medical device makers that they'd otherwise spend on research and innovation. He hopes potential problems can be fixed before the tax goes into effect.

"On the balance we think there are more positives in the bill than negatives for people with disabilities, but we think it will do harm for consumers in terms of wheelchairs, prosthetics and the things they need," says Imparato.

The device tax and a competitive bidding program for medical equipment could put many home care providers out of business, says American Association for Homecare spokesman Michael Reinemer. That would make it harder for patients to get the services they need when leaving the hospital, he says.

United Spinal Association legislative director Andrew Morris adds that a provision that requires Medicare users to rent a power wheelchair for 13 months before they can purchase it may result in health problems for wheelchair users, like pressure sores or infections, from equipment that isn't custom tailored to their needs.

"Once a power wheelchair is fitted for someone, it can't just be put back on shelf and given to someone else," says Morris. "It takes time and money to do all that adjustment. If a person is renting a power wheelchair, it is possible it won't be fitted to their needs, which could cause secondary problems."

See full story at: http://www.cleveland.com/medical/index.ssf/2010/04/health_care_fact_check_the_imp.html

Mobility Matters: Faulty OIG Pricing Analysis Is Misleading Congress, Says American Association for Homecare

Does the U.S. Department of Health and Human Services (HHS) Office of Inspector General advocate for specific policies, rather than objectively monitoring HHS programs and how well their goals are achieved? The homecare community is posing that question after the Office of Inspector General (OIG) issued a report last summer that the OIG acknowledged was flawed but still used the results to advocate this month for lowering Medicare reimbursement for power wheelchairs. Reimbursements for these devices have already been cut by 37 percent over the past three years.

“By law, the OIG’s mission is to protect the integrity of HHS programs as well as the health and welfare of the beneficiaries of those programs,” said Tyler J. Wilson, President of the American Association for Homecare (AAHomecare). “The OIG also has a responsibility to report to HHS Secretary Kathleen Sebelius and Congress on the recommendations based on their audits, investigations, evaluations and other mission-related functions.”

But there should be grave concerns in the Obama administration, Congress, and the homecare community if the OIG’s results and recommendations are based on methodologies that can’t be trusted. That is clearly the case with the OIG’s August 2009 report on the acquisition costs for providing power wheelchairs to Medicare beneficiaries, as well as an October 2007 OIG report that compares Medicare acquisition costs to prices on the Internet. Both studies contain questionable data and were cited as resource material to support the OIG’s ill-conceived recommendation on reimbursements this month.

OIG REPORTS ON INTERNET PRICING AND ACQUISITION COSTS DEEPLY FLAWED
The October 2007 OIG report, “A Comparison of Medicare Program and Consumer Internet Prices for Power Wheelchairs,” concluded that Medicare costs are higher than median Internet prices for power wheelchairs. But this report was deeply flawed. In a letter to Inspector General Daniel Levinson, AAHomecare noted that Internet pricing does not compare to the costs associated with providing these devices to Medicare beneficiaries and adhering to appropriate standards of care. A previous OIG analysis of power wheelchair prices acknowledged that savings estimates would be lower if supplier administrative costs were included. Internet pricing does not account for the specialty evaluations performed by certified medical professionals, training, repairs and other non-equipment costs that are required in furnishing power wheelchairs to Medicare beneficiaries.

Meanwhile, the August 2009 OIG report, “Power Wheelchairs in the Medicare Program: Supplier Acquisition Costs and Services,” determined that the average amount paid for standard power wheelchairs in 2006 is higher than costs in the private sector. But the OIG conceded their research was incomplete because, once again, it didn’t account for all the services that suppliers provide, noting, “We did not determine the cost of performing these services or other general supplier business expenses, such as billing, accreditation, staff salaries, or facility maintenance.”

The August 2009 report fails to include the cost of 26 federally-mandated supplier standards and accreditation requirements that set a floor for the quality of service required of the home medical equipment firms that participate in Medicare. It also excluded the costs for documenting each patient’s medical necessity for a power wheelchair, selecting the appropriate equipment, sizing the beneficiary for the power wheelchair and delivering the equipment.

OIG’S INCOMPLETE DATA MISINFORMS LAWMAKERS
Citing pricing data from the 2009 report, the OIG issued its “2010 Compendium of Unimplemented OIG Recommendations” in March and called on Medicare to further cut the fee schedule for standard and complex power wheelchairs.

Besides using the faulty data, the OIG also failed to note that Congress has imposed steep cuts on reimbursement fees for power wheelchairs over the last three years. Those cumulative cuts amount to 37 percent. In addition, there are new medical policies, updated quality standards, and surety bond and mandatory accreditation requirements imposing additional financial burdens and checks on providers. Already, the policy changes and price cuts have caused many wheelchair providers to close their doors or to no longer offer power wheelchairs.

NEW PRICING CUTS WOULD DEVASTATE PROVIDERS
What’s clear is that the OIG is out of touch with the economic conditions in the home medical equipment marketplace: another round of reimbursement cuts would devastate providers and compromise their ability to provide power wheelchairs to Medicare beneficiaries.

The homecare community welcomes research that can help government officials, providers and stakeholders work together to formulate fair pricing schedules, as well as policies that will provide to Medicare patients and people living with disabilities medical equipment prescribed to improve their safety, ability to function and quality of life. Confidence must be restored in the OIG research process, and their policy recommendations. This will be an important step toward ensuring that mobility assistance remains available to Medicare beneficiaries.

For more information visit www.aahomecare.org/mobility.