Misleading OIG Report Fails to Blame Flawed CMS Documentation Process

The Inspector General’s Office (OIG) of the U.S. Department of Health and Human Services issued a report last week concluding that 61 percent of power wheelchairs provided to Medicare beneficiaries in the first half of 2007 “were medically unnecessary or had claims that lacked sufficient documentation to determine medical necessity.” But their report clearly indicated that medical necessity was actually only questioned on nine percent of the claims.

The OIG report reaffirmed that the major problem is not mobility equipment going to Medicare beneficiaries who don’t need it, but the government’s failure to establish a process that fairly and adequately documents a Medicare beneficiary’s medical necessity for a power wheelchair. In fact, the vast majority of claims cited in the OIG report were flagged as improper because information was missing in the medical records of the patients that received power wheelchairs.

The fact that the OIG concluded that information was missing in 52 percent of the claims underscores that the government needs to fix the documentation process for determining the medical necessity for power wheelchairs. Despite the repeated pleadings of stakeholders — providers, physicians, clinicians, Medicare beneficiaries, consumer advocates and others — the Centers for Medicare and Medicaid Services (CMS) continues to utilize a flawed system that leaves physicians, providers and Medicare beneficiaries confused about what documentation is needed to satisfy their requirements.

Moreover, the flawed documentation system has become the basis for OIG reports and audits that unfairly create the perception that home medical equipment providers acted improperly and Medicare patients have received equipment that they don’t need. It’s unfortunate that these misconceptions are damaging the image of the Medicare program, providers and beneficiaries at a time when Congress is searching for ways to cut spending to address the nation’s escalating budget deficit.

“Stakeholders have asked CMS to improve the documentation process for years,” said Tyler Wilson, president of the American Association for Homecare. “CMS must focus on establishing a process that works for the government, providers, physicians and Medicare beneficiaries. This should include a template that can assist the prescribing physicians in providing the extensive patient medical information that is being required. And CMS needs to adequately educate providers and physicians on what exactly is required, and how that information must be presented.”

Read AAHomecare's full Mobility Matters article.