A study released yesterday by the Office of Inspector General (OIG) at the Department of Health and Human Services illustrates the pressing need for the Centers for Medicare and Medicaid Services (CMS) to give physicians concrete direction to meet policy and compliance mandates. The report found that more than half of Medicare power wheelchair claims submitted in the first half of 2007 did not meet medical necessity requirements. However, the vast majority of audited claims that were considered improper were the result of a lack of full documentation by the prescribing physician in the patient’s medical record. The report validates what the American Association for Homecare (AAHomecare) has been advocating for years: lawmakers need to hold CMS accountable to establish clear and objective guidance to the physician community in the power mobility benefit.
AAHomecare President Tyler Wilson noted that the OIG report, “Most Power Wheelchairs in the Medicare Program Did Not Meet Medical Necessity Guidelines” (OEI-04-09-00260, July 2011) does not focus enough attention on the real problem—CMS has an expectation of documentation in the medical record without providing a tool for all levels of prescribing physicians to follow. And the report highlights the fact that suppliers are lacking understanding with respect to when the medical documentation meets policy requirements.”
Walter Gorski, AAHomecare Vice President of Government Relations, added, “power wheelchair providers are being put into a position of educating physicians on a very complex policy and then judging the physician’s medical record competency. This should not be the power wheelchair provider’s role. The home medical equipment provider needs to feel confident that the physician is documenting everything CMS expects to see within the medical record and the physician needs to feel assured that the information they are recording in the medical record meets policy requirements, guaranteeing coverage for their patients.”
Gorski added that “this problem could be solved very quickly if CMS were to create a mandatory comprehensive medical necessity assessment template for use by physicians to document proof that the power wheelchair is medically required.”
It is also worth noting that the study takes a snapshot picture in time when confusion about what was required of suppliers and physicians was at its peak. The OIG study looked at power wheelchair claims immediately after CMS had completely overhauled the power mobility benefit in late 2006 (including coverage criteria and coding) and then immediately began issuing clarifications and bulletins, which led to a high level of confusion in the power wheelchair provider community. As a result, auditing of these claims was very subjective, leading to misleading conclusions. Moreover, the OIG report in no way implies that power wheelchair providers are participating in any form of unscrupulous or fraudulent behavior. Since the OIG study was undertaken, power wheelchair providers must be accredited and comply with much more stringent quality and operational standards.