OIG Report: Most Medicare Power Wheelchairs Fail Medical Necessity Guidelines

The Office of Inspector General (OIG) released a report stating they found 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. These power wheelchairs accounted for $95 million of the $189 million that Medicare allowed for power wheelchairs during this period.

Recommendations to the Centers for Medicare and Medicaid Services (CMS), based on the OIG’s findings, included:
1. enhanced reenrollment screening standards for current suppliers of durable medical equipment, prosthetics, orthotics, and supplies;

2. reviewing records from sources in addition to the supplier, such as the prescribing physician, to determine whether power wheelchairs are medically necessary;

3. continuing to educate power wheelchair suppliers and prescribing physicians to ensure compliance with clinical coverage criteria; and

4. reviewing suppliers that submitted sampled claims we found to be in error.
After reviewing the report and recommendations, CMS agreed to all of the OIG’s recommendations except for enhanced reenrollment screening standards for current suppliers of DMEPOS.

AAHomecare’s Vice President of Government Relations, Walter Gorski, said, “Not only is the OIG report misleading, the OIG continues to draw the wrong conclusions from the results of the study. Government bureaucrats are overturning physicians’ medical judgment more than six out of every ten times. When the so-called error rate does not decrease despite continued efforts to educate providers over a period of several years, CMS and the OIG must look to simplify the coverage policy and inject common sense back into the auditing process.”

The American Association for Homecare’s Complex Rehab Power and Mobility Council is reviewing this report. To learn more, contact Alex Bennewith at 703-535-1891.

Proposed Rule Issued on Home Health Face-to-Face Requirement

On July 5, 2011, CMS issued a proposed rule that would require a physician who is ordering home health services under Medicaid to document that a face-to-face exam with the patient has occurred. The proposal, called for by the Patient Protection and Affordable Care Act (ACA), requires a face-to-face exam with a physician for home health and durable medical equipment (DME) under both Medicare and Medicaid.

Beginning on April 1, 2011, CMS has required a face-to-face exam prior to certification for Medicare home health for patients, and it has been subject to push back from Congress and the homecare and physician communities. Yesterday’s proposed rule expands this requirement to patients who require home health services under Medicaid as well as clarifies the definition of “medical supplies, equipment and appliances,” which is the term used for DME under the Medicaid home health services benefit.

CMS has not yet issued a rule to apply the face-to-face exam requirement to DME patients under the Medicare program. However, the proposed rule indicates the items that will be subject to the DME face-to-face exam requirement for Medicare will also require a face-to-face exam prior to ordering the items under Medicaid.

Learn more about this homecare issue (AAHomecare members-only)

What CMS is Not Saying About the Competitive Bidding Program

In contrast to CMS reports that there have been no changes in beneficiary health outcomes resulting from the Medicare competitive bidding program for durable medical equipment, AAHomecare and other members of the homecare community are hearing a markedly different story from patients and providers affected by the program.

People for Quality Care has captured a particularly appalling story from Jim Kokenge, president and CEO of PAX Medical Supply, a DME provider in Cincinnati, Ohio. Jim's story illustrates the impact that the confusing and poorly-implemented bidding program is having on patients -- and clearly shows a wide discrepancy between the picture painted by CMS and the reality of this bidding program.

"I am offended when I hear CMS putting out statements that there are no problems when we're getting calls on a weekly basis, daily actually, from therapists who we had dealt with as referral sources who don't know who to go to," says Kokenge.

Watch the video

While there's plenty in this story that causes alarm, we're especially struck by the primary concern of the higher-level CMS staffer who Jim talks about in the latter stages of the video.

Legislation to repeal the bidding program, H.R. 1041, was introduced after hundreds of patients and providers reported problems with the program in the wake of its January 1 implementation. As designed by CMS, the bidding program severely and arbitrarily restricts the number of companies that are allowed to provide commonly used medical equipment and services. Since the program began, patients, clinicians, and homecare providers have reported:

• Difficulty finding a local equipment or service provider;
• Delays in obtaining medically required equipment and services;
• Longer than necessary hospital stays due to trouble discharging patients to home-based care;
• Far fewer choices for patients when selecting equipment or providers;
• Reduced quality; and
• Confusing or incorrect information provided by Medicare.

The legislation has strong bipartisan support in the House, with over 130 cosponsors. AAHomecare would like to thank those members of Congress who have cosponsored H.R. 1041, which will protect Medicare patients' access to home medical equipment.

Medicare’s Audit Process Hampers Access to At-Home Care

Over-reaching by federal audit contractors in Medicare is restricting the ability of legitimate providers to supply medically required care and equipment to patients. The American Association for Homecare is working with policy makers to ensure that fraud prevention efforts are effective at stopping fraud without limiting access to care.

At a June fraud prevention summit conducted by the U.S. Department of Health and Human Services and the Justice Department, the administrator of the federal Centers for Medicare and Medicaid Services (CMS) admitted that audits designed to detect fraud are a “blunt instrument.” After hearing several complaints from healthcare providers participating in the fraud prevention summit, another CMS official stated that federal officials will conduct an “audit audit” to ensure that audit contractors do not needlessly hamper legitimate providers.

“The current auditing strategy is expensive, inefficient, and distorts the Medicare claims error rate for at-home care products,” said Tyler Wilson, president of the American Association for Homecare. “The burdensome process disrupts the service and care provided to patients in need of these at-home services and severely taxes providers’ resources.”

To read the full article, visit the AAHomecare Newsroom.

Home Medical Equipment Sector Continues to Promote Tough Anti-Fraud Measures

Following the Philadelphia Health Care Fraud Prevention Summit on June 17, which is sponsored by the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice, the American Association for Homecare released the following statement:

“The American Association for Homecare and its members have always had zero tolerance for fraud and will continue to work with federal officials to prevent fraud. In 2009, the American Association for Homecare proposed to Congress an aggressive 13-point Medicare Anti-Fraud Legislative Action Plan that includes tougher penalties for fraud, more site visits, and real-time claims audits to prevent fraud at the front-end of the process rather than relying on the ineffective pay-and-chase system. The majority of the Association’s recommendations have been adopted by Congress and the Centers for Medicare and Medicaid Services (CMS). However, we encourage Congress to adopt all of our proposals to ensure a comprehensive approach that directly shuts down avenues for Medicare fraud. A number of important new anti-fraud measures are now in place, which were long overdue. But Congress, CMS, and the HHS Office of Inspector General (OIG) should not impose unreasonable burdens on the existing, accredited home medical equipment providers. “Crooks, cheats, and con artists have no place in Medicare or healthcare in general,” said John Shirvinsky, executive director of the Pennsylvania Association of Medical Suppliers. “Unfortunately the CMS enforcement model has spent more time on punishing legitimate home medical equipment providers than eliminating the opportunity for bad actors to get into the Medicare system.” It’s important to point out that providers of home medical equipment must now be accredited by a deemed accrediting organization and they must also post a surety bond. These two requirements took effect in October 2009, and fraud associated with the home medical equipment sector has likely declined since then. We encourage federal officials to assess and report the rate of fraud since these requirements took effect. Spending in the home medical equipment sector represents less than 1.5 percent of total Medicare spending, and the HME proportion as well as the dollar amount in Medicare are falling. By any measure, any fraud or waste associated with home medical equipment sector can only represent a tiny fraction of total fraud, waste, or abuse in Medicare. The American Association for Homecare understands that lawmakers and regulators face the difficult challenge of reining in growing health care costs – and federal spending overall – which is why it is critical to note that home-based care is the most cost-effective setting for post-acute care. Congress must consider the aging U.S. population, the rising incidence of diabetes, COPD, and other chronic conditions, the high cost of treatment in hospitals and nursing facilities, and Americans’ clear preference for remaining safe and independent at home as they age. All of these factors argue for a stronger approach to providing homecare, not an erosion of the system.”

To see the 13-Point legislative plan, visit www.aahomecare.org/stopfraud.