Power Wheelchair “Clarification” Starts to Hit Home
Doris Kemp cannot walk more than five feet, and even those strides are taken at great risk of falling. Fred Ard ambulates with a cane at only about a mile per hour; with a wheelchair he can travel four times as fast. Both were denied power mobility vehicles under new measures being taken by the Centers for Medicare and Medicaid Services (CMS) to prevent fraud abuse, says Pam Seymour, president of Southeastern Medical.

Part of the CMS effort is a power mobility reimbursement policy clarification, which states that power wheelchairs and power-operated vehicles (POVs) are covered only for nonambulatory beneficiaries who cannot operate a manual wheelchair. It defines nonambulatory patients as those who only can “bear weight to transfer from a bed to a chair or wheelchair” and without such are bed- or chair-confined. Previously, Medicare generally covered power mobility vehicles under more lenient standards provided that a valid certificate of medical necessity was filed.

Seymour says her small DME dealership in Winterhaven, Fla, is in grave danger of having to repossess the chairs and close up shop unless someone does something about withheld Medicare payments. She has decided to make that someone her.

“We’re just waging an all-out war here for three patients,” Seymour says of the three beneficiaries who rely on her store for their power mobility needs and have had their Medicare claims denied.

Seymour has taken her story and that of her beneficiaries to several media outlets, including local newspapers. In January, a television segment detailing the plight of her dealership and its beneficiaries aired on ABC Action News in Winterhaven. She also recently explained her concerns to US Representative Ginny Brown-Waite (R-Fla) at a town hall meeting and even met with Florida Governor Jeb Bush in January.

“If we have to go and picket the office of Congressman [Adam H.] Putnam (R-Fla), we are fully prepared to do that,” Seymour says.

Seymour is not alone in her outcry against CMS’ recent actions. A January 30 New York Times article examining the implications of the CMS policy clarification helped bring national attention to the issue. Manufacturers and providers of mobility equipment alike have written letters to CMS and formed coalitions, including the Restore Access to Mobility Partnership and the National Coalition for Assistive and Rehab Technology (see stories on pages 13 an 14), to persuade the agency to rescind the clarification, which opponents assert is actually a major change in reimbursement policy.

But CMS CFO Tim Hill, concerned about Medicare K0011 payments nearly tripling to more than $845 million in 2002 from just more than $289 million in 1999, says the clarification is simply a restatement of previous policy.

“If you’re going to ask me if we would have paid for something 3 years ago that we are not going to pay for now, that may be the case. But it’s only because we are now focused and reviewing those claims with more scrutiny; it is not because the policy has changed,” Hill says.

However, Hill reassures providers that when CMS reviews claims, it will examine specific cases taking medical documentation and physician notes and prescriptions into consideration.

Meanwhile, beneficiaries across the nation, including those for whom Seymour provided power wheelchairs, remain in danger of losing their primary means of mobility.

“I’ve got myself all worked up over this, and I’m raising my voice,” Seymour says. “If I’m not going to stand up for these patients’ rights, then who is?”

Cara Bachenheimer, JD Mike Hammes

Power Mobility Coalition Forms
Centers for Medicare and Medicaid Services (CMS) must rescind the power mobility reimbursement policy clarification issued in December 2003, says a newly organized coalition of national senior, disability, consumer, clinical, and medical organizations called Restore Access to Mobility Partnership (RAMP). Among others, its members include: the American Association for Homecare (AAHomecare), Alexandria, Va; Invacare Corp, Elyria, Ohio; The MED Group of Lubbock, Tex; Mobility Products Unlimited LLC, Holly Hill, Fla; Pride Mobility, Exeter, Pa; The Scooter Store, New Braunfels, Tex; and Sunrise Medical, Longmont, Colo.

“The whole concept of what this industry has been operating under with the government for rehab and for geriatric is put at substantial danger by this new policy, and that’s why it was felt very important to put forth a focused effort,” says Mike Hammes, chairman and CEO of Sunrise Medical.

Hammes says one of the main focal points of the coalition is to inform the public, especially the end users, of the implications of this policy clarification, issued by CMS on a retroactive basis as part of the 10-point initiative to reduce wheelchair fraud and abuse. The clarification states that power wheelchairs and power-operated vehicles (POVs) are covered only for nonambulatory beneficiaries who cannot operate a manual wheelchair. It defines nonambulatory patients as those who can do no more than “bear weight to transfer from a bed to a chair or wheelchair.”

The RAMP coalition says this is not a clarification, but rather a major change of policy.

Cara Bachenheimer, vice president of government relations for Invacare Corp and cochair of the coalition, says RAMP intends to impose congressional pressure to eliminate the clarification and ensure that, in the future, CMS issues clarifications in a “responsible way” by first getting the entire affected community, including clinicians and consumers, involved in the process.

“If this new policy goes through and is implemented, there will be a substantial reduction of the availability of mobility devices, both power and manual, to very qualified people who need them, and that will be a significant social problem because many of these people, if not the vast, vast majority, simply cannot afford to buy those devices out of their own pocket,” Hammes says.

One of the first items on the RAMP agenda was a listening session arranged by CMS in response to negative feedback regarding the clarification.

Group Tackles High-End Rehabilitation Issues
A newly formed, independent coalition aims to address the needs of suppliers and manufacturers who concentrate primarily on high-end rehabilitation and assistive technology.

“This is a critical time for rehab and assistive technology companies,” says Rita Hostak, vice president of government relations for Sunrise Medical and chair of the organization, called the National Coalition for Assistive and Rehab Technology (NCART). “There must be a concentrated effort in order to ensure access to the technology and services critical to the independence, the function, and the quality of life for the millions of adults and children with disabilities.”

In its inaugural year, NCART will focus on four key areas:

1. The challenges surrounding coding, coverage, and reimbursement under the implementation of the Health Insurance Portability and Accountability Act of 1996 HIPAA.

2. Medicaid reimbursement and coverage changes that the organization says are threatening access to rehabilitation technology across the country.

3. Competitive bidding and the necessity for a “carve-out” provision that would exempt rehab and assistive technology from being competitively bid.

4. The Medicare policy clarification issued by the Centers for Medicare and Medicaid Services regarding the qualification criteria for power wheelchairs.

“I understand the need for a focused effort by a separate coalition that only represents high-end rehab providers,” says Joel Mills, current chair of the Alexandria, Va-based American Association for Homecare (AAHomecare), a member of the coalition. “AAHomecare will continue to represent its rehab technology provider and manufacturer members through its Rehab and Assistive Technology Council.”

WHI Provides Home Care Services to United Healthcare
In February, Walgreens Health Initiatives (WHI), through Walgreens Home Care Inc, began providing infusion, HME, and respiratory services, including respiratory medication, to all members of United HealthCare Insurance Company plans and participating affiliates. United HealthCare Insurance is one of the largest managed care organizations in the United States.

Currently operating accredited home care facilities in Arizona, Florida, Illinois, Indiana, New Mexico, Texas, and Wisconsin, Deerfield, Ill-based WHI initially will serve United HealthCare members in these states through this nationwide agreement. As WHI expands, members will have access to home care services in new locations as well.

Byram Healthcare Grows
In February, home health care provider Byram Healthcare Centers Inc, Milford, Conn, acquired the additional patient base of a medical supply company previously owned by a hospital system in the Philadelphia and southern New Jersey area. With this transaction, Byram has acquired the ostomy, diabetes, and urological business serviced by the hospital system.

“For most hospital-owned HME companies, disposable medical supplies are very difficult to manage profitably. These products typically comprise only a small portion of the HME’s home health business, but require significant management time,” says Dave Karchner, Byram’s vice president of acquisitions. “Byram takes this burden away from the hospital provider.”

Ohio HME Company Acquires Weiss
DASCO, a family-owned HME company with seven locations in Ohio, is expanding its reach in the state. On February 1, DASCO took control of Weiss, a 20-year-old Ashland, Ohio-based respiratory and HME supply company.

“The DASCO team is excited about acquiring Weiss,” says DASCO Vice President Jason Seeley. “This helps to solidify our position in the Ohio home respiratory market.” Also in February, DASCO moved its existing Ashland location to the recently remodeled Weiss store.

National Rehab Provider Cuts Ribbon on 3 Branch Offices
Adding to its more than 50 branch locations, National Seating & Mobility (NSM), Franklin, Tenn, a provider of specialized rehabilitation technology products and services, in November opened new offices in Missouri, Rhode Island, and West Virginia.

“At NSM, the client always comes first,” says Mike Ballard, NSM CEO and founder, “and working with professionals who believe in that philosophy of service is our only motivation to open new branch offices. We are excited about these new offices in three new states, but the five incredible professionals who are the heart and soul of these offices are the primary reason for our excitement in making this announcement.”

In Missouri, branch manager Chris Bennett, RTS, will be headquartered in El Dorado Springs servicing clients throughout Central Missouri, North West Arkansas, Kansas, and North East Oklahoma. John Mignacca, ATS, CRTS, and John “Rocco” Faiola, RTS, are the co-branch managers at the Rhode Island branch office, located in Cranston and serving the entire Providence region. In Charleston, West Virginia, Cyglenda Abbott, CRTS, and Dena Paxton, RTS, co-manage the new NSM branch office.

FDA Head To Succeed Scully at CMS
In February, the White House announced President George W. Bush’s intent to nominate US Food and Drug Administration (FDA) Commissioner Mark McClellan, MD, PhD, to be the administrator of the Centers for Medicare and Medicaid Services (CMS). If confirmed by the Senate Finance Committee, McClellan will succeed former CMS Administrator Tom Scully, who resigned in December to join Alston & Bird, an Atlanta-based law firm that represents the National Association for Home Care and Johnson & Johnson, among others.

McClellan, older brother of White House Press Secretary Scott McClellan, has been at the helm of the FDA since November 14, 2002. Previously, he served as a member of the White House Council of Economic Advisers. Prior to that position, he worked at Stanford University as an associate professor and director of the Program on Health Outcomes Research. He was also an attending physician for internal medicine at Stanford Health Services.

As part of his duties as CMS head, McClellan would oversee the new prescription drug program created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which Congress enacted last year.

Kay Cox, president and CEO of the American Association for Homecare, Alexandria, Va, says the association is pleased with the president’s choice.

“McClellan’s understanding and management of today’s health care issues and concerns were well demonstrated at both the Food and Drug Administration and the White House Council of Economic Advisers,” Cox says. “McClellan’s experience and reputation will serve CMS well as the agency moves forward with the challenges it faces in implementing the new Medicare law.”