“Nothing that we were doing with ‘Operation Wheeler Dealer’ was ever intended to impede access to wheelchairs for those beneficiaries who legitimately needed them,” said Kim Brand, acting director of the Centers for Medicare and Medicaid Services (CMS) Program Integrity Group, in a March 31 open-door meeting following CMS’ decision to rescind the controversial December 9 clarification of its coverage policy for power wheelchairs.

The clarification, Brand said, had been “misconstrued and misinterpreted” as a policy change when really it was just intended as an education effort for providers who wanted additional guidance from CMS after it started looking more closely at power wheelchair claims in 2003.

Drawing from the many comments CMS received in the past few months, Brand and John Warren, of her staff, organized the top issues into eight themes. These were:

1) The confusion over the scope of the DME benefit and the coverage criteria for wheelchairs.

2) The need to ensure that these coverage criteria are enforced consistently by the DME Regional Carriers (DMERCs). Brand said CMS is striving to provide consistent review and application of policy as part of Operation Wheeler Dealer’s 10-point initiative.

3) The problem that, although a case can be made for the benefits of power wheelchairs for use outside the home, CMS is legally allowed to fund only DME that will be used primarily within the home.

4) The issue of some beneficiaries qualified for power wheelchairs being denied them. (Brand noted that despite a high-profile case reported in The New York Times, CMS believes that, under its current coverage policy, persons for whom power wheelchairs are medically necessary are able to obtain them.)

5) The concern that CMS and the DMERCs, through their medical review activities, were usurping the physician’s judgment. “That couldn’t be further from the case,” Warren said.

6) The question of what CMS and the DMERCs would look for in reviews of medical documentation. The answer, Brand said, is corroboration of the medical need for the power wheelchair, especially with documentation produced before the wheelchair was provided.

7) Understanding of CMS’ position that the equipment provider should be the primary person to go to for additional documentation because the provider is the one that accepts the payment.

8) The idea of using national accreditation bodies to prevent fraud without unfairly penalizing honest suppliers. “The way things are set up now, we don't have the authority to do that,” Warren explained. “But under section 302 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, we do have the authority to establish quality standards for suppliers and identify organizations that can measure and work to make sure those standards are publicized. CMS is now working on the implementation of that part of the act and, as we get further into process, you’ll learn more.”

The CMS officials in the open-door session promised further meetings and hinted that additional direction may be coming once CMS’ new administrator, Mark McClellan, MD, PhD, had had time to study the issue.

Although the meeting did not answer all the questions the home health care industry may have hoped it would, Seth Johnson, director of public policy for the American Association for Homecare, was cautiously optimistic that CMS would continue to take steps toward revising the policies to please both suppliers and beneficiaries.

“There is clearly an indication from CMS that they do want to resolve this issue and continue to work with industry to come up with a workable solution,” he said.

However, providers should not hope that CMS will immediately change the way it is reviewing claims simply because it rescinded the clarification and is holding more meetings, Johnson cautioned.

“They still do not believe that there was any change in the medical policy, and they believe the policy that is in effect was the same policy that was in effect prior to December 9,” he said.

His views were echoed by Cara Bachenheimer, vice president of government relations for Invacare Corp, Elyria, Ohio, and co-chair of the Restore Access to Mobility Partnership, a power mobility coalition.

“There is no question that CMS did the right thing by rescinding what I call ‘the coverage restriction’ and they call the ‘clarification,’” she said prior to the open-door meeting. “But there are other things that need to happen to make sure that consumers who medically need power wheelchairs still have access to them....The problem with just rescinding the clarification is that it is backward looking and we need to be going forward. We can spin our wheels all day analyzing the responses and why the clarification was a bad thing, but I would rather see CMS come out with a statement of the issues it has and possible solutions to address those so we could work collectively. We think we have some good ideas and I’m sure CMS has a whole lot of different ideas on how to figure it out.”

Lena Lindahl is editor of Dealer/Provider.