CMS Launches 3-Point Power Mobility Initiative
In late April, the Centers for Medicare and Medicaid Services (CMS) unveiled a three-part power wheelchair coverage and payment policy initiative, which CMS Administrator Mark D. McClellan, MD, PhD, calls the “next stage in strengthening our policies for power mobility devices.”

The three-pronged initiative, released during a Senate Finance Committee hearing on power wheelchair fraud and abuse held April 28, involves the following actions:

1. Developing guidance on who is covered under current Medicare power wheelchair policy. CMS’ chief medical officer is bringing together clinicians from across the US Department of Health and Human Services (HHS) and other government agencies to refine and describe the conditions that are associated with the current coverage definition and to develop draft guidance for determining whether a patient meets the definition of “bed or chair confined”—a standard that currently denotes a beneficiary’s eligibility for the Medicare benefit, but has been controversial in its interpretation. CMS says the public will have an opportunity to comment before the guidance is finalized.

2. Splitting the K0011 code to reflect the various models of wheelchairs and scooters with different market prices. Currently, most power wheelchairs are billed under the K0011 code, for which Medicare pays a ceiling amount of $5,296.50. Recognizing that the power wheelchair market has changed “substantially since the current HCPCS codes for power wheelchairs were added in late 1993,” CMS will work with a national coding panel to develop the new set of codes and corresponding payment ceilings.

As part of prong two, CMS says it also plans to implement competitive bidding for some DME, including power mobility devices, as authorized by the Medicare Prescription Drug, Improvement and Modernization Act of 2003.

3. Implementing quality controls for suppliers “to ensure that beneficiaries receive high-quality power mobility services.” CMS says this entails revising supplier standards for enrolling in Medicare and, as part of the implementation of competitive bidding, developing a proposal for an accreditation program.

CMS says the new three-pronged initiative builds on its ongoing Operation Wheeler Dealer 10-point power mobility campaign introduced last September. According to CMS, Operation Wheeler Dealer reduced claims in Harris County, Texas—the hub of the fraud and abuse activity—by $54.9 million in 7 months, from $59.8 million in May 2003 to $4.9 million in December 2003. Nationwide, CMS says federal officials have recovered $84 million in fraudulent power mobility claims since 2003.

Overall, the industry’s response to the new initiative was positive, especially to the third prong’s promotion of quality controls for suppliers.

Seth Johnson, vice president for government affairs for the American Association for Homecare (AAHomecare), says the initiative is “in line” with what the industry and AAHomecare have advocated for the past few years. His main concern was the speed at which it will take the changes to grind through the bureaucracy.

One point of contention was with CMS calling on clinicians from HHS and other government agencies to refine and describe the conditions associated with coverage policy.

“We would hope that they enlarge the panel to include clinicians outside of the government,” says Sharon Hildebrandt, executive director of the National Coalition for Assistive and Rehab Technology. “We think there should be clinicians involved who have hands-on experience in predicting the need for power wheelchairs or scooters.”

Cara Bachenheimer, JD, vice president of government relations for Invacare Corp, Elyria, Ohio, and cochair of the Restore Access to Mobility Partnership, agrees with Hildebrandt on that point. While she “applauds this CMS initiative virtually all the way” and is thankful CMS is working to provide a more detailed explanation of the conditions that qualify a person for Medicare coverage, Bachenheimer would like to see a broader group refining current coverage policy.

“We really believe that people who are involved in prescribing and fitting for wheelchairs need to be involved from the get-go,” Bachenheimer says. “Otherwise, it’s going to be a deficient process.”

In addition, both Bachenheimer and Hildebrandt hope that CMS in its reworking of the K0011 code accepts the power mobility coding structure proposal submitted by the industry earlier this year. The Power Mobility Coding Task Force, composed of power wheelchair suppliers and manufacturers and other groups, worked for 2 years in developing the coding proposal with input from clinicians.

OIG Exposes CMS Power Wheelchair Blunders
Despite warnings from the four DMERCs, Centers for Medicare and Medicaid Services (CMS) did not control rising power wheelchair spending in a timely manner, according to an Office of Inspector General (OIG) report released April 28 during a Senate Finance Committee hearing.

Testimony during the hearing uncovered government oversights that led to soaring power wheelchair reimbursement spending and finally to a crackdown on power wheelchair abuse and fraud last fall.

For example, almost one third of a random sampling of 300 Medicare beneficiaries who received a power wheelchair under the K0011 code in 2001 did not meet the requirements for any type of wheelchair, the OIG reported.

“In fact, the OIG found that only 13% of those it surveyed actually met the coverage requirement for a K-11,” said Senator Chuck Grassley (R-Iowa), chairman of the Finance Committee, during the hearing. “That, I submit, is not a very good batting average—in any league.”

A second OIG report estimated that Medicare and its beneficiaries could have saved more than $224 million in 2002 if its reimbursement amount were set at consumer prices, which the OIG found to be about $1,434 per K0011 wheelchair less than what it pays.

In response to these and other findings, the OIG recommended that CMS create a new K0011 coding system, consider using inherent reasonableness to review claims, require DMERCs to revise coverage policy and conduct frequent reviews of procedure code, and educate both providers and beneficiaries about Medicare’s coverage criteria. Some of the suggestions were fulfilled by a CMS three-point initiative on power wheelchair coverage and payment policy announced by CMS Center for Medicare Management Director Herbert Kuhn during the hearing (see story, page 10).

The hearing also was attended by several other industry and legislative representatives, including a defendant who pleaded guilty to DME fraud; Leslie Aronovitz, director, health care, Program Administration and Integrity Issues, US General Accounting Office; Dara Corrigan, OIG acting principal deputy inspector general; and Kay Cox, president and CEO of AAHomecare, Alexandria, Va.