Industry cries foul over K0011 coverage criteria

BALTIMORE, Md. - CMS and the DMERCs, in a bulletin that has stunned manufacturers and suppliers of power mobility for seniors, have announced plans to strictly enforce coverage criteria for power wheelchairs that could severely restrict the provision of K0011 chairs. The Dec. 8 and Dec. 9 bulletins from all four DMERCs are widely viewed as a crackdown on the remarkable growth in Medicare expenditures for the K0011 and a reining in of a liberal interpretation of the ‘bed or chair confined' policy that governs medical necessity. “Some regions may not have been as strict in their interpretation of ‘bed or chair confined' and allowed payment of claims where the beneficiary may have been more ambulatory than the national policy language allowed,” said Dr. Robert Hoover, medical director of Region D. The DMERC action follows revelations of a gross power wheelchair racket in Harris County that resulted in CMS's Operation Wheeler Dealer action to curb abuse and a ripple effect that pushed power wheelchairs into newspapers from coat to coast and an NBC Nightly News ‘Fleecing of America' report. National policy on power wheelchair coverage states that a power wheelchair is covered if the patient is bed or chair confined. The DMERCs' clarification states that patients who can walk without assistance or with the assistance of an ambulatory aid do not qualify for a power wheelchair. In other words, the DMERC position makes clear that ‘no steps, nowhere' is the order of the day. The DMERCs are pursuing an “aggressive medical review policy” on a pre-pay or post-pay basis, which means that thousands of filed claims could now be looked at through the prism of this strict new policy. Invacare and Sunrise Medical CEOs Mal Mixon and Mike Hammes have written letters to CMS and the DMERCs, objecting to clarification. Each company believes the clarification is evidence of a “substantive change.” “Changes to Medicare policy must be done in accordance with established procedures, requiring advance notice to affected parties, full consideration of public comments, and a prospective effective date,” Mixon wrote. The clarification may have enormous implications for power chair providers in the Region C DMERC, which approved claims for three times as many beneficiaries as Region D and seven times as many in Region A during the most recent reporting period. In a Nov. 18 meeting with CMS, the Scooter Store revealed that the Region B DMERC was seeking additional documentation on 84% of its 2003 claims. Region D was seeking additional documentation on 78% of its claims. The Scooter Store has received 88 requests for additional documentation in Region A. None are noted for Region C. In a record of that meeting, the Scooter Store notes that these requests are a violation of CMS's Progressive Corrective Action plan and the Paperwork Reduction Act. In Region C, longtime Medical Director Dr. Paul Metzger, who now works for the Scooter Store, said changes to the CMNs in the mid-1990s documented a “change in application of the policy to a more liberal or realistic interpretation.” In Region C, Medicare beneficiaries who were confined to the home and who could take some steps inside the home have not been disqualified for power wheelchairs. The clarification is not expected to change much in Region C, said Hoover. “We have been consistent in our strict application of the national policy for several years,” he said. “As a result, this clarification of national policy will have less of an impact on Region D suppliers than it might in a region that has not been strictly enforcing the ‘bed or chair confined' criterion.” Despite strong industry opposition, some agreed that the clarification was needed to bring some consistency back to the process. “From NRRTS perspective, the clarification overall is pretty good,” said NRRTS President Dan Lipka. “When there are gray areas, it's difficult for people to have a handle on what's needed.” Tim Pontius, CEO of Young Medical Equipment is Toledo, Ohio, also said he was not surprised by the bulletin, but that, like Lipka, he worried that the clarification may prove detrimental to needy beneficiaries. “The concern with this wheelchair policy is that the pendulum may come too far in the other direction, so we can't get people qualified who actually need the chair,” he said. Cara Bachenheimer, vice president of government relations for Invacare, echoed Pontius's concern, saying stringent policy interpretations keep people out of the products they need. “My instinct is that this is a knee jerk reaction by the medical directors to tighten up coverage in response to the Houston scandal,” said Bachenheimer. “If so, a more restrictive interpretation of the Medicare coverage policy for motorized wheelchairs is not an appropriate reaction. That doesn't get rid of the bad apples.”