Medicare’s recently announced demonstration project for power mobility devices (PMDs) is drawing criticism from industry professionals and consumers alike.
The demonstration project, unveiled last month and due to start Jan. 1, 2012, calls for prepayment reviews of claims for a wide range of power wheelchairs and all scooters in seven states: California, Florida, Illinois, Michigan, New York, North Carolina and Texas.
While the Centers for Medicare & Medicaid Services (CMS) said on Nov. 15 that the states were chosen due to “high populations of fraud- and error-prone providers,” critics and industry experts pointed out the high population totals in those states, and that PMD claims from just those seven states made up a large percentage of the total number of Medicare PMD claims.
A Dec. 8 bulletin from the American Association of Homecare noted of the demonstration project, “This will affect nearly half of all Medicare beneficiaries who require power mobility.”
The first phase of the three-year project will require prepayment reviews for most types of PMDs:
— Power-operated vehicles (aka, scooters): HCPCS codes K0800-K0805 and K0809-K0812.
— Standard power chairs: HCPCS codes K0813-K0829.
— Group 2 complex rehab power chairs: HCPCS codes K0835-K0843.
— Group 3 complex rehab power chairs without power options: HCPCS codes K0848-K0855.
— Pediatric and Group 4 power chairs: HCPCS codes K0887-K0891.
— Miscellaneous power wheelchairs with HCPCS code K0898.
Group 3 chairs with powered seating options — with HCPCS codes K0856-K0864 — are excluded from the project.
The second phase of the project would require prior authorization for all of the PMD types involved in the first phase.
The first phase is scheduled to last about three to nine months, with the second phase starting immediately afterward and being rolled out on a state-by-state basis.
Starting Jan. 1, 2012, the DME MACs will send additional documentation requests in response to all claims for the participating PMDs in the demonstration project states. Claims will be denied if DME MACs do not receive the additional, “complete” documentation, CMS said.
A Provider Outreach and Education presentation posted to CMS’s Web site on Dec. 1 said the demonstration project “focuses on error-prone claim type” and “places responsibility on the ordering physician/practitioner to ensure medical necessity for these high-cost items.”
Despite CMS’s assertion that physicians and other prescribers would be responsible for ensuring medical necessity for PMDs, project critics argue that other stakeholders would suffer.
AAHomecare noted that suppliers “are still reeling from the 13-month rental reimbursement policy for mobility equipment, a change implemented last January” which caused “many providers to go out of business or no longer offer power wheelchairs.”
Tyler J. Wilson, president/CEO of AAHomecare, said, “”We are calling on Congress to stop this demonstration project before it prevents older Americans and people living with disabilities from receiving medically required mobility equipment and causes irreparable harm to providers of home medical equipment and services. Members of Congress should be worried about the impact of this program on many of the most vulnerable people in our society.”
AAHomecare quoted United Spinal Association, a consumer advocacy group, as also objecting to the demonstration project.
“The process for receiving a power wheelchair has already become burdensome for Medicare beneficiaries and their physicians,” said Paul Tobin, president/CEO of United Spinal. “There are parts of the country where Medicare patients have to do business with reluctant providers who are hundreds of miles away. This demonstration project will make it harder for them to receive the wheelchair they need for everyday mobility. We will be urging our members to contact their Congressmen and put a stop to this project.”
