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OIG Slams Medicare for Wheelchair Reimbursements, Again

 |  By cclark@healthleadersmedia.com  
   July 08, 2011

Medicare paid $95 million during the first half of 2007 for beneficiaries' power wheelchairs that were not medically necessary or for which claims lacked sufficient documentation, according to an audit released Thursday by the Office of Inspector General. 

The $95 million was 61% of the $189 million that the agency allowed for power wheelchairs – which cost between $4,132 to $11,965 – in the first half of 2007.

"Based on records submitted by suppliers that provided power wheelchairs, 9% of power wheelchairs were medially unnecessary and another 52% had claims that were insufficiently documented to determine whether the power wheelchairs were medically necessary," the OIG said.

For some of these beneficiaries, a less expensive type of equipment or a different type of power wheelchair would have sufficed.

By definition, power wheelchairs are approved for Medicare beneficiaries whose "mobility deficit cannot be addressed using other types of mobility-assistive equipment, such as a cane, manual wheelchair or scooter," the OIG report said.

Additionally, the beneficiary must be physically and mentally able to operate a power wheelchair and that person's home must provide adequate access between rooms for the wheelchair to operate. To qualify for more specific types of power wheelchairs, the beneficiary must satisfy other criteria. For example, his or her weight must be equal to the capacity of the power wheelchair.

The OIG report found that, after reviewing prescribing physicians records, those records did not support the medical necessity of those wheelchairs.

The agency's report said that despite numerous reviews of expenditures for these medical devices, "Medicare has paid significantly more in recent years (since 2007) for power wheelchairs than it did in 2007...(indicating) that CMS (the Centers for Medicare & Medicaid Services) continues to pay for power wheelchairs that are not medically necessary and/or that have claims that do not meet documentation requirements."

Two previous OIG reports found these and other problems with coding and documentation.

The OIG recommends that CMS:

1.     Enhance reenrollment screening standards for durable medical equipment prosthetics, orthotics and supplies (DEMPOS) benefits

2.     Review records from sources in addition to the supplier, such as records from the prescribing physician, to determine whether power wheelchairs are medically necessary.

3.     Continue to educate power wheelchair suppliers and prescribing physicians to ensure compliance with clinical coverage criteria.

4.     Review suppliers of sampled claims that were found to be in error.

In a letter responding to the report, CMS administrator Don Berwick said he agreed with the second, third and fourth recommendations, but not the first.

"CMS has in place other tools that allow for increased scrutiny of existing DMEPOS suppliers – particularly new authorities provided to us under the Affordable Care Act," he wrote. "In addition, CMS can impose a payment suspension against an existing provider or supplier in cases where it has been determined...that there is a credible allegation of fraud against the provider or supplier."

Federal fraud investigators have targeted Medicare's unnecessary wheelchair reimbursements for more than a decade. Between 1999 and 2003, Medicare's bill for power wheelchairs shot up 350% to $1.2 billion a year, more than 12 times overall Medicare program expenditure increases. This prompted CMS to revise its power wheelchair coverage and coding in 2005 and 2006, and costs subsequently decreased to $658 million in 2007.

Now, costs are rapidly rising again, to $779 million in 2008 and to $728 million in 2009.

Sen. Tom Carper (D-Del.), Chairman of the Subcommittee on Federal Financial Management, said the OIG report "raises some troubling questions and shows all too clearly that while the federal government has made some progress in preventing waste and fraud, much more remains to be done."

He added, "When we see that more than half of Medicare's payments for power wheelchairs in a given time failed to meet the appropriate standards required for reimbursement, we know that something is very wrong and that the federal government can and must do better."

Carper's bill, co-authored with Sen. Tom Coburn, MD, (R-OK) calls for improvements in screening measures to prevent fraud and abuse.

 
See Also:

Medicare Spent Four Times More for Power Wheelchairs Than Suppliers

OIG: Medicare Paid $112M for Improperly Documented Power Wheelchair Claims

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