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Effectiveness of Medicare Authorization Program for Power Wheelchairs Rests on Inclusion of a Clinical Template

WASHINGTON, June 19, 2012 /PRNewswire-USNewswire/ -- Power mobility stakeholders await implementation of a Medicare prior authorization program for power wheelchairs, an initiative that could address the flawed claims approval process that has hampered physicians and providers for years.  If not implemented properly, the program will restrict access to power mobility devices for qualified Medicare beneficiaries, according to Mobility Matters, a bulletin published by the American Association for Homecare.

Under the proposed prior authorization program, the Centers for Medicare & Medicaid Services (CMS) will subject all claims for power mobility to a prior authorization process for a period of three years in California, Florida, Illinois, Michigan, New York, North Carolina, and Texas.  Medicare patients in these states receive nearly 50 percent of all the power mobility prescribed to beneficiaries each year.

The need for a significant policy change was underscored when a Comprehensive Error Rate Test (CERT) on power mobility devices in DME MAC Jurisdiction D found a 100 percent error rate, a score supposedly signifying that none of the power wheelchairs provided to Medicare beneficiaries in that region met the reimbursement and coverage criteria. What the CERT did demonstrate is that CMS guidelines for documenting medical necessity for a power wheelchair are so subjective and absurd that virtually any reimbursement claim can be found to be in non-compliance.

In fact, even the CERT testing methodology used by CMS has been questioned. The US Department of Health and Human Services Office of Inspector General recently concluded that thousands of denied claims cited as improper payments in CERT testing in 2009 and 2010 were later overturned and paid upon appeal. Thus, CMS overstated the improper payments by $4 billion over that two-year period. (CERT testing doesn't track Medicare fraud or abuse; it is designed to simplify and monitor billing errors.) CMS repeatedly cites high error rates based largely on technical factors, while physicians certify that their patients have a medical need for power wheelchairs so they can improve their mobility and live safely and independently in their homes and communities.   

"It has been apparent for years that the CMS procedure for reviewing power wheelchair claims must be addressed," said Tyler Wilson, president of the American Association for Homecare.  "Medicare beneficiaries suffer because of delays in receiving the mobility equipment they need. Legitimate businesses suffer because they can't get timely reimbursements for the products and services provided to Medicare patients. A properly designed prior authorization program may resolve some of these problems, but it must be planned and implemented correctly."

The prior authorization concept has worked for 49 state Medicaid programs, as well as Medicare's managed care plans and TRICARE, the healthcare system for U.S. military personnel, military retirees and their dependents. One of the key aspects of these prior authorization programs is the use of a clinical template that standardizes the collection of a patient's medical information provided by physicians. While CMS has publicly acknowledged that it is developing an electronic clinical template, the agency has not linked their template to the prior authorization demonstration. And that is causing some anxiety in the power mobility community.

Without a clinical template, the confusing and subjective guidelines for documenting a beneficiary's medical need will remain in place.  Claim requests will be denied repeatedly – as they are now – resulting in 90-100 percent error rates. Therefore, patient care for virtually all Medicare beneficiaries with prescriptions for power mobility devices will be jeopardized.  A prior authorization program with no clinical template will indefinitely delay delivery of prescribed power mobility devices until the claim denials are resolved; some senior citizens and people living with physical disabilities may never receive power wheelchairs.

Paul Tobin, president and CEO of the United Spinal Association, acknowledged the importance of a properly designed prior authorization program and cited the consequences if the program is not planned and implemented correctly.   

"The prior authorization demonstration could address longstanding ambiguity about the documentation needed by Medicare to authorize the provision of, and payment for, durable medical equipment," said Tobin.  "Or, it can further impede access to medically-necessary equipment and create further turmoil within the disability community.  United Spinal is hopeful that the need for clear documentation standards is both evident on its face, and in the repeated call for such standards by end-users, clinicians, and suppliers."

Stakeholders believe it is essential that a template be a part of the CMS prior authorization process from the start.

The medical community and other stakeholders strongly support the use of a clinical template, saying that if it is implemented correctly, it can dramatically reduce claim processing error rates and associated denials of benefits for seniors and people living with disabilities needing mobility assistance.   A template can provide physicians and clinicians the guidance needed to properly document their patient examinations, while relieving some of the time-consuming, administrative burdens that doctors say have been excessive under the current process.  

"We support the effort by CMS to create a clinical medical necessity template for use by physicians and other prescribing clinicians to document the medical necessity of a Medicare beneficiary for power mobility equipment," Wilson said. "Such a tool to be used by ordering physicians and clinicians is the most relevant aspect of the prior authorization process. It will clarify the specific elements to be evaluated and documented during the face-to-face exam while also reducing improper payments for power wheelchairs and related services."

Furthermore, stakeholders said that when the template is implemented, it's critical that CMS include these considerations:

  • CMS claim reviewers should not be prepositioned to challenge a physician's conclusion that power mobility is a medical necessity when the template is submitted as part of the physician's mandatory face-to-face evaluation of the patient.
  • The template format/process must be used by claim reviewers and auditors of Medicare power mobility claims in all four regions.
  • CMS claim reviewers must collaborate closely with physicians, clinicians, and power mobility providers to ensure that the design and content of the clinical template is efficient, cost effective, and clinically accurate.
  • Until a fully integrated electronic process is established, CMS must provide a transitional process to guide physicians through the necessary elements to be evaluated and documented during the face to face examinations of their patients. 

In implementing the prior authorization program, stakeholders also want CMS to eliminate any subjective guidelines. In the past, CMS has stated that "other relevant medical documentation" can be used to justify medical necessity. But this wording raises significant concerns within the power mobility community because of its subjective nature.  To correct past problems, providers need to know precisely what the documentation requirements are for a prior authorization approval.

"Without clear and concise requirements for the power mobility provider and physician," Wilson said, "claim reviewers will once again have unfettered discretion to question the medical necessity of claims.  The requirements can't be a moving target for providers."

The power mobility community said it is important for CMS to work with physicians, providers, and patient advocates in finalizing the plans for the clinical template and prior authorization program.  CMS is scheduled to hold another "Open Door" conference call with stakeholders on June 28, 2012.

"By accepting input from advocates, physicians, clinicians and providers, CMS can develop and implement a process that will not restrict access for Medicare beneficiaries or put unnecessary financial burdens on providers," Wilson said. "This can be a win-win scenario for patients, providers and Medicare. But that only happens if CMS addresses our concerns."

Mobility Matters is published periodically by the American Association for Homecare to inform Congress, the administration, policymakers, consumer organizations and the media about Medicare's power mobility benefit, and the need to sustain it. AAHomecare is committed to helping seniors and people living with disabilities regain their freedom and independence. The American Association for Homecare represents durable medical equipment providers and manufacturers who serve the medical needs of millions of Americans who require oxygen equipment and therapy, mobility devices, medical supplies, inhalation drug therapy, and other medical equipment and services in their homes. Members operate more than 3,000 homecare locations in all 50 states. Visit  American Association for Homecare - 2011 Crystal Drive, Suite 725, Arlington, Virginia 22202 -703.836.6263   

SOURCE American Association for Homecare
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