MEDICARE ANNOUNCES NEW INITIATIVES ON POWER WHEELCHAIR COVERAGE AND PAYMENT POLICY
Centers for Medicare & Medicaid Services Administrator Mark D. McClellan, M.D., Ph.D. today announced a series of further steps on Medicare coverage and payment policies that apply to power wheelchairs and power scooters building on recent successes in reducing Medicare abuse. CMS is implementing a three-pronged approach focused on coverage, payment and quality of suppliers of power wheelchairs.
“Medicare spending for power wheelchairs and power scooters has skyrocketed in recent years to more than $1.2 billion a year, yet some beneficiaries who really need these mobility devices are not getting high-quality and timely assistance,” said Dr. McClellan.
“CMS has cracked down on fraud and abuse in the wheelchair market, including the launch of Operator Wheeler Dealer last fall in collaboration with the HHS Office of the Inspector General,” said Dr. McClellan. Now we are moving to the next stage in strengthening our policies for power mobility devices.”
The first prong of the plan is to develop guidance on the current coverage of power wheelchairs. Beginning next month, CMS’s chief medical officer will bring together clinicians from across 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agencies to refine and describe the conditions that are associated with the current coverage definition and to develop draft guidance for determining whether a patient meets the definition of “bed or chair confined.” The goal is to focus on a set of clinical and functional characteristics that are evidenced-based and will better predict who would benefit from a power wheelchair or scooter. The public will be given an opportunity to comment before the guidance is finalized.
To further ensure that beneficiaries who get mobility devices receive a high-quality and timely evaluation, appropriate device choice and clear guidance in using the device, CMS will also address requirements for ordering mobility equipment through a proposed regulation. The regulation will, in part, implement provisions of the 2003 Medicare Modernization Act.
The second area in which CMS is taking action is in billing and payment for power wheelchairs and scooters. CMS’ goal is to assure that Medicare pays appropriately for motorized wheelchairs, and that beneficiaries have access to them when needed. The technology, range of products, and market for power wheelchairs have changed substantially since the current HCPCS codes for power wheelchairs were added in late 1993. Currently, most power wheelchairs are billed under a single code (K0011), for which Medicare has set a single ceiling amount of $5,296.50, even though different models of these wheelchairs have substantially different market prices. CMS is working with a national coding panel to develop a new set of codes that better describe the wheelchairs currently on the market. Accurate individual payment ceilings would then be developed for each of the new codes.
Further, CMS plans to implement competitive bidding for a number of items of durable medical equipment, as authorized by last year’s Medicare modernization law. CMS expects to include power mobility devices in the competitive bidding program.
The third prong of the new plan is to ensure that there are strong quality controls for suppliers to assure that beneficiaries will receive high-quality power mobility services. CMS will revise the supplier standards for enrolling in Medicare to include quality measures as required by the MMA, building on existing standards by the industry. CMS intends to finalize new standards in the fall of next year. In addition, CMS will develop a proposal for an accreditation program, as part of the implementation of competitive bidding, to further ensure that power wheelchair suppliers meet industry and community standards for power wheelchair utilization. Lastly, CMS, through its contractor, the National Supplier Clearinghouse, will continue its work to ensure thorough review of all applications for enrollment so that only qualified suppliers are allowed to bill the Medicare program.
These new initiatives build on prior CMS efforts to combat improper payments for power wheelchairs. For example, Operation Wheeler Dealer involved aggressively scrutinizing all new applications for Durable Medical Equipment supplier numbers. Operation Wheeler Dealer also included special program integrity efforts in conjunction with federal law enforcement officials on Harris County, Texas, where a high incidence of fraud had been detected. All power wheelchair claims from Harris County were individually reviewed and approved by our regional office, and suppliers were required to attend training on Medicare wheelchair coverage policies. As a result, claims for the main power wheelchair code billed by suppliers in Harris County dropped from $59.8 million in May 2003, to $33.3 million in August 2003, to $4.9 million in December 2003. These initiatives continue today.
In addition to the successes in Harris County, Operation Wheeler Dealer has proven worthwhile on a nationwide basis. Working collaboratively with the Justice Department and the Office of Inspector General, since 2003 federal officials have recovered $84 million in fraudulent claims for power mobility products nationwide. The contractors that process power wheelchair claims have referred about 155 potential fraud cases (representing 265 suppliers) involving power wheelchairs to law enforcement since September 2003. About 10 percent of these cases have been closed already, indicating a very aggressive approach by law enforcement.
“In launching Operation Wheeler Dealer, CMS and the OIG took action to stop Medicare fraud, and those actions are having an impact,” said Dr. McClellan. “With this new initiative, and with input and feedback from suppliers and beneficiaries, we are going to do even more to make sure that Medicare funds are spent on patients who need them, and that beneficiaries with disabilities are getting the high-quality, modern services they deserve.”