A ‘vast fuzziness’ hampers PWC biz

Friday, April 30, 2004

WASHINGTON - To the frustration of many in the HME industry, a two-hour meeting with CMS officials March 31 shed too little light on who is eligible for a Medicare-reimbursed power wheelchair.

In fact, “a vast fuzziness” still surrounds Medicare’s bed- or chair-confined eligibility criteria, said Cara Bachenheimer, Invacare’s vice president of government affairs.

“There is no question that we as an industry, as mobility care givers, are not satisfied with the outcome of the meeting or where we stand,” said Pride Mobility President Dan Meuser. “There is too much room for misinterpretation.”

As a way to reduce skyrocketing utilization, CMS began strict enforcement of the bed- or chair-confined definition in December, but without providing clear guidance on how to interpret that standard. From the perspective of most, the March 31 forum did little to assuage the industry’s uncertainty.

During the forum, Region A Medical Director Dr. Paul Hughes said he defines bed- or chair-confined as “usually totally non-ambulatory.” In February, CMS Chief Financial Officer Tim Hill told HME News that a beneficiary qualifies for a wheelchair if he would spend the “preponderance” of his day in bed without one.

Those definitions provide some clarity but are still vague, making it difficult if not impossible to predict when CMS will deny or approve a wheelchair claim, say industry watchers.

Whether it takes “nine months or two years,” Meuser said, CMS, consumer groups and the industry need to hammer out a definition of ambulation or non-ambulation that brings predictability to the claims process.

“I don’t think the industry is asking for 100% certainty - that will never happen,” Bachenheimer said. “But the 80/20 rule probably applies. “

Attesting to industry interest in the issue, an estimated 650 people listened to the March 31 forum via telephone. Another 40 or so attended in person.

CMS convened the forum in response to industry uproar over the now infamous Dec. 9 DMERC coverage “clarification.” That communication, which the industry claims is a restrictive and illegal policy change, stated that Medicare only pays for wheelchairs when a patient is bed or chair-confined. Prior to the clarification, CMS adhered to coverage criteria that granted eligibility to beneficiaries who required a wheelchair to maneuver safely around their homes, say industry representatives.

By lobbying members of the U.S. House and Senate, the industry apparently generated enough political pressure to force CMS to retract the “clarification” in mid March. CMS’s Hill told attendees at the March 31 forum, however, that CMS ordered the retraction because it created confusion.

Some industry leaders have called the retraction a victory. Other’s aren’t so sure.

“It was never rescinded,” said Simon Margolis, National Seating and Mobility’s’ vice president of clinical and professional development. “The words are gone, but the intent is still there.”
For a first person provider perspective on CMS’s March 31 Open Door forum on power wheelchairs,click here and see what Georgie Blackburn has to say.