Audit woes

Wednesday, June 30, 2004

WASHINGTON - A prior authorization process for power wheelchairs would reduce denials and better control Medicare fraud and abuse, but don’t expect CMS to adopt the front-end procedure anytime soon.

“Conceptually, it could be done, but it is a budgetary and workload issue,” said Dr. Adrian Oleck, Region B medical director. “It is not as simple as shifting resources. It is not twice as much work, but there is a significant difference in accomplishing that.”

As part of its written comments regarding power wheelchair coverage to the U.S. Senate Finance Committee in late April, the National Coalition For Assistive Rehab Technology advocated for a prior authorization process.

In general, providers supply a wheelchair, submit the claim along with the CMN and then wait for the DMERC to approve or deny it. If denied, they often go through a lengthy appeals process that requires them to gather and submit physician progress notes and other documentation to prove medical necessity. Most Medicaid programs, however, operate under a prior approval process that requires that additional documentation up front and suppliers love it, said Sharon Hildebrandt, NCART’s executive director.

“It seems a much more rational approach, not only for a provider’s cash flow but also for fraud and abuse,” said Sharon Hildebrandt, NCART’s executive director. “The DMERCs would know what a bill was coming in for, look at it and let providers know up front if they are going to get paid.”

Region A Medical Director Robert Hoover agreed with NCART’s rationale. Prior authorization is “ideal” for expensive items like power wheelchairs, he said.

The number of claims a DMERC processes, however, dwarfs the volume that come in to a private insurer or state Medicaid agency,” making prior authorization a very expensive proposition for Medicare, Hoover said.

Next year, for example, Region D estimates it will process more than one million claims a month.

“I don’t know what percentage of that are power wheelchairs, but it doesn’t take much to figure out that even a small percentage of that on a monthly basis is daunting,” Hoover said.

Currently, the DMERCs issue an Advanced Determination of Medicare Coverage or ADMC (a kind of prior authorization) for high-end custom wheelchairs. It’s a labor-intensive, time-consuming process: Clinical staffers review medical records; support staffers log claims and perform other administrative duties, Hoover said.

As a way to control skyrocketing utilization and make sure only people who qualify for a power chair receive one, CMS has looked at expanding ADMC but made no formal decision, Hoover said.

“It is a wonderful thing in theory,” said Tom Hood, The Scooter Store’s vice president of regulatory affairs. But a better, less expensive alternative would be to reduce coverage uncertainty by more clearly defining who qualifies for a power wheelchair.

That would be a good middle ground, but probably won’t happen, said NCART member Gary Gilberti.

“(CMS) feels that if they make it cut and dry, people will know exactly what to put on the paper work,” Gilberti said. “There is a lack of trust for the provider, and our industry has kind of created that. They don’t believe we can work with precise guidelines without abusing them.”