CMS: CMNs enough for POVs, power wheelchairs

WASHINGTON - The rehab and mobility industries are hailing a recent program memo from CMS that says certificates of medical necessity (CMNs) are enough for power operated vehicle (POV) and power wheelchair claims. "It's been like playing Russian roulette, providers waiting to see whether the DMERCs are going to pay a claim or not," said Steve Azia, counsel for the Power Mobility Coalition, which lobbied CMS for greater consistency in processing POV and power wheelchair claims. "This is a step in the right direction." The May 1 memo says the DMERCs can't require that providers submit additional documentation for all POV claims. Moreover, it says the DMERCs can't require that providers submit additional documentation describing a beneficiary's medical condition and functional abilities when equipment is upgraded, i.e. from a manual to a power wheelchair. (The memo also says the DMERCs can't require that providers submit the make and model name/ number for all power wheelchair claims, but that's not a big deal, industry sources say, because the CMN already requires that information be submitted.) In the memo, CMS claims these activities may be in conflict with the Paperwork Reduction Act of 1995. There is one exception, though: The DMERCs can require providers submit additional documentation during audits and investigations. Industry sources say the DMERCs have been requiring additional documentation willy-nilly for half a dozen years now in an effort to deflate the ballooning number of POV and power wheelchair claims it receives and reimburses. They say the Region B and Region D DMERCs were especially arbitrary. In a July 1997 statement, the Region D DMERC claimed that Medicare allowed charges for POVs in 1996 increased from $4.4 million in the first quarter to $6.6 million in the fourth quarter. It also claimed that "in the vast majority of cases," there were inconsistencies between CMNs and the additional documentation submitted. As a result, the Region D DMERC said it would require additional documentation for all POV claims. Azia said the recent memo's a big deal because it will mean fewer denials for providers. He said it also means providers will stand on firmer ground when submitting a claim for a POV or power wheelchair. "The CMN has long been the document of record, and unfortunately, the DMERCs have created new and arbitrary requirements," Azia said. Past inconsistencies led Region B provider Jim Poteet to make submitting additional documentation a habit at his company, Metrocare Home Medical Center in Germantown, Wis. For every POV claim it files, for instance, Poteet said Metrocare attaches an evaluation by a physical therapist. At $150 a pop, it's not a cheap practice. "I'm a financial person by background, and that additional cost has always bothered me," he said. Not only is submitting additional documentation costly, it also takes a lot of time, said Martin Szmal, general manager for reimbursement services and corporate complaints for Pride Mobility in Exeter, Pa. "It's easy to submit the additional documentation," he said. "It's obtaining it that's difficult." Region D Medical Director Dr. Robert Hoover said the memo is an attempt by CMS to reduce the "paperwork burden and hassle" on suppliers, as well as the DMERCs. He said it's not cost effective for the DMERCs to process additional documentation, just as it's not cost effective for providers to submit it. "We're continuing to look at situations where we can reduce the burden and still be able to pay claims correctly and pay claims that meet medical necessity requirements," he said. Hoover said the DMERCs now have data analysis capabilities to examine claims and patterns that they didn't have before. They can automate the process, for instance, rather than do it manually. Providing what he's heard is true, Poteet said he'd stop submitting the additional documentation immediately. "I hope this is a sign that the pendulum is swinging in the opposite direction now," he said. "They're right to investigate fraud and abuse, but the providers I know are doing the right thing. It's time they start trusting us." HME