As the denials started, ‘It was, Oh, my God’

Wednesday, March 31, 2004

WASHINGTON - Medicare officials may claim that beneficiaries and mom-and-pop providers aren’t being seriously affected by the DMERCs’ crackdown on power wheelchair utilization. Don’t, however, tell that to small rehab providers like Jeff West, Tyrrell Hunter and Russ McLellan. If you do, they may tell you to go jump in a lake.

CMS’s all-out effort to rein in power chair fraud following September’s Wheeler Dealer scandal has left providers like these three jittery and, in some instances, on the brink of financial collapse. The result, going forward is that most won’t furnish a chair to any beneficiary who isn’t bed or chair bound, as CMS mandated in a now infamous December coverage clarification. For most providers, the days of providing a PWC to a beneficiary who can walk a few steps have come to a screeching halt.

“In last two months we’ve had seven power wheelchairs that the people, up until that clarification, would have qualified for,” said Hunter, who owns Majors Mobility in Topsham, Maine. “They wanted to know what they could do about it, and I said about the only thing you can do is pressure the politicians to go back to the old standard.”

Hunter’s experience with the CMS crackdown seems mild compared to what West has been going through.

Since September, CMS has denied 18 power wheelchair claims submitted by West, who owns Independent Living Aids in Kissemmee, Fla. In each case, CMS denied the chair for a lack of medical necessity. About 20 additional claims are on prepay audit. Between the audits and denials, which West is appealing, Medicare has tied up about $300,000. To meet his financial obligations, West borrowed $90,000 from family members and leased another $90,000 from VGM.

“When we started getting the denials, it was, ‘Oh, my God,’” West said. “We had to find the money to survive.”

One of West’s denials was a gunshot victim. The woman had been in a wheelchair for 25 years and just recently became eligible for Medicare.

“When I talked to the medical review person, I asked what could possibly be wrong,” West said. “She said, ‘You are going to have to get the original injury notes from 25 years ago.’ That’s a bunch of crap.”

McLellan, who owns Home Health Options in Marietta, Ga., is almost as bad off. He’s also just as bitter at CMS for changing the rules without allowing time for providers to make adjustments that might limit denials.

On Oct. 23, he received a letter from CMS stating the he owned Medicare $157,519.97 related to 36 audited K0011 claims.

After getting over the initial shock, McLellan and his staff began looking into the audit findings and could find nothing wrong. No lack of, as CMS stated, appropriate authorization or medical necessity.

As of March 1, McLellan had paid back CMS $40,000 in offsets. He was scheduled to attend a fair hearing on the denials March 3.

“This company is my dream and someone comes along and changes the rules,” said McLellan, who has been in business six years. “The real story here is not the fleecing of America - it’s the fleecing of the people who help.”