Drug Act provision puzzles providers

Wednesday, December 31, 2003

WASHINGTON - A provision of the Medicare Prescription Drug Act that would send Medicare beneficiaries to their doctors’ offices for “face-to-face evaluations” when seeking a power wheelchair has left HME providers in a scramble to uncover the real world implications on the new rule.

The regulation is murky and has raised many questions that CMS has yet to answer, according to Eric Sokol, director of the Power Mobility Coalition.

“[CMS] just sees it as face to face, it’s pretty clear,” said Sokol. “Well, it is clear, except for A, B, C and D.”

Some of the questions raised about the regulation by the PMC and others in the industry include:

- Must the physician’s visit be power wheelchair-specific;

- What documentation is required to ensure the examination has taken place;

- What is the allowable time frame between the face-to-face examination and certification of need for equipment; and

- What is required of beneficiaries who may have trouble seeing a physician in a timely manner?

“[The law] should say that the doctor should have seen the patient in the past 90 days,” said Calvin Cole, Hoveround’s director of corporate development. “Some reports are saying that the doctor has to sign the CMN while the patient is sitting in front of them.”

Others have taken issue with the concept of the requirement, saying that most physicians do not have the knowledge base alone to correctly qualify patients for power mobility products.

“Most physicians who prescribe equipment, many don’t know what they are talking about,” said Gary Gilberti, vice chairman of AAHomecare’s Rehab and Assistive Technology Council. “You are going to have doctors out there who will have no idea what they are seeing this patient for.”

Other contentions of the provisions are aimed at its presumed intent of curbing incidents of fraud and abuse involving the K0011 code.

“In reality, if you look at the situation in Houston and Harris County, even if they had this provision in place, it wouldn’t have stopped the fraudulent activity from going on,” said Sokol.

Despite these concerns, Sokol said the PMC is supportive of the measure as long as some conclusions can be reached. The council wrote a letter to CMS’s director of medical services, John Warren, asking for guidance on the regulation.

Although already law, the provision most likely will have to see its way through CMS’s program integrity department before providers get the answers they need, and that could take as long as six months, said Cole.