Harris County continues its wayward ways

Thursday, March 31, 2005

HOUSTON -- While the number of power chair claims being filed in Harris County has dropped precipitously since CMS began cracking down on fraudulent providers there, the denial rate is still remarkable high.
Between October 2004 and January 2005, CMS denied 87% of all power chair claims filed in Harris County. Sixteen percent of those denials were the result of failures to supply additional documentation requested to support the claim. CMS denied 67% of the claims for failing to meet Medicare's coverage criteria, said Steve McAdoo, associate regional administrator in CMS's Dallas office.
"It's disturbing that the denial rate is so high," McAdoo said. "I don't have any hard evidence but the contractor (Palmetto GBA) feels like the situation is improving, and by working with some of the individual companies, they are trying to help them understand what they need to have in their records to support coverage."
In 2004, Harris County providers submitted $38 million in power wheelchair claims. Of those, CMS allowed $1.5 million. By comparison, in 2003 providers there filed $378 million in claims for power chairs. Of those, CMS allowed $198 million.
In October 2004, CMS recorded a huge rise in power wheelchair claims. Instead of monthly average of about $3 million claims, providers submitted $10.4 million in claims. The number of power chair claims returned to normal the next month.
"It appears to have been an anomaly," McAdoo said. "There were three suppliers who dumped most of the claims and all three of their numbers had been revoked. None of those claims were paid."
In November, CMS stopped its random review of power wheelchair claims from Harris County, but Palmetto continues to review them all. The carrier eventually plans to take some providers off 100% review if they reduce their denial rate to an acceptable level. McAdoo did not know what qualified as an acceptable level, and added that, as far as removing Harris County providers from 100% review, "nothing is imminent."