Houston providers feel the heat, denials skyrocket

HOUSTON - The aggressive climb of the K0011 market in 2003 has translated into an all-out free fall in 2004, and nobody is more aware of the effects than providers who do business here. Jeff Baird “It's throwing the baby out with the bath water,” said Jeff Baird, a healthcare attorney with Brown and Fortunato in Amarillo, Texas. “[CMS] is forcing suppliers to get out of the K0011 business.” In Houston, Medicare reimbursement has all but shut down following frustration over rampant fraud in the area and a clarification from the DMERCs that stiffened the interpretation of “bed or chair confined.” Medicare on average has approved only five motorized wheelchairs a month since the fraud case broke, according to Steve McAdoo, the associate regional director for Medicare financial management in the Dallas Regional office. Houston suppliers were reimbursed $183,477 for power wheelchairs in December. The total billed was $4.8 million. Providers in Houston, already on pre-pay review, say denials are hinging upon medical necessity and the clarification, which also is being applied retroactively. A vast majority of the claims are being denied because the correct documentation was not sent in. “We have to assume that if we are not getting the documentation that they don't have it at all,” said McAdoo. “This is an insurance company dictating the patient's treatment,” said Mitchell Squires, owner of Scooters and More in Houston. “Your doctors say you have a medical necessity, but [CMS] says you don't. Who is actually treating the patients here?” The concentration of the problem in one area has made Houston the sole target of scrutiny, according to many in the industry.