Maybe, maybe not

Sunday, April 30, 2006

If you haven't yet scanned the HME Databank on page 56, do so now and take a quick look at the K0011 chart at the bottom left. Talk about falling off a cliff. If you bore down a little deeper into the raw data, here's what you find:
While business had previously remained more of less steady, HME providers billed Medicare for 5,711 fewer K0011 power wheelchairs in November 2005 then they did in October 2005. What's more, the denial rate for K0011s increased steadily between August and November 2005, from 11.09% to 15.92%.
Because it takes the DMERCs about four months to collect and tally claims from a particular month, the Medicare data we run in each issue is six months old. That means only time will tell if this downward trend for K0011s continues.
A preliminary analysis of the data, however, suggests a couple of possibilities.
First, the drop off in claims and increased denials coincides with a CMS requirement that changed how providers document medical necessity and bill for power wheelchairs. Uncertainty surrounding that new rule probably lead to a fear of mass denials, forcing providers to turn away business that under Medicare's old rule they would have accepted.
As for the increased denials, you could attribute it, as did one well-placed source, to stepped-up scrutiny by the DMERCs as they transitioned to the new rule.
Looking at this K0011 data, it's impossible not to wonder: Are patients being denied access? Maybe. Maybe not.
It could be that as PWC utilization has shrunk, scooter utilization has increased. That was one of CMS's goal in implementing the new rule, and we'll check on this in a future issue. No doubt, too, the new rule has cut down on some fraud and abuse. Or, maybe what we have here is a bell curve: Once providers get used to the new requirements, they'll begin ramping up their PWC business again.
It's too early to say if these numbers indicate an access problem. But if they do, one hopes that patients can count on CMS to make things right. Will CMS do this? Maybe. Maybe not.