New rule wallops PWC claims

Wednesday, May 31, 2006

YARMOUTH, Maine - One month after CMS changed its documentation requirements for power mobility devices, the number of allowed claims for power wheelchairs nosedived.
In Region D, the number of allowed claims for K0011 chairs was 3,974 in October 2005 vs. 2,792 in November 2005--a 28.7% drop, according to data obtained by HME News from the SADMERC through a Freedom of Information Act request.
In Region A, the number of allowed claims was 1,765 in October vs. 896 in November--a 49.2% drop. In Region B, the number of claims was 1,931 vs. 3,334--a 42.1% drop, and in Region C, the number of claims was 4,713 vs. 6,671--a 29.4% drop.
The SADMERC takes about four months to collect all claims for a given month.
Despite the magnitude of the drop, providers of power wheelchairs were unfazed. For the most part, the SADMERC allowed fewer claims because providers filed fewer claims, they said.
"Our approval rate is as high as it has always been--it may even be higher," said Dan Gibbens, executive vice president of marketing for The Scooter Store in New Braunfels, Texas, one of the biggest sellers of K0011 chairs in the country. "(The drop) is purely the result of a downward trend in claims submissions."
Providers filed fewer claims from late October through November because, beginning Oct. 25, 2005, CMS replaced CMNs with physician prescriptions and medical records. That meant providers had to re-educate physicians and collect additional paperwork.
"It's going to hurt sales for a while, until you get back into a rhythm," said Dennis Kline, president of Source One Medical in Irvine, Calif., another top seller of K0011 chairs.
To varying degrees, providers predict that the number of allowed claims for power wheelchairs will rebound in December and beyond.
"I think the industry is the smallest it's ever going to be," said one industry source, citing an aging demographic that wants to remain active and mobile.
Gibbens, however, isn't so sure the number of allowed claims will rebound completely.
"We've seen our numbers go back up, but I don't know if they'll ever go all the way back up," he said. "It's just a more challenging environment, not really knowing whether or not a beneficiary qualifies for medical necessity" because of the lack of clarity in physician documentation requirements.