OIG: 60% of wheelchair claims no good

Thursday, January 7, 2010

WASHINGTON – Industry stakeholders are blasting the Office of Inspector General (OIG) for reviewing power wheelchair documentation so soon after Medicare turned the benefit upside down.

The OIG published a report late last month that states three out of five claims for standard and complex power wheelchairs did not meet Medicare documentation requirements during the first half of 2007. That’s no surprise, industry stakeholders say, because Medicare implemented new codes, coverage criteria and documentation requirements for power wheelchairs in the last half of 2006.

“I’d like to ask them to do the same review now and see if they get the same results,” said Simon Margolis, executive director of NRRTS. “I don’t think they would. That would validate that this is more about the newness of the program than providers not being compliant.”

The OIG reviewed a random sample of 375 claims for standard and complex power wheelchairs. It then collected documents from providers, determined whether they met the requirements and projected its results nationally. The OIG states the documentation errors it found accounted for $112 million of the $189 million in total improper payments allowed for that time period.

Industry stakeholders point out that, in addition to its newness, the benefit was a moving target for much of the first half of 2007. For example, Medicare began requiring that a specialty evaluation be conducted for certain complex power wheelchairs in late 2006, but it wasn’t clear that the evaluation had to be conducted by an occupational or physical therapist until several months later.

“Initially, they weren’t clear on what the documentation requirements were,” said Tim Pederson, chairman of AAHomecare’s Complex Rehab and Mobility Council (CRMC) and CEO of WestMed Rehab in Rapid City, S.D. “That’s something that has developed and evolved over time.”

The OIG’s report also states that documentation errors varied by provider and wheelchair type: For example, complex power wheelchair claims had a higher error rate than standard power wheelchair claims. Again, that’s no surprise to industry stakeholders, who say there’s way more room for error with complex power wheelchair claims.

“It underscores the complexity of the documentation needed for a complex power wheelchair,” said Don Clayback, executive director of NCART. “There are six different documents that could be required, comprising anywhere from 10 to 20 pages of information.”

The biggest fear of industry stakeholders is that the documentation errors detailed in the OIG’s report will be equated with fraud and abuse.

“It’s not fraud and abuse; they’re mistakes,” Margolis said. “I know how hard the providers who submit 60% of complex power wheelchair claims are working. They’re not doing a bad job.”