Power wheelchair providers fight denials tooth and nail

Tuesday, January 26, 2010

Fed up with Medicare's regional carriers denying a majority of their claims for standard power wheelchairs, some providers are fighting back.

"We're pretty much appealing every one of them," said Frank Bryan, director of revenue and compliance for Source One Medical in Irvine, Calif. "We feel that strongly about our documentation."

Noridian Administrative Services, the DME MAC for Jurisdiction D, notified providers recently that, during a "service specific prepayment probe review" of 117 claims for K0823s, it denied 114 or 97.7%. The DME MACs in the three other jurisdictions have conducted similar reviews and reported similar findings.

Bryan estimates that, at the height of the audits, 10% to 15% of Source One Medical's claims for K0823s were being reviewed. Of those, nine out of 10 were getting denied.

"We have 15 of them moving through the administrative law judge (ALJ) process right now," he said. "There are others--they're stuck at the re-determination or re-consideration level."

The Scooter Store in New Braunfels, Texas, has also had its claims for K0823s reviewed and, increasingly, denied. It, too, appeals all of them and boasts an overturn rate of 96% at the ALJ level.

"It is foolish for Medicare to allow the contractors to deny virtually 100% of these claims only to have virtually 100% of them overturned during the appeals process," said Doug Harrison, CEO and president.

The reason for the majority of the denied claims for standard power wheelchairs, according to the DME MACs: inadequate medical necessity.

Providers say the DME MACs are auditing and denying their claims for silly reasons like illegible physician signatures.

"They've gone from being reasonable to just finding a way to deny a claim," Bryan said. "Forget about whether a wheelchair is medically necessary; it's about whether this was filled out right and whether that was submitted at the right time."

To make claims as bulletproof as possible, providers like Tim Pederson treat standard power wheelchairs like complex power wheelchairs.

"We go through the same process," said Pederson, CEO of WestMed Rehab in Rapid City, S.D. "That means we have a specialty evaluation done by a PT or OT."

That's all well and good, but that's not the way it should have to be, other providers say.

"To suggest that a physician who has completed an evaluation of his or her patient is wrong 94% of the time suggests that there is a serious disconnect in the system," said Mark Leita, director of public affairs for The Scooter Store.