Prepay reviews threaten access

Wednesday, July 24, 2013

YARMOUTH, Maine – HME providers say heavy volumes of prepay reviews have made them more cautious about providing hospital beds and certain other equipment to Medicare beneficiaries.

The end result will be decreased access, they say.

“(Medicare) has no clue about the ramifications of these claim denials,” said Glenn Steinke, owner of Bishop, Calif.-based Airway Medical. “The last prepay review had an error rate of 92%. Could 92% of patients really not need their hospital beds?”

After seeing nearly all of his bed claims get denied, Steinke now requires patients to sign advanced beneficiary notices (ABNs). However, some can’t or won’t pay.

“If they’re not willing, they’ll have to stay in the hospital,” said Steinke. “It’s saddening to tell dying people ‘No, you can’t have a bed unless you’re willing to pay.’”

Provider Lynn Lamprecht says one of his bed claims was denied for lack of medical necessity. The patient needed the bed, he says.

“We had one patient with COPD that had a tough time laying down,” said Lamprecht, owner of Fremont, Neb.-based Promedcare. “We got denied because they said the patient doesn’t have to sit up immediately.”

It has gotten so bad that provider Vince DeStigter has stopped providing beds through Medicare altogether.

“We only do beds for cash sale now,” said DeStigter, CEO of Jackson, Calif.-based Western Healthcare. “We do a lot of work to put those beds out, and Medicare kept coming back and taking the money from us.”

It’s not just beds facing intense scrutiny. Provider Jim Greatorex says intense prepay reviews have forced him to be very strict when providing power wheelchairs to Medicare beneficiaries. He’ll only accept medical documentation from an outpatient center he trusts. 

“They have to meet our guidelines to even be considered,” said Greatorex, owner of Portland, Maine-based Black Bear Medical. “The risk is too high.”