Providers must rebuild trust with clinician community

Tuesday, August 31, 2004

The recent U.S. District Court for the Eastern District of California decision in the case of Maximum Comfort, Inc. v. Tommy G. Thompson states that Medicare’s auditors cannot request any documents beyond the CMN from a supplier to prove the need for a wheelchair. This is not necessarily a step forward.

As a clinician who has prescribed and documented the need for wheelchairs for the last 15 years, I would love nothing more than to reduce the documentation burden on both clinicians and suppliers. But I would caution the celebratory nature of some of the press releases related to this decision as it sends a very negative message to CMS about who we are as an industry. Instead, we need to demonstrate to CMS,and society as a whole, the important role HME suppliers play in the continuum of healthcare delivery. Standing so firmly on a principle that posits the CMN as the be-all and end-all document sends a distorted message - that suppliers are just trying to find the path of least resistance to make money.

The decision could be overturned by a higher court. As one medical official has pointed out already, denying Medicare the right to examine additional documentation to justify medical necessity is like telling IRS auditors they can’t look beyond the 1040.

No doubt, there’s a lot to be desired when it comes to Medicare coverage policies for wheelchairs. We’ve certainly seen much progress - perhaps the most ever in the history of thr whelchair industry - since the Houston power wheelchair scandal and the subsequent implementation of “Operation Wheeler Dealer.” Often it takes a serious crisis to foster opportunities.

Now comes the Maximum Comfort decision, and here’s the CMN at center stage. Remember, the CMN is a faulty document. It’s supposed to stand as an authoritative document, and yet it does not even come close to reflecting currently accepted standards of clinical practice or knowledge based on published peer-reviewed research. Because so many seniors are living longer, mobility has become a complex public health issue. If a CMN were to serve as the sole conclusive document justifying the need for a wheelchair, no therapist or physician would want to answer the questions in a manner necessary to secure funding and sign off on it, especially for patients who have legitimate medical need for a powered mobility device. We need back-up documentation in progress notes and letters of medical necessity to justify our rationale in answering the questions. Often prescribed patients cannot functionally ambulate; they fall and hurt themselves; they stop participating in necessary activities of daily living both in the home and community; and therefore they spend the majority of their time in bed or a chair because it’s too hard to get up and walk.

The CMN will need a major overhaul if it is to be a legitimate, authoritative document and there is every indication there will need to be a new one if it is to reflect updated coverage policies based on current knowledge, demographics, and standards of practice. Questions on a revamped CMN should “at least” ask whether or not the patient can functionally and safely ambulate to carry out their necessary activities of daily living. Another should ask the physician whether sufficient documentation is on file in the medical record to justify the need for the intervention when a patient’s unique needs do not necessarily fit cleanly into a coverage policy.

Today, there are misperceptions between suppliers and clinicians. Generally speaking, suppliers feel most clinicians know little about the vast options for wheelchair seating and mobility interventions. Therefore, suppliers conclude, they need to take a lead role in evaluating a person’s needs and generating the recommendation’s specifications. Since the eruption of the Wheeler Dealer scandal, clinicians are tempted to believe that wheelchair suppliers are somewhat shady dealers who are also trying to infringe on their practice. Both parties are misinformed. Because most curriculums give short shrift to wheelchairs, most physicians and therapists are not especially well versed in the benefits of properly prescribed and fitted wheelchairs. Therefore it is not all that difficult for a supplier to get a clinician to sign off on a CMN if the intervention seems to make sense. But the recent press and policy “re-clarification” is instilling caution about suppliers in the overall clinical community.The supplier industry needs to thwart that unfortunate prejudice.

Clinicians, like suppliers, work long hours to ensure appropriate care. This is the fundamental intent of professional practice and the statutory language of state licensing for clinicians. Celebrating the Maximum Comfort decision is not something this industry should openly applaud but rather should focus resources in the support of professionalizing and credentialing these services as well as cultivating relationships that further support and integrate with the clinical community.

Mark R. Schmeler, M.S., OTR/L, ATP is director of the Center for Assistive Technology at the U. of Pittsburgh Medical Center.