PWC denials skyrocket in Houston

Sunday, February 22, 2004

February 23, 2004

HOUSTON - The aggressive climb of the K0011 market in 2003 has translated into an all-out free fall in 2004, and nobody is more aware of the effects than providers who do business here.

"It's throwing the baby out of the bath water," said Jeff Baird, a healthcare attorney with Brown and Fortunato in Amarillo, Texas. "[CMS] is forcing suppliers to get out of the K0011 business."

In Houston, Medicare reimbursement has all but shut down following frustration over rampant fraud in the area and a clarification from the DMERCs that stiffened the interpretation of "bed or chair confined."

Medicare on average has approved only five motorized wheelchairs a month since the fraud case broke, according to Steve McAdoo, the associate regional director for Medicare financial management in the Dallas Regional office. Houston suppliers were reimbursed $183,477 for power wheelchairs in December. The total billed was $4.8 million.

Providers in Houston, already on pre-pay review, say denials are hinging upon medical necessity and the clarification, which also is being applied retroactively. A vast majority of the claims are being denied because the correct documentation was not sent in.