PWC market takes a beating

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Monday, May 31, 2004

WASHINGTON - An OIG review of 300 random K0011 claims filed in 2001 found that a meager 13% met Medicare’s coverage criteria and that 31% did not meet the coverage criteria for any kind of wheelchair.

The OIG presented its audit report, “Medicare Payments for Power Wheelchairs,” to members of the Senate Finance Committee on April 28. The committee convened to gather data on skyrocketing power wheelchair utilization.

In 2001, the OIG reported, Medicare and its beneficiaries paid $513 million for all K0011s. Based on its audit, however, the OIG determined that $178 million of those claims did not meet Medicare’s coverage criteria.

The OIG embarked on its audit to discover why Medicare payments for K0011 power chairs jumped 43% between 2000 and 2001.

“Although many beneficiaries need power wheelchairs, DMERCs and the OIG have identified fraud cases involving power wheelchairs that were not supplied, not medically necessary or both,” the OIG wrote in its report.

The OIG also blamed the increase on providers, physicians and beneficiaries who don’t understand K0011 coverage criteria.

Among the OIG’s findings:

- In more than half the claims reviewed, CMNs and/or delivery documentation were missing, incomplete or dated after the date of service.

- Almost one quarter of the beneficiaries who responded to the survey learned about their power chair through TV advertising; 9% chose their provider after receiving something in the mail; 4% received a chair from suppliers who visited their homes.

- Sixty-eight percent of beneficiaries who responded to the OIG survey (113 of 166) said they use the power chairs inside the home; 4% said they had never used the power chair; 12% said they do not currently use their power chair but have in the past; 12% said they use their chair outside the home only.

In compiling its report, the OIG reviewed 300 K0011 claims. Investigators then contacted the suppliers who submitted the sample claims, requesting CMNs and additional supporting documentation. From the prescribing physicians, the OIG requested copies of the beneficiaries’ medical records supporting the sample claims. The OIG also contacted 166 of 300 beneficiaries in the sample, querying them on how they learned about suppliers and how they used the equipment.

To improve compliance with K0011 coverage criteria, the OIG recommended that CMS and the DMERCs:

- Request medical records from ordering physicians in addition to supporting documentation from suppliers.

- Educate providers and beneficiaries on Medicare’s coverage criteria.

- Revise the coverage policy for K0011s to include specific information about medical conditions that qualify for this product. The OIG’s findings showed that while many beneficiaries did not qualify for a K0011, they may have qualified for a lower-priced power wheelchair, scooter or manual chair.

In response, CMS officials agreed with most of the OIG’s recommendations, and reported that it had begun implementing many of them. CMS didn’t, however, believe that contacting beneficiaries would yield meaningful results.
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- GAO: CMS failed to stem fraud

- CMS to strengthen PWC policy

- OIG compares K0011 pricing

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