Friday, December 31, 2004

HOUSTON, Texas - Once again something weird and possibly fraudulent appears to be going on in Harris County, Texas, ground zero for the Wheeler Dealer power wheelchair scandal in fall 2003.

Starting in February 2004, Harris County (Houston) providers submitted on average monthly charges of $1.5 million for power wheelchairs. In October, following rumors that CMS might stop its manual review of PWC claims there, the submitted charges spiked to $10.4 million, said Steve McAdoo, associate regional administrator for Medicare in Dallas.

“I had them check it twice because I couldn’t believe it,” McAdoo said. “I said, ‘This can’t be right.’”

Contrary to rumors and newspaper reports, CMS has no plans to discontinue its manual review of power chair claims in Harris County, McAdoo said.

“We would love to stop, if we reached a comfort level that the majority of claims coming in were for covered services,” he said. “We are not interested in continuing this review for the sake of doing the review. But things like this spike in October is out of line and reinforces our need to remain vigilant.”

It’s difficult to attribute the October spike to anything but crooks jumping back into the game after hearing rumors that CMS might be discontinuing its manual review of claims, McAdoo said. It’s also possible that providers, believing the same thing, filed a bunch of backlogged claims because they believed the scrutiny was going to end.

Since CMS began its manual review of PWC claims in the fall of 2003, following revelation of the massive Wheeler Dealer fraud scandal, submitted claims for power chairs in Harris County have dropped precipitously. In 2003, for example, providers there filed $378 million in claims for power chairs. Of those, CMS allowed $198 million. Through October 2004, Harris County providers had submitted $33.4 million in claims. Of those, CMS allowed only about $1 million, McAdoo said.

In November, the Scooter Store, the nation’s largest provider of power chairs, announced it would no longer accept Medicare assignment in Harris County. Company President Mike Pfister said “we are left with no choice.” Since Jan. 1, 2004, the New Braunfels, Texas-based company said it has been reimbursed for only eight of the more than 500 wheelchairs it delivered to Harris County (Houston). The unpaid claims have cost the company $2.5 million.

“We applaud and support CMS’s efforts to combat fraud,” Pfister said. “But the current crisis is not about fraud. The real injustice today is the geographical discrimination against hundreds of qualifying beneficiaries who are being penalized only because they live near Houston.”

Not so, said McAdoo. The central issue causing denials in Harris County remains a lack of appropriate medical documentation, not the level of medical review of claims.

“We are not reviewing the Scooter Store any differently than other suppliers in Harris County,” McAdoo said. “What that says, I’m not sure. We haven’t tried to draw any conclusions, but we are comfortable with the accuracy of the reviews we are doing down there.”

Even with the Scooter Store’s exit, McAdoo said, he anticipates no problems with beneficiary access nor has he seen any since the Wheeler Dealer crackdown began. In March 2004, 171 providers were submitting claims for power wheelchairs. There’s no indication that number has dropped significantly. Suppliers are simply submitting fewer claims, McAdoo said.