The Scooter Store’s Metzger gives his take on K0011 issues

Wednesday, December 31, 2003

After stepping down as medical director of the Region C DMERC Oct. 31, a position he held since the carriers geared up in the early 1990s, Dr. Paul Metzger started work Nov. 10 as the Scooter Store’s chief medical director and vice president of government relations.

These are heady days for providers of durable medical equipment, especially if you’ve got business in the K0011 power wheelchair category. (See story page 1). We spoke with Metzger on Dec. 4 about Medicare reform, the Houston scandal, growth of the K0011 market and DMERC protocols. Here’s what he had to say:

HME: Some of the Medicare reform legislation coming down the pike specifies a greater role for the physician with regard to the K0011 power wheelchair.

Paul Metzger: Yes, and I think that’s a great idea. Physicians will feel more included in the decision making, and we at the Scooter Store agree that physicians should be primarily involved in decisions as to where power mobility is necessary.

HME: Will giving the physician a greater role to play have some impact in the kind of fraud and abuse we saw in Houston?

PM: One of the points I made to CMS and always advocated is that it’s very tough to use medical necessity policy to address fraud.These folks interested in ripping off the Medicare trust fund aren’t going to pay attention to anybody’s rules. They are no different from bank robbers. The fraudulent will find a loophole, and that has to be attacked by our law enforcement agencies as well as the benefits integrity unit of the DMERCs.

HME: Some say the remarkable growth in the power wheelchair market is a consequence of an untapped market. In other words, that there are millions of folks who should have chairs but don’t, and what we are seeing now is catch-up. Do you think that’s the case?

PM: I do. I really do. There are a lot of folks out there who either through pride or not knowing what is available are at risk for falls within their own homes. Their activities of daily living, even within their own home, are very limited because of their inability to get around in the home.

HME: Has there been some evolution at the DMERCs in the interpretation of who qualifies to be in a power chair?

PM: In 1995, I suggested to CMS that, at least in Region C, we should start interpreting bed or chair confined as being within the bounds of the home. Otherwise, when nurses in the different DMERCs apply their different criteria - can he walk 10 feet, or 15 feet - it became inconsistent in claims decisions. We started to apply that in 1995.

HME: And there were changes to the CMN to reflect that.

PM: When the OMB began approving CMNs in 1996, in the first revision, the questions did change to reflect that general agreement in Medicare. The question became: Does the patient need powered mobility to get around within the residence? In 1997, CMS and all four DMERCs agreed that that should be the definition of what it means to be bed or chair confined. The CMN changes document the change in application of the policy to a more liberal or realistic interpretation, which occurred around 1995 or 1996, and has been so since.

HME: So then, it doesn’t necessarily mean that you cannot walk at all in order to qualify for a power wheelchair. You can take some steps in the house and still qualify for a chair?

PM: That’s absolutely correct.

HME: But you can’t be able to walk outside the home.

PM: If they need it inside the home, and also use it outside the home, that’s not a problem for Medicare. They need to draw a line in the sand because of limited resources of where bed or chair confined ends. When I proposed this [definition of bed or chair confined] back in 1995, I know it was accepted as a reasonable and necessary definition that would lead to consistency and reliability.

HME: Is there consistency between the DMERCs on that interpretation?

PM: I can’t speak for the other DMERCs, but because of the fraud situation there may be a tendency by some of the DMERCs, or all of the DMERCs, to tend to overreact and pull in their horns a little. I do believe in due process. I don’t believe that if a policy has been applied as it has been over the last eight years, that that should penalize legitimate providers who have come to rely on that policy interpretation as it is demonstrated in the CMNs.

HME: But it could be tougher, given Houston and operation Wheeler Dealer.

PM: If a DMERC has now decided that they are going to go back to the original interpretation of bed or chair defined, they are putting that physician in a no-win position because if he really believes that his patient needs that power mobility in the home because of a cardio-pulmonary reason or because they need to get to point-a or point-z in their home, he’s going to say yes. Now what do the DMERCs do? If they are going to process the claim off the answers on the CMN, they should legitimately pay that claim.

HME: But there is likely to be more scrutiny.

PM: If they choose to develop a claim and look for additional medical necessity in the records that’s going to corroborate those answers, that’s a perfectly reasonable thing to do. But if they are not, and obviously they cannot develop all claims for all power wheelchairs, then I believe they should continue to adjudicate the claims based on the answers to those questions on the CMN.

HME: Why did no one at Region C pick up on the staggering growth of claims in Harris county. What happened?

PM: CMS only budgets so much, and it’s a matter of how many resources are being allocated. One thing I’ve never understood is: We are paying well over $1 billion for K0011s, but I suspect that there’s a very small fraction that goes to enforcement. The BIU (Benefit Integrity [Anti-Fraud] Unit) does its due diligence with the resources allotted to them. There is a lot of due process involved. This is a democracy. There are legislative constraints. When they decide that someone looks bad and they’d like to pull their supplier number they have to go through the proper procedures.

HME: Knowing what you know about CMS’s 10-point plan and how things might change in light of Houston, do you think we are on a track that makes it much more difficult for something like Houston to happen, or because of the lack of resources are we still in danger of another eruption?

PM: If people are out to fleece the system, they are going to get away with it until or unless more resources are dedicated to stopping it.

HME: Will mandatory accreditation have a significant impact on incidence of fraud an abuse?

PM: I think it will. It’s another form of vetting of suppliers that are good. Suppliers that are willing to go through that process are demonstrating that they’re the good guys.

HME: Do you think competitive bidding is a good idea?

PM: No, if I take it from what I saw in the medical field, in terms of HMOs, I don’t think it’s a good idea.