Scooter store says Region D illegally used diagnoses to suspend claims

Sunday, June 5, 2005

SAN ANTONIO, Texas -- The Scooter Store, now enmeshed in a thicket of legal challenges that are threatening the company's survival, slashed out at the Region D DMERC last week, alleging that the Medicare contractor illegally used diagnosis codes as justification for claims denials and approvals.

This new compliant, filed in U.S. District Court May 27, quotes a letter written by Region D Medical Director Robert Hoover, M.D., which states, "there was a limited set of diagnoses for which medical necessity was scrutinized. If the POV claim did not list one of these diagnoses, the claim was autoadjudicated based only on the claim information and the Certificate of Medical Necessity (CMN) question set."

In such cases, Hoover notes that the DMERC did not request additional documentation. But if the claim did not pass the DMERCS diagnosis review, the claim was then suspended and additional documentation was called for.

For years, the Scooter Store and its Washington-based lobbying arm, the Power Mobility Coalition, have argued that the law, specifically the Paperwork Reductions Act, requires only a CMN to justify medical necessity. In this recent suit, the Scooter Store believes Region D violated that law by using diagnosis codes to screen claims.

The complaint enlists CMS Administrator Mark McClellan as an advocate for its argument by quoting testimony McClellan made in a written statement to the Senate Finance Committee last year: "The clinical criteria for deciding when a manual or power wheelchair is medically necessary and appropriate for a beneficiary has been and will continue to be a matter of clinical judgment by the physician."

The Scooter Store filed this complaint in federal court after exhausting the administrative appeals process.

In another action, the company filed a motion for the court to dismiss the Department of Justice's counterclaims to another TSS lawsuit.