Senate scrutinizes PWC use

Monday, May 31, 2004

WASHINGTON - HME industry fears that a Senate Finance Committee hearing on power wheelchair fraud and abuse might further cripple the Medicare benefit came mostly to naught April 28 as federal officials revealed recommendations and plans that jibe with the industry’s expectations.

“They are going in the right direction,” said Cara Bacheheimer, vice president of government relations at Invacare who is playing an instrumental role in a coalition representing mobility manufacturers and suppliers. “In fact, the OIG made a very specific recommendation as if it were right out of our mouths - that CMS needs to define the conditions under which it will provide coverage. That is what we have been asking for.”

Chairman Charles Grassley, R-Iowa, called for the hearing following the Wheeler Dealer scandal in Houston last year and ongoing concerns about the escalation of payments for power wheelchairs. While Medicare paid a bit more than $100 million for power wheelchairs (PWC) in 1997, the program paid about $1.2 billion last year.

To comment on issues in the market, the committee called representatives from the OIG, GAO, CMS, AAHomecare, Tricare, a coalition that advocates for consumer mobility and a former DME dealer who has pled guilty to participation in a PWC scheme that defrauded Medicare of $25 million. That woman, Rebecca Lewandowski, told her story on ABC World News Tonight with Peter Jennings the night before.

Just before the hearing began on Wednesday, CMS released a new three-pronged plan that builds on Medicare’s 10-point plan to combat fraud and abuse in the wake of the Houston scandal. The new initiatives will formulate new coverage policy for power wheelchairs, develop new codes for reimbursement and, per the MMA, revise the standards for participation as a Medicare supplier.

While the industry appears favorably disposed toward these developments, a pair of OIG reports provides less welcome news for an industry that feels unfairly tarnished by scam artists.

An OIG audit of 300 PWC claims found that only 13% of the beneficiaries qualified for the benefit while 31% did not meet the coverage criteria for any type of wheelchair. For more than half the claims reviewed, CMNs and/or delivery documentation were missing, incomplete or dated after the date of service, the OIG stated.

Bewildered by the suggestion that nearly nine out of 10 Medicare power wheelchair users doesn’t belong there, the industry is questioning the OIG’s methodology.

The industry is also troubled by the methodology used to obtain pricing information about power wheelchairs. In a second report, the OIG found that Medicare could have saved $459 million last year if CMS paid for power wheelchairs at the same price suppliers paid to wholesalers.

As a result, the OIG recommends that CMS either break up the K0011 code - an initiative that a significant portion of the rehab community supports - or implement IR to reduce reimbursement for power chairs.

That, according to Bachenheimer, was the big negative to come out of the hearing.

“The data collection that the OIG went through doesn’t begin to reach the threshold that’s required in the IR regulations,” she said. “They looked at eight suppliers and 36 invoices. How can that be representative.”

HME industry leaders believe CMS is more likely to pursue a reorientation of wheelchair coding, as soon as this January. If the K0011 code is split, that could have a substantial financial impact on providers of senior mobility.

In its testimony, the GAO criticized CMS for not doing too little too late when it came to combating PWC fraud and abuse. John Gallagher, vice president of government relations at the VGM Group, didn’t think the GAO went far enough.

“Systemically, CMS is not up to the challenge,” said Gallagher. “Somebody needs to be in there pointing fingers, saying these guys got to go.”
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For a special, in-depth look at recent developments in power wheelchair politics, including revelations by the Senate Finance Committee, see our expanded Rehab section.