Advocates Speak Out Against Medicare/Medicaid Power Wheelchair Demonstration Project

A new Medicare prepayment review of claims for power wheelchairs and scooters is under fire from advocates and users of mobility devices.

"The process for receiving a power wheelchair has already become burdensome for Medicare beneficiaries and their physicians," said Paul Tobin, president/CEO of United Spinal, in a news release. "There are parts of the country where Medicare patients have to do business with reluctant providers who are hundreds of miles away. This demonstration project will make it harder for them to receive the wheelchair they need for everyday mobility.”

The plan or demonstration project, which goes into effect Jan. 1, will affect a wide range of power wheelchairs and all scooters in seven states: California, Florida, Illinois, Michigan, New York, North Carolina and Texas.

Under the demonstration project, home care providers will be required to submit claims for preapproval before they will be reimbursed for the cost of the equipment. The preapproval process is expected to cause significant delays in fulfilling equipment prescriptions.

Under the current system, a mobility equipment provider fills out a claim for the equipment and the Medicare Durable Medical Equipment Medicare Administrative Contractor (DME MAC), the entity responsible for approving Medicare claims, reviews the claim to ensure the required information is supplied and then pays the provider for the equipment. In certain circumstances, such as audits or prepayment reviews, the DME MAC demands additional documentation, which the provider should have on file, such as physicians’ notes about the patient’s disability. Providers do not send this information to the DME MAC unless requested but always keep it on file.

In phase 1 of the demonstration project, however, all claims will be subjected to prepayment review. The DME MACs do not want additional documents sent until they specifically request it, which will significantly slow down the payment process.

In phase 2, the prepayment review will be replaced by a prior authorization requirement, which requires a home care provider to contact Medicare to get permission to provide the equipment before actually doing so. It’s akin to the prior authorization currently required by health insurance companies before doctors do something big, such as a surgical procedure. The prior authorization will be required for the same categories of power mobility devices that were subjected to phase 1’s prepayment review.

While the Centers for Medicare & Medicaid Services (CMS) said on Nov. 15 that the states were chosen due to "high populations of fraud- and error-prone providers," critics and mobility device experts pointed out that claims from those seven states made up a large percentage of the total number of Medicare power mobility device claims because of the high populations in those states.

A Dec. 8 bulletin from the American Association of Homecare, an advocacy organization for home care providers in Washington, D.C., noted that the demonstration project "will affect nearly half of all Medicare beneficiaries who require power mobility."

The first phase of the three-year project will require prepayment reviews for most types of power wheelchairs and scooters:

  • Power-operated vehicles (scooters): HCPCS codes K0800-K0805 and K0809-K0812
  • Standard power chairs: HCPCS codes K0813-K0829
  • Group 2 complex rehab power chairs: HCPCS codes K0835-K0843
  • Group 3 complex rehab power chairs without power options: HCPCS codes K0848-K0855
  • Pediatric and Group 4 power chairs: HCPCS codes K0887-K0891
  • Miscellaneous power wheelchairs with HCPCS code K0898

Group 3 chairs with powered seating options—with HCPCS codes K0856-K0864—are excluded from the project.

The first phase is scheduled to last about three to nine months, with the second phase starting immediately afterward and being rolled out on a state-by-state basis.

Tyler J. Wilson, president/CEO of AAHomecare, said, "We are calling on Congress to stop this demonstration project before it prevents older Americans and people living with disabilities from receiving medically required mobility equipment and causes irreparable harm to providers of home medical equipment and services. Members of Congress should be worried about the impact of this program on many of the most vulnerable people in our society."

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.