Physician Explains Flaws in Medicaid’s Preauthorization Process

Although the Centers for Medicare and Medicaid Services (CMS) has planned a demonstration program in seven states that will require prior authorization for power wheelchairs, the funding source has yet to commit to a clinical template to assist physicians in prescribing.

Organizations representing the community of people with mobility disabilities, including United Spinal Association, the National Council on Independent Living and the Association of Programs for Rural Independent Living, recently sent a letter to CMS urging the release of a clinical template.

"As we have stated before, the program CMS has designed thus far does not constitute a demonstration,” explained Kelly Buckland, executive director of the National Council on Independent Living, in the letter. “Instead it has the potential to eliminate the Medicare benefit for power mobility devices for individuals who reside in one of the seven states where this experiment will transpire. This could be rectified very easily if CMS designed, developed and implemented a prior authorization process that includes the utilization of a clinical medical necessity template to provide necessary clarity and guidance to physicians, treating practitioners, suppliers, and beneficiaries attempting to meet the prior authorization documentation requirements."

Physicians need clarity regarding documenting medical need for people who need power wheelchairs. To explain why, the American Association for Homecare (AAHomecare), an organization that represents providers and manufacturers of durable medical equipment in Washington, D.C., reached out to Dr. Meg Allyn Krilov. Dr. Krilov practices rehabilitation medicine at Montefiore Medical Center and Premier HealthCare in New York and has prescribed hundreds of power wheelchairs.

AAHomecare: How does the Medicaid prior authorization process work?
Dr. Krilov: I can't say that it is completely perfect, but when I prescribe a Medicaid power wheelchair, the prior authorization process makes it a bit smoother, less time-consuming and better for the patient. To meet their requirements, I have to write a prescription, justify the need for a power wheelchair and explain why a power wheelchair is needed rather than a manual wheelchair or a scooter. After that documentation is completed, I send it to a vendor and Medicaid, and they decide if it's approved or if they need more information.

AAHomecare: Is the Medicaid process quicker and more efficient than the Medicare process?
Dr. Krilov: Yes, that's true.

AAHomecare: What is wrong with the current Medicare process? Can the problems be fixed?
Dr. Krilov: It's very awkward and very cumbersome. It's a burden for physicians, the suppliers, vendors… We examine the patient and then prescribe what the patient needs. I do that evaluation. Then I have to write a letter of justification and complete the seven elements required in the report on the face-to-face examination. These details include name, address, telephone number, diagnosis, and why the patient can't use a cane, crutch or walker. Now, for instance, I've already stated that the patient has cerebral palsy (CP), is quadriplegic and can't walk. But the process requires that I repeat that information and write again that the patient has CP, is not ambulatory, cannot walk and has contractures. Then I have to write that the patient can't self-propel in a manual wheelchair because they can't use their upper extremities and have contractures and coordination deficits. And then I have to write that the patient can't use a scooter because they can't transfer in and out of the scooter. One of the big problems now is that they do not allow prior authorization for a standard power wheelchair. In many cases, the vendor has already provided the equipment to the patient. Then, after the fact, the claim evaluators will say, "it's not enough, we deny it," and that's not really fair to the patient or the vendor.

AAHomecare: Do you think a prior authorization process would improve the Medicare process?
Dr. Krilov: Well I think so. The other problem is that some of the questions that they ask are confusing and hard to answer accurately.

AAHomecare: Physicians and providers are very concerned that Medicare may implement a preauthorization process but not include a clinical template. Will this create more problems rather than solve any?
Dr. Krilov: Yes, it could make a bad situation even worse. I think it's very important that we include a template. It is what will make the process more efficient. It's common sense to include a template. I've had clients denied who really needed a power wheelchair.

AAHomecare: How long does it take you to do the paperwork for a Medicare beneficiary to get a power wheelchair?
Dr. Krilov: It takes at least 45 minutes to 1 hour to examine them inside the clinic. Then I go home and write the letter. Depending on how complicated a case it is, the entire process can take 2-2.5 hours for each patient. I would rather be spending more time with the patient than doing paperwork. I don't have time to do the Medicare administrative work in my office, so I have to take it home and work on it in the evening. So each power wheelchair for a Medicare patient requites me to work afterhours at home.

AAHomecare: Would a template cut down the amount of time needed?
Dr. Krilov: Definitely. A template and prior authorization would help. I strongly urge Medicare to simplify the process by having a template that is easy to follow so the work can be completed at the clinic. Being forced to write a letter of justification where I have to reiterate everything is just really cumbersome and awkward.