Most power wheelchairs provided by Medicare, the federal program that provides healthcare services to individuals over 65 years old, did not meet medical necessity guidelines, according to a report released July 7 by the U.S. Office of the Inspector General.
The 55-page report examined the extent to which standard power wheelchairs and complex rehabilitation power wheelchairs provided to Medicare beneficiaries during the first half of 2007 were medically necessary based on records from wheelchair suppliers. The agency investigated 375 claims in 2007 and looked at whether records from physicians who prescribed these wheelchairs to patients were consistent with suppliers’ guidelines for medical necessity.
Surprisingly, 61 percent of power wheelchairs provided to Medicare beneficiaries in the first half of 2007 were medically unnecessary or had claims that lacked sufficient documentation to determine medical necessity.
Seventy-eight percent of claims without supplier record errors were not supported by records provided by physicians who prescribed the power wheelchairs. That is, while suppliers’ records indicated that power wheelchairs were medically necessary, physicians’ records indicated that they were medically unnecessary, or physicians’ records provided insufficient documentation or no documentation of medical necessity. In most cases, physicians’ records had insufficient documentation to support the medical necessity of power wheelchairs.
From 1999 to 2003, Medicare payments for power wheelchairs increased a whopping 350 percent, from $259 million to $1.2 billion annually, raising concerns about inappropriate Medicare payments. In response, the Centers for Medicare & Medicaid Services revised its policies related to power wheelchair coverage and coding in 2005 and 2006. After these changes, Medicare’s annual payments for power wheelchairs decreased to $658 million in 2007. But spending for this equipment rose again over the next two years, to $779 million in 2008 and $723 million in 2009.
“These increases may indicate that CMS continues to pay for power wheelchairs that are not medically necessary and/or that have claims that do not meet documentation requirements,” the report says.
Medicare Part B allows beneficiaries to receive power wheelchairs under a provision that covers durable medical equipment. Medicare recipients who are prescribed power wheelchairs receive them from suppliers, which bill the Medicare program for reimbursement. Before a supplier can provide a power wheelchair to a patient, the supplier must first receive a prescription from a doctor for the power wheelchair as well as have documentation from the patient’s medical record that supports the medical necessity of a power wheelchair.
But based on 2007 records submitted by suppliers that provided power wheelchairs, 9 percent of power wheelchairs prescribed to patients in the first half of the year were medically unnecessary. Another 52 percent had claims that were insufficiently documented to determine whether the power wheelchairs were medically necessary.
The findings are significant considering that, of the $189 million that Medicare spent on power wheelchairs in the first half of 2007, $95 million of that went toward paying for wheelchairs that were medically unnecessary or had claims that were insufficiently documented.
Beneficiaries who received medically unnecessary power wheelchairs needed a less expensive type of equipment or a different type of power wheelchair, the report says. For 2 percent of claims, a less expensive type of equipment, such as a scooter or a manual wheelchair, should have been provided. For the remaining 7 percent of claims, the beneficiaries should have received a different type of power wheelchair than was actually provided.
Based on the findings of the report, OIG is recommending that CMS enhance reenrollment screening standards for current Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies, also known as DMEPOS. OIG also wants CMS to review records from the prescribing physician to determine whether power wheelchairs are medically necessary and continue to educate power wheelchair suppliers and prescribing physicians to ensure compliance with Medicare coverage criteria.
Read the full report here: http://oig.hhs.gov/oei/reports/oei-04-09-00260.pdf