CMS Moves in the Right Direction

CMS Moves in the Right Direction

Cara C. Bachenheimer

Byline: Cara C. Bachenheimer, Esq.

The Centers for Medicare and Medicaid Services (CMS) announced its three-pronged initiative to address power wheelchair issues at the Senate Finance Committee’s April 28 hearing on Medicare coverage and payment for power wheelchairs. Overall, CMS’ initiative is a significant step in the right direction to address perceived and real issues in this area.

There are, however, several recommendations to improve and refine CMS’ initiatives that will yield improved results.

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Coverage guidance development needs input from practicing clinicians at the outset. CMS’ initiative to develop more coverage guidance for power wheelchairs is limited to convening clinicians from Health and Human Services (HHS) and other government agencies to refine and describe the conditions that are associated with the current coverage definition and to develop draft guidance for determining whether a patient meets the definition of “bed or chair confined.”

CMS needs, however, to include non-government clinicians actively involved in prescribing motorized wheelchairs and clinicians who evaluate and fit beneficiaries for power wheelchairs to ensure that the consumer receives the medically appropriate wheelchair and necessary components/accessories.

Without the input of currently practicing clinicians, CMS’ guidance will lack necessary and important “real life” current medical practice input.

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New codes will address many issues. CMS’ second initiative is to develop a new set of HCPCS codes, in conjunction with the National Coding Panel, to better describe the wide array of available power wheelchairs and to set Medicare fee schedules that are more closely aligned with the actual product provided. This initiative should be applauded, and I strongly recommend that CMS review the industry’s detailed coding recommendations for motorized wheelchairs.

The industry’s submission also provides clinical indicators for each of the six recommended new codes. These clinical indicators could serve as the basis for Medicare coverage policy descriptions. Moreover, clinical indicators, functional levels and diagnosis codes, when used together, can provide critical support for medical need.

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Stronger supplier standards. We must fully support CMS’ third initiative to implement stronger quality controls on the process for suppliers receiving a Medicare Part B supplier number. In fact, the industry has recommended that every Medicare Part B mobility supplier be accredited by a national accreditation organization. This measure will help ensure that only legitimate providers are able to bill Medicare on behalf of beneficiaries.

RAMP’s 10-Point Plan

Consistent with CMS’ initiative, the industry coalition RAMP, the Restore Access to Mobility Partnership, has recommended a 10-point plan to help CMS fight fraud without harming the people who require power wheelchairs to increase their mobility. The coalition has developed this plan and is actively lobbying CMS and members of Congress for CMS to implement all 10 points.

Following are the details of RAMP’s 10-point plan:

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Fraud task force – With industry assistance, the government should organize a special task force and implementation strategy to combat fraud and abuse. CMS, the Office of Inspector General (OIG), and the industry can work together to eliminate fraud. Industry representatives would serve on the task force with CMS representatives.

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Comprehensive coverage policy – CMS should establish a clear national coverage policy for mobility products. This would establish national guidelines that would end confusion over coverage policy.

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Provider/supplier accreditation – Requirement for all Medicare/Medicaid mobility suppliers to be accredited by a nationally recognized accrediting organization. This measure will improve the standards for suppliers.

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Advanced rehab certification – Requirement for a strict certification plan for suppliers who provide advanced rehab equipment for disabled pediatric and the severely disabled. This will help ensure that only qualified, certified/credentialed individuals are responsible for the treatment of those with severe disabilities.

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Medical documentation requirements – Establish that a certificate of medical necessity (CMN) – signed by a physician, with a corroborated state licensed physical therapist or occupational therapist evaluation – is required documentation to establish non-ambulation and whether a mobility product (such as a power wheelchair) is medically necessary. This will provide clarity for providers and physicians as to the proper documentation requirements to establish medical necessity.

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Advisory group on mobility issues – Appoint representatives from groups representing persons with disabilities, consumers and the industry to advise CMS on issues related to mobility questions. The group would be a sounding board for CMS, so that the agency could better gauge the impact of any new policies or guidelines.

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New code development – CMS should establish new HCPCS codes for mobility equipment as the industry has recommended. There is such a vast range of technology that old codes need to be updated to adequately differentiate between the products. The industry has recommended a detailed plan with clinical indicators.

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Establish advertising best practices – Establish clear advertising guidelines for the health care industry. This will help prevent non-compliance with Medicare standards. Many other industries have advertising requirements and regulations; the power wheelchair industry can also accept them.

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Fraud reporting system – Work with CMS to establish an enhanced fraud reporting system that will help curtail fraud as well as encourage people to report any irregularities.

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Regulatory reform – Implement the regulatory reform procedures outlined in the Medicare Modernization Act that establish a clear procedure for reviewing medical claims and providers to determine compliance with established documentation requirements. It is essential that clarity in medical documentation be established to achieve efficient claim processing.

A specialist in health care legislation, regulations and government relations, Cara C. Bachenheimer is vice president, government relations, for Invacare Corp., Elyria, Ohio. Bachenheimer previously worked at the law firm of Epstein, Becker & Green in Washington, D.C., and at the American Association for Homecare and the Health Industry Distributors Association. You can reach her by phone at 440/329-6226 or by e-mail at cbachenheimer@invacare.com .

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