Citing Lack of Information, Providers Seek 30-Day Delay in Medicare's "Prior Authorization" Program for Wheelchairs

WASHINGTON, Aug. 27, 2012 /PRNewswire-USNewswire/ -- Five days before Medicare implements a "prior authorization" process for beneficiaries who need power wheelchairs, physicians and providers are alarmed that they haven't yet received critical details about the program. Stakeholders are also concerned that the massive project will launch without a key tool for determining a patient's medical need for power mobility assistance. 

The American Association for Homecare (AAHomecare) said today that the prior authorization program currently planned for implementation on September 1 will delay and possibly even block many vulnerable seniors and disabled Americans from receiving medical equipment prescribed by their physicians.

Stakeholders, including physicians, providers and advocates for people living with disabilities, are upset that the Centers for Medicare and Medicaid Services (CMS) is hastily implementing the program, even though as of today stakeholders hadn't received an operational guide with comprehensive instructions for the program.

"It is disheartening that CMS is launching a program that will affect senior citizens and disabled Americans across the country, but haven't even released the instructional guide," said Tyler Wilson, AAHomecare's president and CEO. "Unfortunately, it demonstrates the disregard that CMS is showing some of the most vulnerable people in our society.  Prior authorization, as currently constructed, will jeopardize the health of Medicare patients, yet the government hasn't provided the information that physicians and homecare providers need to mitigate the pain and suffering that is sure to come."

Under the three-year demonstration program, all power mobility claims from Medicare patients in California, Florida, Illinois, Michigan, New York, North Carolina and Texas must be submitted for prior authorization.  Medicare beneficiaries in these states annually receive nearly 50 percent of the power wheelchairs obtained through Medicare.

AAHomecare and other stakeholders support prior authorization if the program is properly designed. However, there is widespread concern that the CMS program fails to include a clinical template to help physicians document a patient's medical need for mobility assistance – a significant factor that will undoubtedly affect patient care.

The criteria that CMS uses in its claims-approval process, as well as in documenting a Medicare patient's medical need for mobility assistance, are central to the controversy surrounding the prior authorization program.

Wilson said the CMS contractors have created "a deny-at-all-costs culture" that routinely denies Medicare beneficiaries' claims for power wheelchairs.  Denials have stemmed from such trivial factors as difficult-to-read dates on the documentation paperwork.  Many of the denied claims have been paid after lengthy appeals by the providers. Medicare patients have been largely unaffected because under the current system their power wheelchairs were received before CMS had made any determination on the claims.

But prior authorization transforms the procurement process, putting Medicare patients at far greater risk: power wheelchairs can't be delivered until after prior authorization is received, a change that will delay deliveries.  Some Medicare beneficiaries may never be approved.

The impact of this change is underscored by the high error rates that CMS has cited with power wheelchair claims. Recently, a Comprehensive Error Rate Test (CERT) on power mobility devices in the jurisdiction covering 17 states, including California, found a 100 percent error rate. This score supposedly signifies that no power wheelchairs provided to Medicare beneficiaries in that region met the reimbursement and coverage criteria.  The CERT results demonstrate that the guidelines for documenting medical need for mobility devices are so flawed and subjective that virtually every reimbursement claim can be found to be in non-compliance. Other recent claim reviews have cited 87 percent error rates. With prior authorization, patients cited in those claims won't receive power wheelchairs.

"It is likely that the prior authorization program will simply shift the current high error rate to a high denial rate during the prior authorization process," said Wilson. "It will increase the risk to Medicare beneficiaries who will not have access to the physician-prescribed power mobility devices they need."

"AAHomecare is committed to implementing an effective and efficient prior authorization program and will be ready to help CMS address issues with this demonstration program as they arise," Wilson said.

Most problems with the prior authorization program could be eliminated with a standardized format to collect needed information, such as a clinical template for physicians to use during the mandatory face-to-face exam. AAHomecare will continue to make recommendations to CMS on how to make the program successful, like those already in place in the private sector and a number of state Medicaid programs.

AAHomecare is eager to work with CMS, but is calling for an implementation delay until 30 days after a final version of the operational guide is published on the CMS website to ensure that providers, physicians, and beneficiaries have been educated on all aspects of the program.

Studies show that Medicare beneficiaries with power wheelchairs suffer fewer fall-related injuries, make fewer hospital emergency room visits, and delay confinement in costly nursing homes and care facilities. Power wheelchairs often allow seniors and disabled Americans to live independently and safely in their own homes, which reduces government spending on hospital visits, nursing homes, and other institutional care facilities.

The American Association for Homecare represents durable medical equipment providers, manufacturers, and others in the homecare community that serve the medical needs of millions of Americans who require oxygen systems, wheelchairs, medical supplies, inhalation drug therapy, and other medical equipment and services in their homes. Visit www.aahomecare.org.

SOURCE American Association for Homecare