Clinical Template may Address Flawed Documentation Process

WASHINGTON, April 16, 2012 /PRNewswire-USNewswire/ -- The Centers for Medicare and Medicaid Services (CMS) is developing a clinical template for physicians to use to evaluate a Medicare beneficiary for power mobility. The move, which has long-standing support from home medical equipment providers, physicians, and other stakeholders, is desperately needed to address the unreliable, subjective and ambiguous current system for documenting medical necessity for power wheelchairs and scooters, says the American Association for Homecare.

Several recent claim reviews by Medicare audit contractors underscore the extent of the problems faced by physicians and home medical equipment providers in satisfying the subjectively applied rules for documentation. One Medicare contractor, National Government Services, conducted a prepayment review for group 2, standard power wheelchairs in the 4th quarter of 2011, and determined the error rate was 81 percent. Of 615 claims reviewed, 119 were paid in full or partially paid, while 496 were completely denied. Put in context, Medicare bureaucrats are overruling the clinical judgment of physicians more than 80 percent of the time.

That just doesn't add up. 

At some point, Congress must recognize that the problem is with CMS and not the providers. For far too many years, the arbitrary documentation rules and inconsistent auditing standards have been used to deny claims that should have been approved. Nine out of ten appeals of these denials are won by providers, but their cash flow is restricted, threatening their businesses. Some documentation rules are absurd. The current process calls on physicians to respond to more than 40 different points during their face-to-face examination of a Medicare patient and to provide written patient notes that must show a developing need for mobility assistance over a long period of time. Any point not answered in the manner the auditor wants can result in a denial of payment. 

"These denied claims are not fraudulent or abusive," said Tyler Wilson, president of the American Association for Homecare (AAHomecare). "The problem is that the vague and subjective documentation requirements make it easy for the claim reviewers to reject any claim. That's why the stakeholders have repeatedly called for clear and unambiguous standards in the form of a physician evaluation template that will help make this a more objective process and make it less burdensome for physicians to document the necessary information."

For years, the Medicare program has struggled to produce a process that adequately documents legitimate use of its mobility benefit for senior citizens and people living with disabilities—people who need power wheelchairs to perform the daily necessities of life in their homes. After several revisions of the documentation process and efforts to educate physicians, the situation today has not improved. Physicians, clinicians, providers and beneficiaries are now more confused about what it takes for a reimbursement claim to be approved.   

Auditors are denying more claims than ever, while tying up physicians and providers to work on time-consuming paperwork rather than focusing on patient care.

Recently, AAHomecare reviewed home medical equipment audits, finding that CMS auditors often don't comply with policies, laws, and regulations. They are denying the reimbursement claims or requesting refunds for claims that were paid, even though the treating physician determined that the Medicare beneficiary had a legitimate medical need for the equipment. "Our review shows that Medicare contractors often deny claims for reasons that are not specified in Medicare coverage requirements or impose new documentation requirements without notice to providers," Wilson said. "Auditors are performing detailed medical reviews that include unspecified requests for additional documentation and give providers little guidance about what they must do to satisfy the claims reviewer."

Oftentimes, new documentation standards are introduced and applied retroactively to deny previously approved claims. Physician chart notes are required for all claims, CMS applies the most restrictive interpretation of coverage criteria, and if a doctor doesn't chart in his patient notes each component of the national coverage criteria, the claims are denied.

CMS has used the absence of a form or an objective documentation process to make shifting demands that the majority of physicians say are unrealistic. It has created an environment where auditors are routinely overruling prescribing physicians and their clinical assessments. Numerous claims are denied, not because of questions related to whether a Medicare beneficiary needs mobility assistance, but because the physician documentation wasn't presented in the format that CMS desired.

What's more, this process is too time-consuming, especially for the busy physician who only writes a few power wheelchair prescriptions a year. That's why providers see hope with the announcement that CMS will develop a physician evaluation template.

Most providers are cautiously optimistic it can simplify the documentation process.

There is some concern, however, that the initial draft of the template may once again ask physicians to do more than they can reasonably handle. In fact, some of the requested information may need to be provided by clinicians and physical therapists who specialize in treating patients with mobility limitations—not general practice physicians who haven't had that specific training.    

Thus far, the CMS division working on the electronic template has reached out to providers and seems willing to listen to recommendations from the power mobility community, which has not always been the case when the agency is producing new policies and regulations. An initial draft of the clinical template has been released for review, while discussion sessions have been organized so CMS can receive feedback from stakeholders. 

"We're hoping this signifies a new era of cooperation," said Wilson. "The current documentation process is jeopardizing patient care by denying prescribed medical equipment to Medicare beneficiaries. It is also adding financial burdens to providers."  

Mobility Matters is published periodically by the American Association for Homecare to inform Congress, the administration, policymakers, consumer organizations and the media about Medicare's power mobility benefit, and the need to sustain it. AAHomecare is committed to helping seniors and people living with disabilities regain their freedom and independence. To learn more about the Medicare power mobility benefit, go to www.aahomecare.org/mobility. American Association for Homecare - 2011 Crystal Drive, Suite 725, Arlington, Virginia 22202 -703.836.6263

SOURCE American Association for Homecare