Disability Advocates Tell Medicare: Use a Clinical Template to Accurately Document Medical Need for Wheelchairs

New program may jeopardize access to mobility for Americans with disabilities

WASHINGTON, July 27, 2012 /PRNewswire-USNewswire/ -- Four national organizations that advocate for people living with disabilities are urging the Centers for Medicare and Medicaid Services (CMS) not to implement a "prior authorization" program for power wheelchairs without including a clinical template for physicians to document patients' medical need for mobility equipment, reports the American Association for Homecare. CMS is the federal agency that administers Medicare and Medicaid.

In recent letters to CMS, the Association of Programs for Rural Independent Living (APRIL),  the National Council on Independent Living (NCIL), the United Spinal Association and the American Association of People with Disabilities (AAPD) warned that many Americans with physical disabilities may lose access to mobility devices.  The organizations said that a clinical template is needed to address the Medicare program's flawed documentation process that has been sharply criticized by physicians, as well as providers.

"Without a standardized set of data elements or guidance for these physicians and treating practitioners to document the medical needs of their patient, we are deeply concerned that the prior authorization request will be denied upfront by a Medicare contractor even though the medical need exists," wrote Billy Altom, APRIL's executive director. "As a result, beneficiaries will be denied access to independence by the Government until this information is deemed sufficient."

Under the proposed prior authorization program, the CMS will subject all claims for power mobility to a prior authorization process for a period of three years in California, Florida, Illinois, Michigan, New York, North Carolina, and Texas.  Medicare patients in these states receive nearly 50 percent of the power mobility prescribed to beneficiaries each year.

The need for significant changes to the documentation process was underscored in a recent Comprehensive Error Rate Test (CERT) report. CERT is a program run by CMS. The CERT on power mobility devices in the jurisdiction covering 17 states, including California, recently found a 100 percent error rate, a score supposedly signifying that none of the power wheelchairs provided to Medicare beneficiaries in that region met the reimbursement and coverage criteria.  Clearly, the CERT demonstrated that CMS guidelines for documenting medical necessity for mobility devices are so subjective and absurd that virtually any reimbursement claim can be found to be in non-compliance.

"Consumer organizations are right to be worried about Medicare patents in need of mobility assistance," said Tyler Wilson, president of the American Association for Homecare. "As the CERT demonstrated, if the same flawed documentation guidelines are in place after the prior authorization program is implemented, then none of those Medicare beneficiaries in that region would have received power wheelchairs because the determinations would have been made before the equipment was provided.  CMS will be seriously jeopardizing patient care."

Wilson said that CMS acknowledges it is developing a clinical template, but the agency has not linked their template to the prior authorization program.

Consumer advocates, providers, and physicians say it's critical that a clinical template address the documentation problems. Today, claims are repeatedly denied, with CMS contractors often ruling that the documentation of medical need wasn't sufficient.  Their determinations are routinely overturned after appeals that take place after patients have received the equipment.  But a prior authorization program with no clinical template will indefinitely delay delivery of prescribed power mobility devices until denials are resolved.  Some senior citizens and people living with physical disabilities may never receive power wheelchairs.

"From the users' standpoint, the consequences of inadequate documentation will be more serious in a system which requires prior authorization than they are in the current system in which prior authorization is not required, and users gain access…subject to subsequent audit and review of the documentation," wrote Mark Perriello, AAPD's president and CEO.   

Perriello warned that if physicians are not aware of the documentation CMS needs, many initial submissions will be inadequate, resubmissions will be required, and there will be months of delay in giving persons with disabilities access to the power wheelchairs they need to participate independently in their communities and avoid unnecessary institutionalization.

"Stakeholders believe it is essential that a template be a part of the CMS prior authorization process from the start," wrote Paul J. Tobin, president and CEO, of the United Spinal Association. "Prior authorization works for 49 state Medicaid programs, as well as Medicare Managed Care Plans and Tricare, because such templates are applied to standardize the collection of a beneficiary's medical record."

The United Spinal Association, Tobin said, believes that the use of such a template, which would create prompts to assist physicians and treating practitioners in evaluating beneficiaries for their power mobility device, is essential to the success of the prior authorization demonstration.

"Without a clinical template, confusion and subjectivity will reign and undermine the program's validity," he said. "It is feared that absent a standardized template, the data on unjustified claims denials (exceeding 90% by CMS' own accounting) will continue unabated and unnecessary delays in the delivery of needed equipment will not be improved upon. This may affect virtually all Medicare beneficiaries with prescriptions for power mobility devices."

Kelly Buckland, executive director of NCIL, wrote that, as a power wheelchair user, he understands the "value of independence and mobility" afforded by the Medicare benefit.

"However, we are very concerned that Medicare beneficiaries will be denied their mobility independence if CMS designs and develops a prior authorization process that does not follow similar, time tested processes and procedures or incorporate a clinical medical necessity template prior to the implementation of the Prior Authorization Demonstration project later this summer," he wrote. "NCIL is asking CMS to work with power wheelchair users and stakeholders to develop a well-defined program that maintain(s) access to these much needed devices while preventing fraud and abuse… Failure to do so poses too great a risk to the health, safety and independence of people with disabilities."

Buckland said that Medicare beneficiaries are essentially caught in the middle, having "no choice but to rely on their physicians and/or treating practitioners to document medical necessity and verify the plan of care executed by the prescription of a power mobility device in order to meet Medicare's coverage criteria and payment requirements. In our experience most beneficiaries provided a PMD have a genuine medical need for the device."

Meanwhile, Altom of APRIL, wrote, "We remain concerned that the program CMS has designed… has the potential to eliminate the Medicare benefit for power mobility devices for individuals who reside in one of the seven States where the program will be implemented. 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."

Altom, as well as the leaders of the other organizations, supported the prior authorization process as long as a clinical template is included.

The American Association for Homecare represents durable medical equipment providers and manufacturers who serve the medical needs of millions of Americans who require oxygen equipment and therapy, mobility devices, medical supplies, inhalation drug therapy, and other medical equipment and services in their homes. Members operate more than 3,000 homecare locations in all 50 states.  Please visit www.aahomecare.org/athome.

SOURCE American Association for Homecare