Homecare Community Dismayed that Medicare Will Start Prior Authorization for Wheelchairs without a Clinical Template for Physicians to Document Need

WASHINGTON, Aug. 7, 2012 /PRNewswire-USNewswire/ -- The American Association for Homecare is disappointed that Medicare is implementing a prior authorization program for power wheelchairs without including a key component.  Physicians, providers, and advocates for disabled Americans insist that patient care will be jeopardized without a clinical template to help physicians document a patient's medical need for mobility assistance. 

Last week, the Centers for Medicare and Medicaid Services (CMS) announced that prior authorizations will begin September 1, 2012. Under the three-year demonstration program, all power mobility claims 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.

"Most stakeholders, such as physicians, providers, and advocates for people with disabilities, would support the prior authorization program if the clinical template were included," said Tyler Wilson, president and CEO of the American Association for Homecare. "Prior authorization when combined with a clinical template can vastly improve the documentation process. But this decision by CMS is very disappointing. There will be Medicare beneficiaries forced to leave their homes for expensive nursing homes and other care facilities because they won't receive the power wheelchairs prescribed by their physicians."

Under the documentation guidelines that will remain in place, CMS contractors routinely deny claims for power wheelchairs. But most Medicare beneficiaries receive the medical devices anyway while their providers appeal these decisions. In fact, many denied claims are overturned during the appeals process. But the stakes are higher under the prior authorization program: Medicare patients would not obtain a power wheelchair until after the denials are resolved and some beneficiaries may never be approved for the equipment.

Furthermore, there is plenty of evidence to support the stakeholders' belief that care will be jeopardized. Recently, a Comprehensive Error Rate Test (CERT) report on power mobility devices in the jurisdiction covering 17 states, including California, found a 100 percent error rate. That score supposedly signifies that no power wheelchairs provided to Medicare beneficiaries in that region met the reimbursement and coverage criteria.  That CERT result underscores the fact 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.

That's why a clinical template is so crucial.  The template would standardize the collection of a patient's medical information provided by physicians.  Instead of trying to figure out the confusing guidelines on what patient data CMS is seeking, a template would ask physicians for specific information.

CMS agrees that a template may be helpful and is developing one. But the agency failed to link it to implementation of the prior authorization program. Mobility stakeholders are also concerned that when CMS begins the pilot program physicians won't have the tools needed to make the program successful.

"Clearly, patient care is going to be jeopardized when CMS begins prior authorization without a clinical template," said Wilson.  "Some of the most vulnerable people in our society, seniors and people living with physical disabilities, will face delays in receiving power wheelchairs or won't get them at all.  It's time for CMS to acknowledge that it must fix the system for documenting a patient's medical need for power wheelchairs."

Moreover, stakeholders are also concerned that in announcing the start of prior authorization, CMS touted the program as one that would reduce fraud and abuse.

Wilson said that homecare providers steadfastly endorse efforts to combat fraud and abuse, but that CMS is creating a smokescreen to divert attention away from their badly flawed documentation process.  The CERT errors, he said, were caused by poorly written documentation guidelines that left physicians and providers confused over what information was needed for claims to be approved.  He noted the claims were largely denied because of missing patient information that had nothing to do with fraud.

"A prior authorization program with a clinical template can address the problems in the procurement system," Wilson said. "We support efforts to prevent fraud and abuse, and fixing the broken documentation system will help. Let's put in place a system that prevents fraud but also allows the most vulnerable people in our society to receive the mobility assistance they need to remain safe and live independently in their homes."   

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. Members operate more than 3,000 homecare locations in all 50 states. Visit www.aahomecare.org/athome.

SOURCE American Association for Homecare