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Big Bucks, Big Problems

Unnecessary Power Wheelchairs Approved by Medicare

Recently we learned $98 million dollars were paid by Medicare in the first half of 2007 on power wheelchairs that were deemed medically unnecessary or lacked sufficient documentation to determine medical necessity. This accounted for approximately 61% of the claims submitted in that time frame. This was a ‘news flash’ released by the US government (Office of the Inspector General- OIG) of a study done on Medicare’s power wheelchair coverage based on data from the first half of 2007. It is now 2011, and my head spins on what Medicare must have paid out on ‘unnecessary or insufficiently documented’ power wheelchairs since then. What’s wrong with this picture?

From where I sit, I see a few. Forget the fact we’re using data 4 years old, and only looking at 375 claims. The main issue I see is it appears to be the usual ‘pay and chase’ scenario. The wheelchairs are issued to the patient and then the paperwork is submitted to Medicare for payment. The payment is made on the equipment, and then it is ascertained if it should have been paid on that equipment in the first place.

Upon review of the claims submitted during the study, only 9% were medically unnecessary – with 7% needing a different type of power wheelchair, and the remaining 2% needing a less expensive type of equipment (such as a cane or walker). The remaining 52% had insufficient documentation.  It seems to me the area to concentrate on would be the 52%. Three conclusions can be drawn here; 1) either there is significant fraud and abuse, 2) there are some sloppy paper pushers on either the supplier or physician’s side or 3) the documentation required is arduous and nebulous. I suspect it’s a combination of all three. However, I prefer any of these scenarios over the alternative of a community of senior citizen wheelchair shysters!

As Medicare is already putting steps in place to help mitigate fraud and abuse, (see my blog ‘It’s about time’), let’s concentrate on the second and third scenarios. Perhaps the documentation process for wheelchairs has become such a bureaucratic mess that the physician and supplier have become negligent in the process.  Perhaps there are one too many steps.

Medicare Pre-Authorization Not Required

I also have to ask myself if prior authorization wouldn’t help alleviate these problems, or at the very least, help curtail the problem. One of my colleagues contacted Medicare directly to ask if prior authorization was required for a power wheelchair. She was told no. She then contacted her own insurance, a huge player in the industry, and was told yes, they do require prior authorization, as does Medicaid in Illinois. I don’t know if they have similar problems, but I do find in interesting 2 out of 3 insurers require pre-authorization.

One of the OIG’s recommendations submitted to Medicare was to further educate the physicians and suppliers on regulations and compliance. In addition, I would also recommend Medicare scrutinize their documentation process and see if therein lies at least part of the problem, as well as exploring prior-approval. Pre-Authorization won’t alleviate the paperwork, but it could prevent the pay and chase. These statistics are just too big to not take action, and soon. What do you think?

Thanks for reading!

Healthcare Advocate

Rebecca Busch

adminBig Bucks, Big Problems

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  • Luck - September 8, 2012

    Heck yeah this is exactly what I ndeeed.