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Wheelchair Fraud Attacked by CMS

October 2, 2012
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This article really hit close to home for me, and outraged me when I read it. As a disabled person who uses mobility carts when I shop, and used a wheeled walker (the kind that has a small basket and a seat), I read this with despair for anyone who is disabled, but can still manage to navigate their home without needing a wheelchair, powered or not.The following is a list of rules from Medicare on what is required in order to get a powered wheelchair:

Most of the cost of your power wheelchair is covered under your Original Medicare Part B coverage. But you must meet all the criteria:

  1. Your doctor must write an order for your electric wheelchair. A face-to-face examination is required and the order must inform Medicare why you need the mobility product.
  2. Your wheelchair must be medically necessary.
  3. You must be able to operate the wheelchair. Your doctor’s orders must say that you are physically capable of operating the chair.
  4. You are unable to do the normal activities of daily living. This includes bathing, dressing, getting out of bed or going to the bathroom.
  5. You’re able to safely operate the wheelchair. You can get on and off the wheelchair or have someone with you that can help.
  6. You must be able to use the equipment in your home. You have clear pathways in your house so the wheelchair will not be blocked.

Medicare Part B will pay up to 80 percent of the cost of the electric wheelchair from a Medicare-approved provider. You will have to meet your yearly deductible.

So you have to have an order from your doctor, and he has to examine you and verify that you meet Medicare’s qualifications for a power wheelchair. I haven’t met a doctor yet who is willing to lie and say that one of their patients needs a power wheelchair to navigate their house when that patient is still mobile.

The conditions for getting a mobility scooter are nearly as stringent. From the Medicare site on mobility scooters:

Medicare Part B will cover most of the cost of electric mobility scooters, but only if your doctor determines that it is medically necessary. The scooter must also be used primarily for moving about your home and not as a “recreational” vehicle. You may have to pay up to 20 percent of the cost after meeting your Part B deductible.

Other requirements for Medicare coverage include:

  1. Your evaluation must be with a doctor or other qualified health provider
  2. The evaluation must be documented and say that you need a mobility aid for a medical condition (called a “Certificate of Medical Necessity)
  3. You must present the order or prescription to the Medicare-approved electric scooter supplier before Medicare can be billed
  4. You must be able to safely operate, and get on and get off of the scooter
  5. You must have good vision
  6. You must have a health condition that causes difficulty for you to move around in your home

Again, like the power wheelchair, the mobility scooter has to be necessary for use in the home. Although it can be used for “recreation” outside, it has to be mainly used to get around inside the home.

Under a new pilot program launched in seven states, providers will have to submit a prior authorization form before Medicare will reimburse a patient for a motorized wheelchair.

The program was highlighted during a Wednesday hearing of the Senate Special Committee on Aging on eliminating Medicare fraud and waste.

“This prior authorization demo will also help ensure that a beneficiary’s medical condition warrants their [power mobility device] under existing coverage guidelines,” Deborah Taylor, chief financial officer at the Centers for Medicare & Medicaid Services (CMS), told committee members Wednesday.

Am I missing something here? If a disabled person needs a power wheelchair/mobility scooter, they go to their doctor, ask for an order from him, get evaluated, find an authorized provider of said power wheelchair/mobility scooter, then the provider bills Medicare and the patient pays their 20% (and deductible if they haven’t met it for the year).

CMS is targeting motorized scooters because of the product’s high fraud potential. A report from the agency last year found 80% of claims for motorized wheelchairs didn’t meet Medicare coverage requirements, an error rate that represents more than $492 million in improper payments.

Under the prior authorization program, CMS will review the patient’s medical record before a device is shipped to ensure they need a wheelchair. The pilot, which started Sept. 1, is ongoing in California, Illinois, Michigan, New York, North Carolina, Florida, and Texas.

80% of claims for powered wheelchairs didn’t meet Medicare’s coverage requirements? Could it be that the people who applied for, and got, those chairs did need them in order to be able to navigate their homes, but they were still able to do the normal activities of daily living (e.g., bathing, dressing, getting out of bed or going to the bathroom). Just because you can still do those things doesn’t mean you can get from your bed to the bathroom without help, or from the bedroom to the kitchen without help.

CMS is going to review the patient’s medical record before the power wheelchair or mobility scooter is shipped to ensure that they actually need it? Exactly what is going to be in that patient’s medical record that will tell CMS that the patient needs a power chair or mobility scooter in order to navigate their home?

When I was researching mobility scooters, I got spam emails out the wazoo about power chairs/mobility scooters, and most of them had a list of questions to be answered that supposedly would qualify you. Evidently this crackdown has scared most of the providers of power chairs/mobility scooters, because when you go to provider websites now, there isn’t any guidance to see if you might qualify.

Now, you have to fill out a form with your name, address and email address so they can contact you. They also tell you to set up an appointment with your doctor to be evaluated, and then they will coordinate everything with your doctor and Medicare to get approval once you’ve been evaluated.

Sen. Bob Corker (R-Tenn.), a member of the Senate Aging Committee, said he began examining the issue of power wheelchairs after seeing a television commercial promising the chairs to almost anybody who wanted one.

“People could, it appeared, just call up and the companies would figure out some way for this person to own these mobility devices with little or no money down,” Corker said. “It gave the impression you [would] pay little or no money for that.”

Well, Senator Corker, those commercials happen to give a true impression of what people actually pay for their power chair/scooter under Medicare, if they qualify. If I had qualified for Medicare to pay for mine, I would have had to pay 20% of the $2,868 that my scooter cost me, but since I also have secondary insurance, and have met the deductibles for Medicare and my secondary insurance, my secondary insurance would have paid that 20% and I wouldn’t have paid anything for my scooter. That’s not fraud, that’s the way it works when you have Medicare and secondary insurance.

Jerome Epplin, MD, testified he’s received instructions from motorized wheelchair makers instructing him how to fill out applications to gain a favorable CMS decision. Even worse, company representatives will offer to fill out the forms themselves.

“I see this as an inappropriate attempt to circumvent or influence my objectivity and clinical judgment when evaluating the patient,” said Epplin, speaking for the American Geriatrics Society.

He told the story of a doctor he works with who had a patient denied Medicare reimbursement for a wheelchair. The doctor was soon contacted by a representative of the company telling him how to change the request to gain CMS approval. The doctor refused.

I have no doubt that these situations exist — motorized wheelchair makers wanting to fill out the forms, or instructing doctors on how to fill them out to get favorable CMS decisions. But how many of those situations are because the disabled people can still navigate their homes, but can’t navigate the outside world without a power chair or mobility scooter?

I’m one of those people. I manage our house just fine, since it’s small, and I don’t have to walk far to get from living room to bathroom, or living room to kitchen, or living room to bedroom. And the driveway where my minivan is parked is less than 10 feet from our front door. But I can’t navigate our yard, nor can I navigate any store that doesn’t provide mobility carts for its customers. Yes, I have a walker, but I’m in severe pain after using it for less than 10 minutes, and stopping to rest on its seat doesn’t make the pain end — that starts up again as soon as I start walking. So shopping anywhere without a mobility scooter is out. Traveling is out because sightseeing without a mobility scooter is too painful (I did that this summer and I will never do that again).

CMS wants to end the “fraud” associated with power chairs and mobility scooters? How about if CMS ends the requirement that disabled people must be completely unable to navigate their homes before they qualify for a power chair or scooter? Why does CMS think that disabled people don’t deserve to be able to navigate the outside world? I can tell you from experience that just because you’re able to navigate inside your home with some semblance of ease doesn’t mean it’s easy to navigate the outside world easily (and don’t even get me started on doing it pain-free). I want to know why CMS thinks that being housebound is a perfectly acceptable thing for disabled people.

I didn’t realize how circumscribed my life had been until I got my mobility scooter. Before the scooter, my life was basically home, Walmart, Coborn’s (local grocery store that also has mobility carts), the drive-in movie, doctor appointments at the VA hospital  with DH, my doctor appts, and the few weekend trips we took, which I dreaded because I was going to have to do a lot of walking with my walker (and I’m never sure if it’s going to fit through doors as it’s 30″ wide, so I sometimes have to fold it up to get it through the door). I didn’t like going places with my husband because if we had to do much walking, he would have to stop and wait on me when I had to take a break because I was in pain. And we might end up leaving a place early because I’m in too much pain to enjoy whatever we’re doing. It’s not fair to him and it’s not fair to me.

That’s just my experience, but I wonder how many other disabled people CMS claims got their power chairs/scooters “fraudulently” had similar experiences? If that’s the case, maybe CMS should be reconsidering their criteria for qualifying disabled people for power chairs and mobility scooters. Maybe quality of life should include the ability to navigate the outside world as well as one’s home?

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10 Comments leave one →
  1. Ada permalink
    October 2, 2012 10:53 am

    My dad had a similar experience several years ago when he was trying to get a wheelchair under Medicare. He has MS and some days are fine while others his mobility is severely limited. He’s had his truck retro-fitted with hand controls so he can drive cross-country to visit family and to live part-time with one of his sons and he wanted a manual-operation type chair that he could easily travel with, alone. He was denied twice and told that if he wanted a power chair, they’d get him one no problem since according to their statistics individuals diagnosed with MS would need one about three years after diagnosis anyway and that’s how long it would take to for them to basically recoup or rationalize the cost of the chair. It took his physician really, *really* fighting for him and his needs/desires for Medicare to help him get the type of chair he needed, stating that “[he] has lived with this condition since he was first diagnosed at age 19. He has not needed medical interventions or assistance until now and it has been over 30 years. Your statistics may hold true for most cases of diagnosis in [this man’s] age group, but his case, and thus his needs, are very different. This man’s independence has been the cornerstone of his entire life and forcing him to get a motorized wheelchair now, while he is still predominantly able-bodied, all but eliminates any and all independence he has left.”

    His physician also went on to describe all the travel Dad does on his own and to state how important staying physically active/mobile was to maintaining fitness and overall well-being not only for people his age, but *especially* so for individuals of all ages who are living with MS. And I think that is a point that Medicare completely does not get when it comes to accessibility and mobility issues. Keeping people in a place where they can maintain what mobility they have is very important to both physical and mental well-being. While a motor-chair might not be needed for *all* locomotion right now, that doesn’t mean that a person’s life would not be greatly improved or their discomforts (and, thus, some of the reasons for their seeking medical assistance) eased. It has been well over three years since Dad first got his chair, and it looks like it will be a few more years until he needs to look into a motorized one or a scooter. But he would likely only need the motorized option to get around in public. Makes me wonder what kind of a fight we’ll all have to go through to get it when the time comes.

  2. bronwenofhindscroft permalink
    October 2, 2012 11:16 am

    The point to remember here, its that Medicare, like all insurances, just wants to pay the least amount of money. In for profit insurance companies (all other insurance out there except Medicaid), it’s so the investors can make the most money possible. In Medicare/Medicaid, it’s because there so much going out (legitimately) that the government keeps trying to find ways to reduce outgo.

    That doesn’t make it *right*. It just makes it what it is.

    I guess my Mother-in-Law would fall into that 80% of recipients who didn’t meet Medicare requirements. See, she can’t even walk around her apartment, but she can bathe herself, go to the bathroom herself, get herself dressed, etc.

    But she’d be stuck in bed if she didn’t have that wheelchair! *sighs*

    • vesta44 permalink
      October 2, 2012 11:37 am

      And that’s the infuriating thing to me – that someone who can’t walk around their house/apartment, but can bathe herself, dress herself, and go to the bathroom herself wouldn’t qualify for Medicare/insurance to pay for a wheelchair/power chair.
      People like her, without the means to pay for those chairs, are the ones who end up in nursing homes (if they don’t have family that can care for them). Medicaid can end up paying for that (for people with no long-term care insurance or the means to pay for that), and that is much more expensive than paying for a wheelchair/power chair, FFS.

      • Kala permalink
        October 2, 2012 4:22 pm

        This is the way that they do anything. My mother had Medicaid for dentistry. Rather than try to save any of her bad teeth, Medicaid’s solution was to remove ALL her remaining teeth, bad and good, and give her full (and thus cheaper) dentures.

        They only cover fillings (I believe only with the cheaper crappier filling material) and pulling teeth, no endodontics or crowns or bridges, etc. She had to wait a few weeks to get the dentures, leaving her with no teeth.

        I understand that dentistry is expensive, but I think it’s a little absurd to remove so many good teeth merely to make room for cheap ass fucking dentures.

    • Jennifer permalink
      October 2, 2012 12:05 pm

      The profit theory holds up for Medicare and Medicaid too, now that they’re privately run & influenced by corporate lobbyists. Now it’s bureaucracy AND corporatocracy.

      Since private insurers also tend to use Medicare criteria as a bare minimum, I went through the same BS. It took me 10 months to get my manual chair and it was nothing but a headache.

      Greed gets in the way of common sense AGAIN.

  3. lifeonfats permalink
    October 2, 2012 7:09 pm

    My grandfather has rheumatoid arthritis. He uses a wheelchair to get around the house. Based on this criteria, he wouldn’t qualify for a power chair because he can dress and bathe himself (although he does it while in the wheelchair) and he still drives. He can transfer to and from chairs and from toilets. But he can only walk short distances with his walker and needs a mart cart when he goes grocery shopping.

    If I wasn’t living with him and my mom and brother weren’t only minutes from home, he would probably have to go to assisted living or a retirement home, and that costs even more money. I understand they have to check for fraud, but they’re going to end up just making it even more difficult for a lot of people. One thing that should not be so difficult is health insurance and getting the proper things you need to live with dignity.

  4. Len permalink
    October 5, 2012 5:53 pm

    This is dreadful! Taking a few steps between the bedroom and bathroom – especially when there are walls and handrails for stability – is a MILLION MILES away from being stuck out in the open in a public space, trying to maintain balance and manage personal belongings, and surrounded by other people racing by without and care or thought for your personal safety.

    I have issues with mobility and balance is a serious problem for me. Falling over when you can’t reach a wall or some furniture to help you up is no mean feat – and forget relying on the kindness of strangers, especially when fat.

    I am simply appalled by this!

    • Len permalink
      October 5, 2012 5:59 pm

      Modified to point out that GETTING UP after falling over is no mean feat – falling is the easy part 😦

      I was too freaked to type sensibly. I guess I always considered if my condition becomes too bad I could use an electric mobility device (it’s hard to operate a standard wheelchair with bad arthritis). Now it’s looking like another potential safety net may or may not be there. Siiigh.

  5. October 9, 2012 11:14 am

    Hopefully, someday they’ll start asking why medical equipment costs so much, rather than how Medicare can manage to pay the enormous costs in such a way that they have to ration care. Cost is the problem.

    Peace,
    Shannon

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