Medicare to require prior authorization for power wheelchairs

Washington Medicare will require doctors’ orders for power wheelchairs and scooters in seven states to undergo a prior authorization process by a contractor before suppliers can fill the orders.

The Centers for Medicare & Medicaid Services published details of the three-year Medicare demonstration project requiring prior authorization for power mobility devices prescribed in California, Florida, Illinois, Michigan, New York, North Carolina and Texas. The agency announced that the demo will begin Sept. 1.

Medicare has seen rampant fraud involving power wheelchairs. Federal law enforcement agencies have prosecuted more than 600 cases with 1,150 defendants who billed a total of $2.9 billion in fraudulent claims since 2009, CMS said in a Aug. 3 notice about the demonstration. CMS also has taken to task physicians and suppliers for billing Medicare for wheelchairs incorrectly. A 2010 agency report found that 92.6% of claims for motorized wheelchairs did not meet paperwork requirements for coverage.

“We believe this demonstration will provide the agency with valuable data through which the agency, working with its partners, can develop new avenues for combating the submission of fraudulent claims to the Medicare program” for power mobility devices, CMS said.

Physicians in the seven states will send authorization requests and supporting documentation to a Medicare contractor when ordering power wheelchairs for patients. The durable medical equipment contractor then will review the request to ensure that it meets national and local coverage requirements. CMS will attempt to complete its review within 10 business days.

The contractor will issue an authorization number that the supplier needs to fulfill the order. If an issue arises with an application, the contractor will request more information and attempt to complete its review within 20 days. Expedited reviews are available for cases where a patient’s health would be harmed without access to the item, CMS said.

The American Medical Association has been among those lodging concerns with the demonstration and other prior authorization programs. Organized medicine has called for these programs to be targeted on claims outliers instead of subjecting all physicians and health professionals to extra scrutiny.

“The preauthorization process can adversely affect patients, interfering with the patient-physician relationship and causing delays in treatment,” said AMA President-elect Ardis Dee Hoven, MD. “The AMA urges CMS to consider the implications of preauthorization on both patients and physicians as they develop strategies to cut waste.”

The seven states are the setting for more than 40% of power mobility devices ordered through Medicare, said Walter Gorski, vice president of the American Assn. for Homecare, which represents equipment suppliers and manufacturers. The association has called for Medicare to develop a template to cut down on confusion regarding coverage criteria. A template also would ensure that patients receive the essential devices that allow beneficiaries to stay healthy and prevent the falls or other injuries that can require hospitalization.

“We support a prior authorization program, but we don’t think this program is it,” Gorski said. CMS must get the prior authorization model right, because it may be expanded to other equipment types and to other areas of the country, he said.