Medical Device Daily Washington Editor

WASHINGTON - In the latest chapter in its ongoing effort to define its motorized wheelchair policy, the Centers for Medicare & Medicaid Services (CMS; Baltimore, Maryland) unveiled a new effort on Wednesday to combat fraud and improper payments, in addition to clarifying patient eligibility to receive the devices. The announcement followed testimony by Herb Kuhn, director of CMS' Center for Medicare Management, before the Senate Finance Committee.

"CMS' three-pronged initiative sets a very aggressive agenda, and I believe this approach will improve access to high-quality power mobility devices for beneficiaries and ensure appropriate coverage through the regulatory process," Kuhn told the committee.

According to a statement from CMS administrator Mark McClellan, MD, Medicare spending for power wheelchairs and scooters has risen to more than $1.2 billion a year. Despite the rise, McClellan said some beneficiaries who still need the mobility devices are not getting access. "CMS has cracked down on fraud and abuse in the wheelchair market," McClellan said. "Now we are moving to the next stage in strengthening our policies for power mobility devices."

The first part of CMS' plan involves assembling a team of clinicians from throughout the Department of Health and Human Services to develop draft guidance for determining whether a patient meets the definition of "bed- or chair-confined." According to CMS, the goal is to focus on a set of evidenced-based clinical and functional characteristics that will better predict who would benefit from a power mobility device.

The second initiative is aimed at billing and payment.

According to CMS, the technology and market for power wheelchairs have changed substantially since the current codes for power wheelchairs were added in 1993. Right now, most power wheelchairs are billed under a single code, for which Medicare has set a single ceiling amount of just less than $5,300, even though different models of these wheelchairs often have substantially different market prices.

To develop accurate individual payment ceilings, CMS is working with a national coding panel to develop a new set of codes to better describe the wheelchairs currently on the market. CMS also said it will include power mobility devices in a competitive bidding program for durable medical equipment, as authorized by the 2003 Medicare Modernization Act (MMA).

The third part of the new plan is to develop strong quality controls for suppliers. CMS said it would revise the supplier standards for enrolling in Medicare to include quality measures as required by the MMA, building on existing industry standards. CMS hopes to have the new standards finalized by fall of next year. CMS also announced plans to develop an accreditation program as part of the implementation of competitive bidding, further ensuring that suppliers meet industry and community standards for power wheelchair use.

Independent of CMS' Wednesday announcement, a coalition of companies and organizations representing the power wheelchair industry released its own 10-point plan designed to target Medicare fraud, while also ensuring that products remain accessible to the patient populations that need them.

The Restore Access to Mobility Partnership (RAMP) organization said its 10-point plan would help CMS fight fraud without harming the people who require power wheelchairs to increase their mobility.

"There is a lot that is in common with the new CMS initiative, more than where we differ," Michael Hammes, chairman and chief executive officer of Sunrise Medical (Fremont, California), told Medical Device Daily. Sunrise is one of the members of RAMP.

"Everyone is committed to limiting fraud," Hammes said. "But we need to find ways to make sure the equipment gets to those who need it. We hope that CMS and industry can work together to find some common ground. This is a step in the right direction."

Hammes said that the government, for the most part, has been very open to industry's suggestions. He said one of the biggest helps would be revamping an "ancient" coding system. The industry submitted a list of recommendations, including a coding proposal to CMS last year, he said, adding, "At the time, they weren't ready for it. But now they have asked us to resubmit it, which we have."

The coalition's recommendations include establishing a CMS and industry fraud task force. RAMP also recommends creating a comprehensive national coverage policy for mobility products. The association says this would establish national guidelines that would end confusion over coverage policy.

In line with the new CMS proposal, RAMP's plan includes establishing provider and supplier accreditation standards. The 10-point plan also recommends new code development as similarly addressed by CMS. Also similar to the new CMS initiative is RAMP's call for a fraud reporting system and regulatory reform.

According to RAMP's plan, government should implement the regulatory reform procedures outlined in the MMA that establish a clear procedure for reviewing medical claims and providers to determine compliance with established documentation requirements.

Other parts of the plan include establishing medical documentation requirements where a certificate of medical necessity signed by a physician with a corroborated, state-licensed physical therapist evaluation is used as required documentation to establish non-ambulation and whether a mobility product is medically necessary.

RAMP also suggests the creation of a CMS advisory group on mobility issues, representing persons with disabilities, consumers and the industry, to counsel on issues related to mobility questions.

RAMP also would like CMS to establish clear advertising regulations for the healthcare industry. The organization said it hopes that best practice guidelines in this area will help prevent non-compliance with Medicare standards.

According to CMS, since 2003, federal officials have recovered $84 million in fraudulent claims for power mobility products nationwide. The contractors that process power wheelchair claims have referred about 155 potential fraud cases (representing 265 suppliers) involving power wheelchairs to law enforcement since last September.

Medical Device Daily, April 30, 2004