A Primedia Property
May 9, 2005 Volume 11, Issue 17
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For more industry news, features and highlights from our latest issue, please visit our Web site at http://www.homecaremag.com.

Headline News
CMS Releases New Mobility Coverage Policy
BALTIMORE--CMS' national coverage determination for mobility equipment, announced late last Thursday, eliminates the requirement that Medicare beneficiaries be bed- or chair-confined and instead adopts function-based criteria for determining medical necessity.

Medicare's new coverage policy, effective immediately, hinges on how well a beneficiary can perform activities of daily living such as toileting, grooming and eating. It takes clinicians through a "stepped" process to determine which mobility-assist device--encompassing a range of equipment from canes and walkers to scooters and power wheelchairs--is medically necessary.

"This coverage policy ensures that a beneficiary's functional status and individual circumstances are considered so that the most appropriate technology for each beneficiary's personal needs is covered," said Barry Straube, CMS' acting chief medical officer and acting director of the office of clinical standards and quality. "It is also consistent with the documentation of the functional needs of the patient that should be in medical records for our beneficiaries."

The policy continues to limit wheelchair coverage to beneficiaries who need the equipment primarily in the home--a sticking point for HME industry stakeholders. But according to the CMS decision memorandum, the in-the-home rule comes from the Medicare statute, so "an NCD would not be the appropriate mechanism to change that [rule]."

The coverage decision is part of Medicare's larger three-pronged overhaul of its mobility benefit, begun in 2004 and since dubbed the Modern Mobility Initiative, which focuses on coverage, payment and supplier quality standards. In February, the agency introduced 49 new billing codes for power chairs and scooters that will take effect Jan. 1, 2006. According to a tentative schedule released earlier this year, CMS has also said it expects to issue new quality standards for suppliers by this summer.

But some pieces of Medicare's new mobility reimbursement puzzle are still missing. Industry insiders had expected the new coverage policy to be released with several other elements of the initiative, including a face-to-face physician exam requirement and a new wheelchair Certificate of Medical Necessity.

"This was supposed to come out as a coordinated package that would take care of all of the issues," an agency spokesperson told HomeCare Monday. However, the NCD was released separately because it had a deadline dictated by the Medicare Modernization Act. The spokesperson added that "it is a very high priority to get the rest of the coordinated package out."

The government also has yet to release documentation guidance for providers who must show that beneficiaries meet medical necessity requirements for mobility equipment. According to the agency's decision memo, "While CMS does require adequate documentation to establish that coverage conditions are met, the complexity of the issues indicate that this is best addressed in an initiative separate from the NCD."

A press release from the agency said CMS plans to issue additional guidance "in the near future to help physicians and treating practitioners better understand the new coverage criteria and CMS' expectations about proper documentation in the medical record. Because the new functional criteria more explicitly refer to standard clinical evaluative methods, CMS expects that the medical documentation generated during the patient evaluation will more accurately be reflected in the beneficiary's medical record. It is CMS' intent that this will make the power mobility device coverage more straightforward."

"During the course of reviewing Medicare's policies for power mobility equipment, CMS came to the conclusion that there are more accurate tools to root out fraud and abuse," said Kimberly Brandt, director of CMS' Program Integrity Group. "The combination of the new NCD and the planned enhanced educational outreach by Medicare to physicians and treating practitioners, as well as to suppliers, will eliminate most honest billing errors. More accurate claim submission will allow CMS to better analyze claims data and focus claims review to target abusive billers."

In the meantime, the DMERC medical directors are working on a transition article to be posted on the DMERC Web sites. "In the transition article, you'll see [how] the existing CMN will be used ... in line with the new national coverage determination," said Dr. Robert Hoover, medical director for the Region D DMERC. "All those details are still being worked out aggressively."

Although a new wheelchair CMN is still under consideration, the transition article will refer only to the wheelchair CMN currently in use, he said, adding that he is hopeful the interim guidance will be posted "shortly."

On Friday, industry reaction to the mobility NCD was mixed. Some praised the elimination of "bed- or chair-confined" language but expressed concern about the lack of documentation guidance. Others said they were disappointed that the policy does not treat mobility itself as an activity of daily living.

  • "We're very excited," said Dan Meuser, president of Pride Mobility, Exeter, Pa. "It is indeed night and day from the previous ... archaic 'bed- or chair-confined' policy. It's almost like the Wicked Witch is dead. There are concerns with documentation clarity that still exist. However, we do expect the DMERCs to understand there is a new, clearer coverage policy; therefore, new, clearer documentation requirements should be reflective of this new policy."
  • "We are pleased at what we saw," said Eric Sokol of the Washington, D.C.-based Power Mobility Coalition. "We are disappointed that CMS did not provide [guidance] for current and pending claims. This NCD is only for times moving forward. Providers are still in the dark," Sokol said, regarding what documents prove medical necessity for a wheelchair. "It is our hope a new [wheelchair] CMN will ensure suppliers have more than a reasonable explanation of what documents meet eligibility criteria."
  • Laura Cohen, a clinical research scientist at the Shepherd Center in Atlanta, said that though the policy does treat activities like grooming and bathing as activities of daily living, CMS does not consider mobility itself as such an activity. That, she said, could create problems for clinicians. "[CMS] says that by itself, [mobility] does not serve a medical purpose. It's ironic that a wheelchair isn't being acknowledged as necessary for [someone to attain] mobility." Cohen is also co-coordinator of the Clinician Task Force of the Coalition to Modernize Medical Coverage of Mobility.
  • According to Barbara Crane, CTF co-coordinator and professor at Hartford University, "Environmental considerations are essential in order to match an individual to the appropriate technology solution," she said. "The new NCD ties our hands and confines clinical practice to the confines of the home."
  • A statement from the Restore Access to Mobility Partnership--a coalition that includes the American Association for Homecare, Invacare Corp., the MED Group, Mobility Products Unlimited, Pride Mobility and Sunrise Medical--echoed the clinicians' concerns. While the new NCD is "a step in the right direction," the statement read, "Clinicians, as well as advocates for people with disabilities, have repeatedly advised CMS that 'mobility for mobility's sake' should be treated as an activity of daily living. Giving a Medicare beneficiary increased mobility with a power wheelchair can be just as significant for an individual as using the equipment to improve the ability to get to the bathroom, eat, dress, groom or bathe. CMS also chose not to change the requirement that power mobility equipment be restricted to increasing a Medicare beneficiary's ability to perform activities in their home. This provision contrasts sharply with clinical practices ...

    "Lastly," the statement continued, "these new coverage guidelines make it imperative that a clear and comprehensive documentation process be quickly established so that all of the stakeholders--beneficiaries, doctors, clinicians and providers--have a full understanding of what medical documentation will be definitive for claims to be approved."

  • "Our next steps? Documentation, documentation, documentation," said Cara Bachenheimer, vice president of government relations for Elyria, Ohio-based Invacare. "The DMERC medical directors are responsible for Local Medical Review Policies based on this national coverage determination, so there's an opportunity for the DMERCs to provide significantly more clarity than what now exists in the national policy."

The NCD is posted on CMS' Web site, available by clicking here.



Scooter Store Says Company Is Government Target
NEW BRAUNFELS, Texas--In a May 4 letter to CMS Administrator Mark McClellan, the nation's largest power chair provider said it has been unfairly targeted by the federal government in its attempts to drive down power mobility utilization.

"The barrage of punitive actions taken against [The Scooter Store] over the past two months lead inescapably to one conclusion: that the federal government is targeting TSS as a high-volume supplier of power mobility equipment in order to drive down utilization," said TSS counsel Marc Racicot of Washington, D.C.-based Bracewell & Giuliani LLP.

The letter is the latest volley in an ongoing legal battle between the national provider and HHS.

Earlier this year, The Scooter Store filed suit against HHS, claiming the government wrongfully denied hundreds of its power chair claims and had illegally requested patient documentation in addition to a physician-signed CMN for reimbursement. On April 29, the U.S. Department of Justice filed a countersuit against TSS, alleging the provider had submitted fraudulent claims to Medicare and Medicaid.

In last week's letter, Racicot said that TSS has received 990 post-pay review requests from the DMERCs. "These information collection requests are very difficult--if not impossible--to satisfy because they require, upon penalty of automatic denial of a claim, the production and submission of physicians' chart notes. Physicians are not required by law to chart their notes in the manner the DMERCs have arbitrarily decided they should chart, as the American Medical Association has stated. Moreover, suppliers cannot force physicians to turn over their chart notes so that a supplier can submit them to the federal government."

For more than 18 months, the company has also been "subjected to undercover investigations and repetitive demands for information," Racicot said.

"Like the information collections, the allegations made by Justice Department lawyers are baseless and punitive in nature. Simply put, allowing such actions to proceed is just plain wrong. It is incredibly unfair, wholly inconsistent with the principles of good government, and threatens the very existence of TSS," the letter stated.

According to the DOJ, since 1997 The Scooter Store has billed Medicare for claims worth more than $400 million.



To revisit this news any time during the week, go to http://www.homecaremonday.com.

State News
Tennessee Medicaid Cuts Blocked
NASHVILLE, Tenn.--Plans to trim the state's Medicaid rolls have been put on hold once again after a federal judge ruled the cuts would violate some recipients' constitutional rights.

U.S. District Court Judge William J. Haynes said the state's plan to eliminate coverage for 323,000 does not fully protect the due-process rights for TennCare beneficiaries who wish to appeal their loss of coverage.

In January, Gov. Phil Bredesen announced the plan for cutting the TennCare rolls and capping benefits for another 396,000 in the program to save the state $1.7 billion annually. (Children would not be affected.) Last month, the governor said he had reached a deal with one set of enrollee lawyers and state hospitals that would protect 97,000 of the sickest patients scheduled for the cuts. But that agreement hinged on a favorable ruling from Haynes, a favorable ruling in another federal court over changes to enrollee benefits and a sign-off from federal officials.

Haynes had previously blocked the proposed cuts while he held hearings over whether they violated a consent decree. But before he could issue a ruling, his decision was overturned by a federal appeals court that said Haynes had overstepped his authority. State attorneys are now appealing to the 6th U.S. Circuit Court, claiming that time is crucial in order to prevent fiscal crisis for the TennCare program. "The bottom line is that if this stands, we will not have the financial ability to go forward," State Attorney Michael Kirk told the Associated Press.

The longer the TennCare changes are delayed, state lawyers explained, the more expensive the program will become, costing $44 million per month beginning July 1. According to reports, the state had already begun the TennCare overhaul, ending the chance for new applicants to enroll in the program in certain categories.

However the scenario plays out, according to Gayla M. Sasser, executive director of the Tennessee Association for Homecare, it will just be a shifting of costs to others such as doctors and hospitals. "What we will see happening is the [health care] provider community will end up paying bills for those folks," she said. For now, the organization is concentrating on communicating with the governor's office on the issue, she said. "I think it's a wait-and-see game."

In Brief
Although a small percentage of Medicare beneficiaries is responsible for a disproportionate amount of the giant program's spending, reducing these costs could be difficult, according to a Congressional Budget Office report. Titled High-Cost Medicare Beneficiaries, the report said that the costliest 25 percent of beneficiaries accounted for 85 percent of annual expenditures in 2001. Lowering costs through early intervention and disease management could help, though some interventions ultimately may lead to increased use of medical care and, hence, additional cost. The report is posted on the CBO Web site, available by clicking here.

The chairman of the National Governors Association said Congress' $10 billion Medicaid cut is "disappointing," and that savings from the cuts should be reinvested in the program. "What I think is most significant about that was--with all the entitlement programs that were being discussed, it was Medicaid that was singled out for a disproportionate share of those cuts," Virginia Gov. Mark Warner told the American Hospital Association last week. In April, the House and Senate approved a $2.6 trillion budget that includes $10 billion in Medicaid cuts over five years beginning in 2007.

HHS Secretary Michael Leavitt said adopting a standardized information technology health system is key to improving the country's health care system and lowering costs. If the federal government does not step in soon, he said, the country could end up with a number of incompatible technology systems as more hospitals, physicians and others use IT in health care. "It's a massive number of systems that can't interact with each other," Leavitt said at the American Hospital Association annual membership meeting, Washington Technology reported. HHS has requested $125 million in the fiscal 2006 budget for health IT programs.

Democrats have proposed a health care agenda that they say would cut the number of uninsured Americans in half. The plan proposes lowering drug prices by allowing the reimportation of medications from other countries and giving the government power to negotiate prices with drug companies. Other initiatives include offering care to parents under Medicaid and the State Children's Health Insurance Program, allowing retirees under 65 to buy into Medicare and offering a 50 percent tax credit for small businesses and the self-employed to buy health insurance.

Enrollment in health savings accounts topped one million in March, according to a study released last week by America's Health Insurance Plans. In September 2004, only about 438,000 were enrolled in an HSA, the insurance association said. Established by the MMA, the savings accounts will help the uninsured obtain health insurance by giving financial incentives like tax breaks, say supporters. Others have said many uninsured will not use the savings accounts since most owe no income taxes--so tax breaks would not help them.

May is Older Americans Month, a celebration that, since 1963, has recognized the contributions of America's seniors. For more information, visit the U.S. Administration on Aging at www.aoa.gov.

CMS will hold a Special Open Door Forum on the agency's draft guidance document on coverage with evidence development today at 2 p.m. Eastern Time. To participate by phone, call (800) 837-1935 and reference conference ID 5394065. For more information, visit the CMS Web site by clicking here.

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