Wheelchairs Can Yield Profits if You Bill 'Em Right "The lack of education in this industry is astonishing," says Bunch, who also has been an HME provider for 17 years. "When it comes to reimbursement, 90 percent of providers aren't doing it the right way. They're trying to do it the right way and may think they're doing it the right way, but most just don't know how."

Yet when billed to Medicare correctly, wheelchairs can be a profitable proposition for HME providers, Bunch and other experts say. The wheelchair business boasts a healthy volume. In 1998, wheelchairs were the largest market segment in the HME industry, accounting for 38.3 percent of the entire market, according to Find/SVP, New York.

How does this all add up? The top three wheelchair Medicare codes-K0011, K0001 and K0004-totaled nearly $381 million in Medicare reimbursements that year.

Each year, however, sees the government tightening its reimbursement documentation requirements, and it's becoming apparent that the successful wheelchair providers will be the ones who know how to properly bill for reimbursement.

Here are a few tips on how to bill wheelchairs correctly-and some cautions about the most common billing mistakes.

Know What You Don't Know "IGNORANCE IS BLISS." Whoever coined that phrase obviously wasn't an HME provider trying to get reimbursed for a wheelchair. In fact, ignorance is extremely costly when it comes to wheelchair reimbursement. The problem is, most providers are ignorant of their billing ignorance.

"Most providers simply don't know that they don't know," confirms Jeanie Lane, an independent consultant based in Jackson, Miss., and who formerly was an accounts receivable manager and trainer for two large HME companies. "It's very difficult for providers to see themselves as they really are. And if they are doing something wrong all this time, unfortunately they don't know it is wrong until somebody brings it to their attention."

Jerry Johnson, owner of Certified Respiratory, Baxley, Ga., admits that he didn't know the first thing about billing when he entered the business five years ago. "I knew all about the business side of things and how to take care of patients, but billing was a problem," he recalls. And worse, Johnson hired someone who claimed she knew how to bill Medicare, only to find that she, like all too many others, only thought she knew what she was doing, which resulted in reimbursement for equipment being delayed or ultimately denied. Eventually, Johnson had to dismiss the employee.

To avoid just such a problem, Eric Parkhill, vice president of Home Medical Professionals, Gainesville, Ga., hired a consultant when he first started his business. "We've always worked with a consultant, so that's made things a bit easier," he says. "It's better to do it right from the beginning than to have a claim come back and have to figure out why."

Prove the Necessity THE TWO WORDS every provider should remember if it wants to be reimbursed by Medicare are "medical necessity." If a wheelchair is not medically necessary-and if you don't submit the paperwork to prove it-then Medicare will not pay for it.

This may seem obvious, but Lane says she gets many calls from clients who say they've been denied reimbursement even though they have a certificate of medical necessity and "plenty" of documentation.

One case involved a rehab technician who billed for an ultralight wheelchair. The patient was a leg amputee and had been diagnosed with upper extremity weakness. But reimbursement was denied-despite the fact that the technician had good documentation-because the paperwork submitted did not include a medical diagnosis to support the claim of upper extremity weakness.

"I have so many providers come to me and say, 'The doctor ordered it, the patient needed it, and I delivered it. I didn't do anything wrong,'" says Lane. "Well, the fact that the doctor ordered it makes no difference, nor does the fact that the patient wanted it. A Medicare card is not a charge card; it is a medical necessity card. Many beneficiaries [and physicians] may believe that a Medicare or Medicaid card is like a Visa card-'I show it to you, you give me what I want and don't ask me any questions'-but that is just not the case."

For example, Bunch once had a client who provided a patient a wheelchair, then tried to bill it on Code 36900-blindness. Blindness is not an impairment that necessitates a wheelchair, so the provider was denied reimbursement. Yet another client billed for a motorized wheelchair for a patient with Alzheimer's, and Medicare in fact paid for it, she reports. But then a year and a half later, the bureaucrats realized their mistake and wanted their money back. The provider had to give back to Medicare the reimbursement money it received for the new equipment. In return, although the provider reclaimed the chair, all it got was a used wheelchair worth perhaps only half of what it was new. Too many more fiscally unsound transactions like this, and it wouldn't be long before a provider finds itself out of business.

"If you don't have a diagnosis that qualifies the patient for the wheelchair," Bunch warns, "Medicare can come back on a review, say the item wasn't medically necessary and get their money back, assuming they even pay you in the first place."

Be Your Own Best Defense "IT BOILS DOWN to knowing what qualifies a patient for the equipment, checking the diagnosis to make sure the patient qualifies, and then knowing that the patient medically needs it," Bunch says.

If, for example, a patient can walk into your place of business, he probably doesn't need a wheelchair-even if he has a prescription for it that is signed by a physician. He obviously wants a wheelchair, "but 'want' and 'need' are two separate things," Bunch says.

It can be difficult to turn people away. No one wants to look in the face of someone who has a disability and refuse to help. But if you want to keep your business healthy, you must focus on what help you can offer, experts say."Some providers let their heart get in the way of their business sense when dealing with sick people," Lane says. "They want to please the patient and please the referral, but sometimes they forget that somebody has to ultimately pay for this equipment."

Unfortunately, says Bunch, some providers don't treat their businesses like a business. "People walk in with a CMN for a wheelchair, and some providers will just hand over the wheelchair without any kind of background check on the beneficiary or anything else," she says. "Providers should etch in their brain, 'If it's not medically necessary, then the beneficiary doesn't need it.' Not remembering this is what has gotten our industry into trouble. Officially, Medicare can review an item within six years and three months of reimbursement for that item. That's a long time-and potentially a lot of money."

Watch the Factory Options AUTOMOBILE DEALERS CHARGE extra for customer-added options, such as power windows, power locks, keyless entry and the like. It makes just as much sense, particularly fiscally, that HME providers charge for added options on wheelchairs.

Trouble is, many providers don't properly assess the patient to include all necessary accessories or don't realize they can bill accessories separately-or both. Indeed, according to Bunch, not billing wheelchair accessories such as anti-tippers and wheel-lock extensions is one of the most common mistakes.

"It's amazing," she says, "but when I give seminars and start telling providers they can bill separate for accessories, most look at me and say, 'What?'

"Providers get in this business and have all kinds of questions because they're not properly educated about HME and Medicare billing," she adds. "Half of the providers I see the first time just issue a standard wheelchair when they get a wheelchair CMN. They don't pay attention to how much the patient weighs or to his or her height. They don't assess the patient properly, and they don't know how to get paid for issuing something other than the minimum."

To clear the ambiguity between what is part of the wheelchair base and what would be considered an accessory, Lane suggests that providers regularly consult the manual issued by their Durable Medical Equipment Regional Carrier. These manuals list, by make and model number, how the base of a chair should be coded and what accessories are included. "You have to determine that the base is covered," she advises, "and then from there, each accessory has to have a diagnosis as well as a functional impairment that describes the condition that warrants it."

This process isn't always easy, Lane notes. Many manufacturer price lists don't match the DMERC manuals. In many cases, a manufacturer will charge separately for an item on a wheelchair, when that same item is included on the wheelchair base, according to the DMERCs. Wheelchair makers are working to prevent such discrepancies; meanwhile, the burden still falls on providers to sort out what is billable and what isn't.

Make It Work for Everyone ALTHOUGH THE HME provider suffers the most financial loss, improper billing and patient assessment eventually affect everyone involved in the process, from manufacturer to Medicare to individual patient, experts say.

"These things not only lose revenue for the DME company, but at the same time do not do the patient justice," Bunch says. "And in the long term, patients' conditions will worsen, costing Medicare more-all because patients aren't assessed properly originally. I see it too many times, especially in wheelchairs. Everybody loses: the provider, the patient ... everyone."

Conversely, she says, "the most successful companies are the ones that build their companies by learning how to bill their equipment."

Billing Medicare can be a complicated business. It can also be extremely difficult to get good answers to your billing questions. But what makes matters even worse is that many providers don't realize they're billing their equipment improperly.

So how do you fix something that you don't know isn't right?

"Providers need to perform internal audits," advises Jeanie Lane, a home medical equipment reimbursement consultant. "They need to have somebody from the outside look at their files so they can help the company become compliant before the [Durable Medical Equipment Regional] Carrier gets to them." HME providers should hire employees who are knowledgeable-and can prove they're knowledgeable-about billing and reimbursement.

Consultant Jane Wilkinson Bunch also suggests that providers attend educational seminars at state association events and trade shows. Joining state associations and other industry groups can also help providers stay in the loop on the latest reimbursement issues, she adds.

"You've got to know what you're doing before you start doing it," Bunch says. "That's the main thing in DME."-J.P.P.