OIG Report: More PWC Documentation Problems

WASHINGTON — More than half of power wheelchairs provided to Medicare beneficiaries in the first half of 2007 had claims that lacked sufficient documentation to determine medical necessity, the Department of Health and Human Services Office of Inspector General said July 7.

Based on its review of a 375-claim sample, an OIG report showed 9 percent of the PWCs were medically unnecessary, and another 52 percent had claims that were insufficiently documented.

The report, "Most Power Wheelchairs in the Medicare Program Did Not Meet Medical Necessity Guidelines," is the OIG's latest based on the same 2007 sample. Two previous OIG reports found problems with PWC claims coding and documentation.

"Across all three reports, 80 percent of claims for power wheelchairs supplied to beneficiaries in the first half of 2007 did not meet Medicare requirements," the OIG stated.

But that was in 2007, HME advocates point out, immediately following CMS' overhaul of the power mobility benefit, which in turn was followed by a raft of clarifications that left mobility providers waiting on additional guidance about exactly what documentation was required to support power mobility claims.

They're still waiting, said The MED Group's Tim Pederson, former chair of the American Association for Homecare's Complex Rehab and Mobility Council.

"There was a lot of confusion in the industry then, and I think there still is today," Pederson said. "The report says half of the claims in 2007 didn't meet medical necessity requirements, but if you look into the detail of it, the lack of documentation by the physician in the patient's medical record is by and large the biggest culprit, and we still have a lot of questions about what is acceptable documentation.

"We don't have any more clear guidelines about documentation now than we did then," he said.

According to the OIG report: "Seventy-eight percent of claims without supplier-record errors were not supported by records provided by physicians who prescribed the power wheelchairs. That is, while suppliers' records indicated that power wheelchairs were medically necessary, physicians' records indicated that they were medically unnecessary, or physicians' records provided insufficient documentation or no documentation of medical necessity. In most cases, physicians' records had insufficient documentation to support the medical necessity of power wheelchairs."

"We can't help but fail because they are measuring the wrong stuff," said Pederson, who recently sold South Dakota-based WestMed Rehab and now heads MED's O&P network. "What they should be looking at is what kind of effort CMS is making to educate physicians …

"Until that gets addressed, we are going to see these reports and audits look really, really bad."

The OIG report also noted that "although CMS has taken steps since 2007 to decrease errors among suppliers of power wheelchairs and other DME, Medicare has paid significantly more in recent years for power wheelchairs than it did in 2007. These increases may indicate that CMS continues to pay for power wheelchairs that are not medically necessary and/or that have claims that do not meet documentation requirements."

As a result, the OIG made four recommendations, one being enhanced reenrollment screening for current DME suppliers.

"Federal regulations place new DMEPOS suppliers at a risk level of 'high,' whereas currently enrolled DMEPOS suppliers are placed at a risk level of 'moderate,'" the report said. "We believe that currently enrolled DMEPOS suppliers should be subject to the same enrollment screening standards as newly enrolling DMEPOS suppliers and should also be placed at the risk level of 'high.'"

CMS disagreed, noting that it has other tools that allow increased scrutiny of current suppliers. But the agency agreed with the OIG's additional recommendations that it should: