ARLINGTON, Va. — The American Association for Homecare sent the latest edition of its bimonthly Mobility Matters bulletin to lawmakers on Capitol Hill last week. The issue documents the case of a 68-year-old amputee from Yucca Valley, Calif., whose Medicare claim for a power wheelchair was denied.
According to the bulletin, two years ago, the man, who was referred to as John, sought a power wheelchair from Medi-Source Equipment & Supply, a home medical equipment provider in rural Yucca Valley. Both his legs had been amputated; after a stroke he had the use of one "good" arm that constantly ached.
"His power wheelchair, battered and broken down, lay crumpled on the side of his caregiver's garage," Mobility Matters reported. "At the time, that garage was the place that John called home. Often his power wheelchair served as both his transportation and his bed. But his power chair had seen its last day."
Here's the rest of the story from the bulletin:
Under Medicare regulations, power wheelchairs are supposed to last at least five years before being replaced, but John's had worn out after three years from heavy use.
"His power wheelchair served as his only means of getting around," said Esta Willman, owner of Medi-Source. "When his caregiver wasn't available, he literally slept in his wheelchair. He couldn't get out of it on his own. He came to our place, and we started the process to provide him a new chair, thinking that even if the Medicare claim was initially denied, his extenuating circumstances would allow it to be approved on appeal."
Tyler Wilson, AAHomecare president, said the chain of events in this particular case reinforces the need for substantial changes in the way that Medicare claims for home care equipment are handled by CMS. He said that across the country, small and large providers are outraged over the broken process — claims rejected for Medicare beneficiaries who clearly need power wheelchairs, a high percentage of these denials later overturned in administrative appeals, good providers pushed to the brink of bankruptcy because of delays in getting paid for legitimate claims and new standards for documenting medical necessity applied retroactively to claims filed long before the new guidelines were established.
"John's case isn't about disruptions in the claims process," Wilson said. "At the core, it is potentially much more serious. It's about flaws in how people are treated by a government program that President Lyndon Johnson created as a centerpiece of his Great Society. He envisioned health safeguards for the most vulnerable people in America — the elderly and people struggling to live with disabilities. But today, sadly, Medicare is failing people like John."
Medi-Source fitted John for a new chair, and a short time later, he had a Pride Jazzy 600 wheelchair. Under Medicare regulations, the company provided the wheelchair before filing the reimbursement claim. Willman was aware that recovering the $2,400 cost of the chair, as well as reimbursement for the services she provided, would likely take longer than normal because the five-year use period had not expired on his last chair.
Medi-Source's original claim was denied, and Willman appealed, documenting John's unique situation — he was literally living in his chair, sometimes 24 hours a day, and at the time, was staying in a friend's garage. His physical handicaps prevented him from doing maintenance on his chair, leading to greater than normal wear and tear. She included pictures of his old wheelchair, showing it beyond repair.
Much to her surprise, not only was the appeal denied but the case was referred to Medicare's patient culpable neglect unit; John was being investigated for allegedly abusing his original wheelchair and was in danger of having his Medicare benefits restricted.
"This poor guy was not abusive to the equipment, he just needed to use it more than most," said Willman. "Maybe I shouldn't have had faith that they would want him taken care of. But don't go after him. Without the power wheelchair, he's in a bed. This is truly appalling. It is stunning that Medicare would deny him a way to even exit in case of fire. He can't walk; he has no legs and he can't push a manual wheelchair because his one good arm is killing him all the time. How can he not be qualified for a power wheelchair?"
In September of 2008, the neglect investigation began. Despite letters and telephone calls, Willman has been unable to receive any information about the investigation. The delay has had ramifications for her and the beneficiary, John. Her appeal of the claim denial has stalled because the neglect investigation has not been completed. Like other providers dealing with claim denials, Willman hasn't taken John's chair away. But he needs new batteries to keep it running — something that Medicare would cover if the original claim had been approved.
"Patients are being let down by the government all across the country," said Wilson. "Providers, like Medi-Source, are doing the best they can to help them. It is disappointing that the Medicare program is creating more hurdles for providers, rather than improving services and care options for beneficiaries."
