The RAMP Report: CMS Issues Medicare Coverage Policy; Needs Refinement and Clarifications
WASHINGTON, May 20 -- The following is the latest RAMP Report from the Restore Access to Mobility Partnership:
Volume II Issue 7
May 20, 2005
CMS ISSUES MEDICARE COVERAGE POLICY; NEEDS REFINEMENT AND CLARIFICATIONS
The Centers for Medicare and Medicaid Services (CMS) has moved quickly to issue a National Coverage Determination (NCD) seeking to create function-based, coverage criteria for mobility assistance equipment. While this is a key first step, this new Medicare coverage policy for power wheelchairs and other devices needs clarification and refinement to succeed in its goal of making mobility equipment accessible to beneficiaries with disabilities.
Perhaps the most glaring issue for the industry may be what CMS didn’t do, rather than what has been done thus far.
The new coverage policy took effect immediately, but CMS has not released documentation guidance or a revised Certificate of Medical Necessity, which can outline the information needed to substantiate Medicare coverage, and be used by providers at post-payment audits. Moreover, CMS has not published the final rule regarding mandated face-to-face examinations of beneficiaries by their physicians, or revisions to the coverage policy for powered scooters; the regulations currently make access to scooters more difficult. These regulations are critical to proper implementation of the NCD. Without more information and additional details regarding documentation, uncertainty and access issues will remain for beneficiaries.
“It is imperative that the issues related to documentation be answered quickly so that CMS and the industry can go forward together in providing consistent appropriate coverage for all beneficiaries,” said John Ward, President of Mobility Products Unlimited.
Since the release of the NCD, CMS has listened to the industry’s concerns about the need for clarifications, and appears on a course towards addressing them in a satisfactory manner. RAMP urges that CMS move quickly to make the necessary refinements, and to also publish precise instructions on documentation, so that little is left to interpretation by the Durable Medical Equipment Regional Carriers (DMERCs), who process Medicare claims across the country.
Scott Meuser, Chairman and CEO of Pride Mobility Products Corp., said that some clarification will come with the additional regulations that CMS will issue. “We are hopeful that clarity will be provided in the near term from CMS and the DMERC medical directors so that access to mobility products is provided to all who need them,” he said.
RAMP maintains that the clarifications are key. “To be effective, the NCD must be accompanied by other guidelines and regulations that fill in the gaps,” said Mal Mixon, Chairman and CEO of Invacare Corp. “The industry wants an end to vague and ambiguous regulations that can create inconsistency in the way claims are reviewed, and can prevent qualified beneficiaries from receiving mobility equipment.”
Specifically, RAMP cited these concerns in discussions with CMS, and the agency is working on resolving the problems:
-- The NCD states that any mobility equipment prescribed must “restore the beneficiary’s ability to participate in mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.” The wording leaves open the question of what other mobility-related activities of daily living will be considered. If there is going to be a consistent coverage policy that is followed in all the regions, this provision should be clarified so that everyone, particularly the DMERCs, understand what additional activities of daily living will trigger coverage of mobility equipment for Medicare beneficiaries.
-- The NCD says coverage is appropriate when a beneficiary’s mobility limitations can be “ameliorated or compensated” with power mobility equipment that significantly improves their ability to participate in the activities of daily living. The NCD addresses the possibility of a “caregiver” playing a role in the coverage decision, but it doesn’t clearly define the caregiver role. What happens if the caregiver is not present all the time? Will coverage be denied in those instances? Will suppliers or clinicians now be responsible for verifying the existence and consistency of the presence of a caregiver?
-- In another issue regarding caregivers, the policy states that if a beneficiary is unable to self-propel a manual wheelchair, but a caregiver is available to assist, a manual wheelchair may be appropriate. Claim processors could interpret that to mean a beneficiary should be restricted to a manual wheelchair if there is a caregiver available.
-- The NCD notes that even when a beneficiary meets broad conditions for coverage, the individual needs to comply with his or her medical treatment if it is essential to their ability to use mobility equipment to perform activities of daily living. While the NCD clearly states that substantial non-compliance, whether willing or involuntary, can be grounds for denial of wheelchair coverage, it adds that “it may be determined that partial compliance results in adequate amelioration or compensation for the appropriate use of mobility assistive equipment.” RAMP agrees with allowing beneficiaries leeway on this provision, since their ability to follow therapy or take their medicine, for instance, may be completely involuntary and should not impact on their need for increased mobility. But CMS has not outlined how partial compliance will be measured. One DMERC region may judge partial compliance differently from another. The result would be that identical claims could be approved in one region and rejected in another.
These inconsistencies, as well as the lack of a provision allowing mobility for mobility’s sake, could put two groups of beneficiaries at risk of being denied coverage. One group is beneficiaries who have mobility limitations but these do not prevent them from brushing their teeth, grooming, eating, etc. The new coverage policy could be interpreted in a way that would deny them coverage. Another group at risk is beneficiaries with severe mobility limitations, who can’t perform the daily activities even with mobility equipment. CMS cites the caregiver as being compensatory, but this does not solve the problem.
“In both scenarios, these beneficiaries only need mobility for mobility sake,” Mr. Mixon said. “But they could be denied coverage under the new policy. Indications are strong that CMS now recognizes these potential problems and wants to fix them.”
Like clinicians and advocacy groups, RAMP is disappointed that CMS did not eliminate a restriction that can make elderly and disabled beneficiaries homebound. CMS maintains that the NCD process was inappropriate for addressing the “in the home” restriction, which limits mobility equipment to usages in a residence. Advocates for the disabled, clinicians and the industry will continue to look for ways to eliminate this egregious policy.
Restore Access to Mobility Partnership is a coalition representing power wheelchair providers and manufacturers. Members include: the American Association for Homecare; Invacare Corporation; the MED Group; Mobility Products Unlimited, LLC; Pride Mobility; and Sunrise Medical. For more information contact Michael K. Frisby, 202-625-4328 or Mike@FrisbyAssociates.com.
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