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Report (OEI-04-09-00260)

07-07-2011
Most Power Wheelchairs in the Medicare Program Did Not Meet Medical Necessity Guidelines

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Summary

We found that 61 percent of power wheelchairs provided to Medicare beneficiaries in the first half of 2007 were medically unnecessary or had claims that lacked sufficient documentation to determine medical necessity. These power wheelchairs accounted for $95 million of the $189 million that Medicare allowed for power wheelchairs during this period.

Medicare beneficiaries are eligible to receive power wheelchairs under Medicare Part B coverage of durable medical equipment (DME). Beneficiaries who are prescribed power wheelchairs receive them from suppliers, which bill Medicare for reimbursement. We conducted a medical record review of a random sample of 375 claims for standard and complex rehabilitation power wheelchairs supplied to beneficiaries in the first half of 2007. Reviewers determined whether each claim was for a power wheelchair that was medically necessary and whether the claim was supported by sufficient documentation to determine medical necessity based on suppliers' records. They also reviewed records from prescribing physicians. For claims without errors based on suppliers' records, reviewers determined whether prescribing physicians' records supported suppliers' claims.

Based on records submitted by suppliers that provided power wheelchairs, 9 percent of all power wheelchairs were medically unnecessary and another 52 percent had claims with insufficient documentation to determine medical necessity. Beneficiaries who received power wheelchairs that were medically unnecessary needed a less expensive type of equipment (such as a manual wheelchair, cane, or walker) or a different type of power wheelchair. We also found that medical necessity and documentation errors varied by power wheelchair type. Standard power wheelchairs were less likely to be medically unnecessary than complex rehabilitation power wheelchairs (8 and 24 percent, respectively). Conversely, claims for standard power wheelchairs were more likely to have insufficient documentation to determine medical necessity than claims for complex rehabilitation power wheelchairs (53 and 32 percent, respectively). Finally, we found that 78 percent of claims were for power wheelchairs that were medically necessary based on suppliers' records but were medically unnecessary, insufficiently documented, or undocumented based on physicians' records. In most cases, the physicians' records had insufficient documentation to support the power wheelchairs' medical necessity; less often, physicians' records contradicted suppliers' records.

Two previous OIG reports based on the same sample of power wheelchairs found problems with coding and documentation requirements, and this report shows additional problems with suppliers' compliance with Medicare requirements. Across all three reports, 80 percent of claims for power wheelchairs supplied to Medicare beneficiaries in the first half of 2007 did not meet Medicare requirements. 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 have claims that do not meet documentation requirements.

Based on our findings and prior work, we recommend that CMS (1) enhance reenrollment screening standards for current suppliers of durable medical equipment, prosthetics, orthotics, and supplies; (2) review records from sources in addition to the supplier, such as the prescribing physician, to determine whether power wheelchairs are medically necessary; (3) continue to educate power wheelchair suppliers and prescribing physicians to ensure compliance with clinical coverage criteria; and (4) review suppliers that submitted sampled claims we found to be in error. CMS concurred with the second, third, and fourth recommendations. CMS did not concur with the first recommendation.

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