Physician Details Problems with Medicare Approval Process for Power Wheelchairs

Consumer Advocates Join Providers and Physicians to Call for a Clinical Template as Part of Medicare's Prior Authorization Program 

Interview with physician Meg Allyn Krilov, MD in the American Association for Homecare bulletin, Mobility Matters

NEW YORK, July 10, 2012 /PRNewswire-USNewswire/ -- For more than 25 years, Dr. Meg Allyn Krilov has practiced rehabilitation medicine in New York City, prescribing hundreds of power wheelchairs to patients in need of mobility assistance to improve their quality of life in their home, and their communities. She practices at Montefiore Medical Center and Premier HealthCare. One of her biggest frustrations is the burdensome process of obtaining power wheelchairs for her patients who are on Medicare. 

Physicians, clinicians, providers, and advocates for people with disabilities for years have cited flaws in the process for providing power wheelchairs for Medicare patients so they can live safely and independently in their homes. The Centers for Medicare and Medicaid Services (CMS) plans to implement a prior authorization demonstration program in seven states, covering nearly half of the power wheelchairs provided annually to Medicare beneficiaries. But CMS has not committed to including a clinical template for physicians in the pre-authorization process when physicians prescribe power wheelchairs.

Yet, stakeholders ranging from providers to physicians and consumer advocates say it is critical that the prior authorization program include a clinical template. Three influential consumer groups – United Spinal Association,  National Council on Independent Living and the Association of Programs for Rural Independent Living – recently wrote to CMS asserting that patient care may be jeopardized if a clinical template is not used.  "As we have stated before, the program CMS has designed thus far does not constitute a demonstration. Instead it has the potential to eliminate the Medicare benefit for power mobility devices for individuals who reside in one of the seven states where this experiment will transpire. This could be rectified very easily if CMS designed, developed, and implemented a prior authorization process that includes the utilization of a clinical medical necessity template to provide necessary clarity and guidance to physicians, treating practitioners, suppliers, and beneficiaries attempting to meet the prior authorization documentation requirements," wrote Kelly Buckland, executive director of National Council on Independent Living.  

Indeed, physicians, in particular, need clarity when documenting the medical need for their patient to receive a power wheelchair. In a wide-ranging interview with the American Association for Homecare, Dr. Krilov discusses why physicians are asking that the current Medicare approval process be changed, why she supports a prior authorization process, and why a clinical template is an essential element to that process.  

Q:  Is there a difference in the process when you prescribe a power wheelchair for Medicaid patients versus Medicare patients?

A:  Well, one important difference is that Medicaid has a prior authorization process.

Q:  How does the Medicaid prior authorization process work? 

A:  I can't say that it is completely perfect, but when I prescribe a Medicaid power wheelchair, the prior authorization process makes it a bit smoother, less time-consuming, and better for the patient.  To meet their requirements, I have to write a prescription, justify the need for a power wheelchair, and explain why a power wheelchair is needed rather than a manual wheelchair or a scooter.  After that documentation is completed, I send it to a vendor and Medicaid and they decide if it's approved, or if they need more information.

Q:  Is the Medicaid process quicker and more efficient than the Medicare process?

 A: Yes, that's true.

Q: What is wrong with the current Medicare process?  Can the problems be fixed?

A: It's very awkward and very cumbersome.  It's a burden for physicians, the suppliers, vendors… it's burdensome!  We examine the patient and then prescribe what the patient needs.  I do that evaluation. Then I have to write a letter of justification, and complete the seven elements required in the report on the face-to-face examination. These details include name, address, telephone number, diagnosis and why the patient can't use a cane, crutch or walker.  Now, for instance, I've already stated that the patient has Cerebral Palsy (CP), is quadriplegic, and can't walk. But the process requires that I repeat that information and write again that the patient has CP, is not ambulatory, cannot walk and has contractures.  Then I have to write that the patient can't self-propel in a manual wheelchair because they can't use their upper extremities, and have contractures and coordination deficits. And then I have to write that the patient can't use a scooter because they can't transfer in and out of the scooter. One of the big problems now is that they do not allow prior authorization for a standard power wheelchair. In many cases, the vendor has already provided the equipment to the patient, then after the fact, the claim evaluators will say, "it's not enough, we deny it,"  and that's not really fair to the patient or the vendor.

Q: How many power wheelchairs do you prescribe a year?

A:  About 20 a year for Medicare patients and usually between 16 and 20 for Medicaid patients.

Q: Do you think a prior authorization process would improve the Medicare process?

A:  Well I think so.  The other problem is that some of the questions that they ask are confusing and hard to answer accurately.

Q:  If there was a template available, would physicians then know exactly what information is required and it could reduce the number of claim denials for Medicare patients who need power mobility? 

A:  Right. One would hope, yes.

Q:  Physicians and providers are very concerned that Medicare may implement a pre-authorization process, but not include a clinical template.  Will this create more problems rather than solve any?

A:  Yes, it could make a bad situation even worse.  I think it's very important that we include a template.  It is what will make the process more efficient. It's common sense to include a template.  I've had clients denied who really needed a power wheelchair.

Q. How long does it take you to do the paperwork for a Medicare beneficiary to get a power wheelchair?

A:  It takes at least 45 minutes to 1 hour to examine them inside the clinic.  Then I go home and write the letter.  Depending on how complicated a case it is, the entire process can take 2 – 2 1/2 hours for each patient.  I would rather be spending more time with patient than doing paperwork. I don't have time to do the Medicare administrative work in my office, so I have to take it home and work on it in the evening. So, each power wheelchair for a Medicare patient requites me to work afterhours at home.

Q:  Would a template cut down the amount of time needed?

A:  Definitely. A template and prior authorization would help.  I strongly urge Medicare to simplify the process by having a template that is easy to follow, so the work can be completed at the clinic. Being forced to write a letter of justification where I have to reiterate everything is just really cumbersome and awkward.

Q. Earlier you said that the Medicaid process is more efficient. Why is that?

A: The big difference is that they do not require that I write a letter with the seven elements explaining the face-to-face examination. I can complete the Medicaid process in about an hour or so, a much shorter time than with the Medicare process.

Q.  What advice would you give to CMS?

A. Get this done!

The American Association for Homecare represents durable medical equipment providers and manufacturers who serve the medical needs of millions of Americans who require oxygen equipment and therapy, mobility devices, medical supplies, inhalation drug therapy, and other medical equipment and services in their homes. Members operate more than 3,000 homecare locations in all 50 states.  Please visit www.aahomecare.org/athome.

SOURCE American Association for Homecare