States such as New Jersey have already used pre-authorization programs to crack down on fraud schemes tied to non-emergency ambulance transportation, and now the Centers for Medicare & Medicaid Servics (CMS) is applying the same program to power wheelchairs, according to NJ.com.
Similar to New Jersey's pre-authorization program for ambulance transportation, the federal program requires the approval of an administrator to allow Medicare coverage of power wheelchair orders. According to NJ.com, CMS instituted the program in several states in 2012, and then expanded the program to 12 states in October, including New Jersey. The news organization reports that the Department of Health and Human Services has denied half of power wheelchair applications in states that started the program in 2012.
Historically, Medicare fraud schemes involving power wheelchairs have been notoriously problematic in states across the country. A 2011 Office of Inspector General report found that 61 percent of power wheelchairs paid for by Medicare in 2007 were medically unnecessary or lacked documentation.
Just last month, two Los Angeles medical suppliers were implicated in multi-million schemes involving unnecessary power wheelchair orders, FierceHealthPayer: AntiFraud previously reported. In the past, CMS has advocated for prior authorization programs for other durable medical equipment orders, such as prosthetics and orthotics.
Just as the ambulance program has raised concerns about patient care, some argue that the tightening regulations are restricting access for patients with legitimate health concerns.
"Unfortunately, prior authorization often translates into prior denial or at least prior delay," Judith Stein, executive director for the Center for Medicare Advocacy, told NJ.com. "We have people who can't get the kind of wheelchairs that they need."
New Jersey was also supposed to begin a prior authorization program for hyperbaric oxygen therapy as well, but CMS put the program on hold until further notice, according to the article. Although prior authorization programs have been met with mixed fanfare, many federal administrators, including President Obama, believe it is an effective tool in combating Medicare fraud and abuse.
- read the NJ.com article