Power wheelchair industry lobbies against Medicare

WASHINGTON -- Medicare is refusing to pay for Andy Campbell's recently delivered $6,242 motorized wheelchair despite the advanced prostate cancer and heart disease that makes his every step painful.

Campbell, a former California policeman who lives in Henderson, Nev., will not be stuck with the bill under Medicare rules. Unless the government changes its mind, the Scooter Store, based in New Braunfels, Texas, will absorb the loss.

The medical equipment company and four other businesses are undertaking a national lobbying campaign, starting with a commitment of about $250,000, to challenge Medicare's new get-tough policy on reimbursements for power wheelchairs.

The coalition says companies will be reluctant to provide the wheelchairs without any upfront payments from the patient.

Strict enforcement

In September, officials with the government health-care program for 40 million older and disabled people ordered more scrutiny of claims for power wheelchairs, whose prices range from $5,000 to $6,000 or more, depending on accessories. The program ordered its insurance contractors to enforce strictly a policy that normally limits reimbursements to those unable to walk.

Cara Bachenheimer, a vice president at Invacare, a large manufacturer of home medical equipment, said the lobbying effort would "turn over every stone" to convince the White House and the Health and Human Services Department that "they made a mistake."

Disclosure records show the company, based in Elyria, Ohio, spent $260,000 last year to contact the Bush administration and Congress to ensure favorable treatment of medical equipment in the Medicare legislation.

Timothy Hill, Medicare's chief financial officer, said the lobbying is more about profits than patients.

"Much of what we have seen in the increase the last few years is a direct result of consumer marketing in the industry, which creates the appearance the benefit is broader than it is," he said.

Hill said he does not accept the industry theory that more claims will be rejected under heightened scrutiny for wheelchair claims. He said the companies behind the lobbying are large ones with big marketing operations.

These companies, he said, "have a stake in raising this issue. We're not hearing from therapy centers and small mom-and-pop stores working with physicians on a one-on-one basis."

Campbell, who was a policeman in Santa Monica, Calif., is more concerned with his newfound freedom to move around the house than a high-stakes lobbying effort.

"My wife is my primary helper, and I had to ask her to bring everything to me," said Campbell, 62. "I sat all day in my room. Now I can go into the kitchen and restroom. I can go outside and get fresh air. I'm able to do a lot of things without bothering her."

Cigna Medicare, the contract insurer that processed the claim submitted by the Scooter Store, ruled in Campbell's case: "These are noncovered services because this is not deemed a 'medical necessity' by the payer."

When a Medicare beneficiary wants a motorized wheelchair, a supplier evaluates whether the patient would be likely to qualify for the program's 80 percent reimbursement.

A supplier that believes the claim might be rejected may provide the chair only if the beneficiary signs a form agreeing to pay.

If the supplier believes the patient would qualify, the store would provide the chair and submit the claim, but could not, under Medicare rules, bill the patient later if the claim were rejected.

The Scooter Store determined that Campbell would qualify for reimbursement and took the chance, submitting the claim without first requiring payment.

The Scooter Store says it will not take back the chair from Campbell. That is a store policy; Medicare rules do not prevent the supplier from repossessing the chair.

Claims for power wheelchairs have increased from 62,000 in 1999 to 168,000 in 2003. Payments in 1995 came to $22.3 million; in 2003, they rose to $666.5 million.

In November, The Associated Press reported the HHS inspector general identified $167 million in fraudulent power wheelchair claims and had 50 active investigations in close to two-dozen states.

Medicare's policy of allowing reimbursements mainly for those confined to chairs or beds has not changed. But there is evidence that the four regional insurance contractors that administer medical equipment claims for Medicare approved reimbursements for people who walked with great difficulty.

Dr. Paul Metzger, former medical director for Medicare contractor Palmetto GBA, said he resigned from the insurer in October because, he contends, the company "started denying claims left and right" on orders from the administration. He now works for The Scooter Store.

"They started putting the thumb on legitimate suppliers," said Metzger, adding this did nothing to stop phony claims from fraudulent businessmen.

Bob Cheatham, of Tulsa, Okla., who uses a power wheelchair, learned the hard way that some equipment stores are now reluctant to deliver the equipment.

After going to several stores, he found a company that supplied a motorized chair without payment.Cheatham, 69, has severe rheumatoid arthritis and is unable to walk, which would appear to qualify for reimbursement.

A store representative, who failed to send in the claim, "told us right off the bat that there had been too much corruption," Cheatham said. "He told us too many people had beaten Medicare out of money."

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On the Net:

Industry site, Restore Access to Mobility Partnership: http://biz.yahoo.com/prnews/040130/dcf015(underscore)1.html

Government site, Centers for Medicare and Medicaid Services: http://www.cms.hhs.gov/default.asp

An interactive look at Medicare wheelchair fraud is available at: http://wid.ap.org/interactives/wheelchair/chair1.swf