Why is it so hard to get Medicare to pay for a power wheelchair or Scooter when the TV ad makes it seem so easy?
Several years ago Medicare discovered they were getting ripped off by criminals stealing from the Medicare program by making false claims for power wheelchairs and electric scooters. To combat this, Medicare GREATLY increased the amount and complexity of the documentation they must be provided in order to pay for one of these products to any Medicare client. The ads you see on TV conveniently leave out this information. They often just want you to call them so they can twist the situation around and try to get you to privately pay for these products.
In order for Medicare to legally pay for a power wheelchair or electric scooter (these are also known as P.M.Ds (or Power Mobility Devices) ALL of the following issues must be documented:
- You must have a need for the PMD inside your residence to complete activities of daily living such as dressing, eating, bathing, or toileting. A report must be completed by your physician, or a physical therapist, detailing what you cannot do now and what you could do if you had one of these devices. The report must describe what kind of danger you may be in if you don’t get a PMD (such as risk for falls, etc). If your power mobility needs are only for outside the house, Medicare will deny the claim.
- In the report by your doctor, or a physical therapist, they must medically explain why you cannot do these daily living activities with the assistance of a cane, crutches, a walker or a manual wheelchair. The report must also have measurements of the strength and range of motion in your arms. The report must state that you can safely use a PMD and that you are motivated to get one. If the request is for a power wheelchair, the report must discuss why you cannot use an electric scooter (they cost less than a power wheelchair, so Medicare wants to know why you medically require a higher priced electric wheelchair).
- Any needed accessory on the PMD must be separately medically documented. Not all accessories are covered by Medicare even though you may medically require them.
- You must have a visit with your primary care physician where the only thing discussed at the meeting is your need for a PMD. The physician must carefully document this discussion in your chart notes. If the physician wants to have a physical therapist do the report, they must refer you to such a person. The physician must review and sign off on that report after the physical therapist completes it.
- After the doctor orders what kind of equipment is medically correct for you, the provider of that PMD must come to your home to verify that the equipment can be safely used in your home. If it cannot be safely used, the process must start all over again from scratch.
- If any part of the process is not done exactly as Medicare requires it to be done, it must be started all over again from the beginning. Medicare will not allow a doctor or physical therapist to change anything in your medical record. If its not done right, they have to do it again (the doctors and therapist really don’t like this, but those are Medicare rules).
- Certain date time frames are allowed for each of these steps. If the work is not completed within the time frame set by Medicare, they will deny your claim….even if it’s a legitimate claim. If one of the date time deadlines is missed, the process must be started all over again.
This process is not easy and not quick. Even if Medicare pays for PMD for you, they have the right to come back later and audit the provider and take back their money from that provider if everything was not perfectly completed. You would not lose your PMD in this event but Medicare would not pay for any future repairs on it because they will say you never should have received it in the first place!
Most insurance companies follow the same standards Medicare has adopted. Unless you really need one of these products, you won’t get one paid for by Medicare. However, if you really DO need one based on the Medicare expectations, and can prove it, the Medicare program will pay for it.
Rule of thumb…
If you can walk into a provider’s office with a prescription from your doctor stating you need a PMD, you won’t qualify for one. It’s that strict. In 2008, when these new rules were established, over 90% of the audited claims for these products by Medicare were denied. That doesn’t mean 90% of the people trying to get these products didn’t need them, it just shows how difficult it is to get these paid for today. In 2010, it’s better with about a 55% denial rate….still bad, but slowly getting better as the medical community slowly begins to understand the challenge of getting these items covered. Hang in there everyone!
Paul Gammie
Manager and Owner of Gammie HomeCare
Gammie HomeCare specializes in Home Medical Equipment needs for clients on the islands of Maui and Kauai in Hawaii. In business on Maui since 1986 and Kauai since 1999.