February 25,2004

Grassley Seeks Balanced Motorized Wheelchair Criteria

WASHINGTON -- Sen. Chuck Grassley, chairman of the Committee on Finance, hasquestioned whether the Centers for Medicare and Medicaid Services (CMS) has struck the properbalance between policing potential fraud and preserving beneficiaries’ access to medically necessarypower wheelchairs. “No one who qualifies for a Medicare-financed motorized wheelchair shouldbe denied one,” Grassley said.

Last month, Grassley asked the General Accounting Office to analyze whether the Medicare reimbursement rules for motorized wheelchairs are too loose, leading to some providers exploiting the rules to over-bill and possibly to defraud Medicare. Now, Grassley is asking CMS to explain how it developed its criteria and procedures for determining eligibility of individuals for power wheelchairs.

The text of his latest letter follows.

February 24, 2004

VIA FACSIMILE: (202) 690-8168
ORIGINAL BY U.S. MAIL

Mr. Dennis G. Smith
Acting Administrator
Centers for Medicare & Medicaid Services
Department of Health & Human Services
200 Independence Avenue, SW Room 339G
Washington, DC 20201

Dear Mr. Smith:

As a U.S. senator, my paramount concern has always been to identify and control fraud,waste and abuse in the federal government’s programs and operations. Recently, my interest hasbeen drawn toward reports of fraud and abuse involving power wheelchairs purchased through theMedicare and Medicaid programs. As chairman of the Committee on Finance, which hasjurisdiction over both Medicare and Medicaid, improper expenditures involving these programs areof special interest to me, particularly since these two programs pay a substantial share of the totalexpenditures for power wheelchairs.

I appreciate that increased attention is now being given to this problem by the Departmentof Health & Human Services and Centers for Medicare & Medicaid Services (CMS). I recognizethat managing these programs can be challenging, especially since CMS has to be viewed as anhonest broker. It must be mindful of the needs of the taxpayers and operate efficient, cost-effectiveprograms. At the same time, CMS has to provide its beneficiaries and program recipients with theequipment and services they need and are eligible to receive.

I do not underestimate the difficulties balancing these objectives can impose. Nevertheless,we all recognize that this is precisely what must be done. In that vein, you are undoubtedly awarethere has been some recent criticism leveled at CMS and its four durable equipment regional carriers(DMERCs) concerning the clarifications last fall of the Local Medical Review Policy for powerwheelchairs.

Some representatives of the power wheelchair manufacturers, durable medical equipmentsuppliers, and disabled community are raising questions about the definitions of “ambulatory,”“nonambulatory,” “walking,” “upper extremity weaknesses,” and “within the home” -- for example-- as well as the criteria used by the DMERCs to make uniform judgments about beneficiary andrecipient eligibility.

While ensuring that we do all that we can to eliminate fraud and waste from governmentprograms, I also want to be certain that we are not inappropriately preventing our eligible citizensfrom obtaining the medically-needed equipment they are authorized to receive. Therefore, I wouldlike to have a very clear understanding of the process CMS and its DMERCs used last fall to developthe recent clarifications, and the criteria and procedures being used by the DMERCs to make uniformjudgments about the eligibility of individuals for power wheelchairs. Please clarify for theCommittee the process used by CMS and/or the DMERCs to develop and document the recentclarifications, as well as provide the uniform criteria used to assess the eligibility of beneficiaries andrecipients.

Thank you in advance for your assistance and for your response by March 10, 2004. Pleasedo not hesitate to contact me if you have any concerns.

Sincerely,

Charles E. Grassley
Chairman

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