The Patient Access and Medicare Protection Act (PAMPA), enacted on December 28, 2015, delayed application of competitive bid program (CBP) adjusted payment rates for accessories furnished in connection with complex rehabilitation technology (CRT) power group 3 wheelchairs. PAMPA also included a provision requiring the General Accounting Office (GAO) to study Medicare utilization and expenditures for wheelchair accessories. The GAO report, released on June 1, 2016, provides information on utilization, expenditures, and how the 2016 CBP adjusted payment rates for accessories compare to the 2016 unadjusted fee schedule payment rates for the same items.
The GAO study found CRT power group 3 wheelchairs accounted for 2% (approximately 13,000) of all wheelchair utilization and 22% (about $69 million) of wheelchair expenditures, while accessories used with them accounted for approximately 18% (about 312,000) of all accessory utilization and 51% ($159 million) of accessory expenditures. The top accessory (a combination tilt and recline power seating system) accounted for an estimated $56 million, or 35%, of total accessories used with these chairs. The top 10 accessories accounted for 82% of Medicare expenditures. Among the 10 accessories with the highest estimated expenditures when used with the CRT power group 3 wheelchairs, 8 had CBP-adjusted payment rates, and the average CBP-adjusted rates for these ranged from 5-17% lower than the unadjusted fee schedule payment rates.
The critical issue that advocates need to understand is whether this 5-17% decrease in payments will reduce margins from suppliers in such a way that discourages them from distributing the accessories, thus making access to the necessary items difficult. The challenge for suppliers is to demonstrate that their margin of profit does not support a decrease in payments. Table 3 of the GAO report outlines each accessory by coded-item and shows the percentage difference between the unadjusted payment rates and the CBP adjusted payment rates. For each item a supplier believes it may no longer be able to make accessible to beneficiaries, they must make the case that there is not a reasonable margin for that accessory.
In the meantime, suppliers should not use vulnerable beneficiaries in their profit battles. Maintaining the integrity of the Medicare program is in the best interest of all. Medicare has a deep interest in providing coverage for these accessories at reasonable prices. There is no question that the necessity for this equipment has been validated.