Power wheelchair claims are one of the most costly medical device codes submitted to Medicare and Medicaid each year. So much so, that the Office of Inspector General conducted a study in 2001 to determine whether these chairs are actually “medically necessary” in most cases and, if so, whether a less-expensive alternative exists.
In a False Claims Act lawsuit filed by two former employees of Orbit Medical, Inc., the U.S. government has opted to intervene and investigate claims that Orbit forged medical documentation and prescriptions for power wheelchairs, then subsequently billed Medicare in violation of the FCA. If found liable under the FCA, Orbit co-owner Jacob Kilgore could face triple damages in addition to pending criminal charges, including three counts of healthcare fraud, making false statements, and wire fraud.
Medicare Standards for Reimbursement of Power Wheelchair Expenses
As with any healthcare reimbursement, a physician must certify that the service, procedure, or device is medically necessary. For patients facing mobility issues, a power wheelchair is the most costly option and is only reimbursed if a cane, walker, or power scooter will not be sufficient to meet the patient’s needs. In order for Medicare to properly reimburse the claim, it must receive documentation from a doctor affirming that the patient received an in-person, face-to-face examination. Further, coverage for a wheelchair is only appropriate when all of the following conditions are met:
- The patient’s condition is such that, without the use of a wheelchair, the patient would be bedridden or confined to a chair;
- The beneficiary is unable to operate a manual wheelchair; and
- The patient is capable of operating the controls for a power wheelchair.
Submission of an invoice to Medicare for reimbursement on behalf of a patient that does not meet the above criteria is considered a false claim and punishable under the FCA.
Details of U.S. ex rel. Clyde et al. v. Orbit Medical Inc. et al.
The case against Orbit Medical began with the filing of a whistleblower complaint by former Orbit employees Dustin Clyde and Tyler Jackson. In the complaint, plaintiffs alleged that Kilgore directed employees and staff to alter physician prescriptions and supporting documentation in order to qualify the patient for a more costly power wheelchair option. Likewise, staff was directed to alter documentation in order to make certain patients eligible for Medicare coverage who would not otherwise qualify for coverage.
The specific allegations against Kilgore and Orbit Medical reveal somewhat shocking fraudulent tactics designed to maximize Orbit’s power wheelchair sales. For instance, Kilgore is alleged to have altered documentation by falsely certifying that a doctor had examined a patient in person and deemed the power wheelchair a medically necessary device. Kilgore is also alleged to have altered or falsely created medical charts in order to support the assertion to Medicare that the patient needed the wheelchair. Further allegations suggest Kilgore directed his staff to forge signatures and create fraudulent stamps to make medical documentation appear as if it was signed by a doctor and sent by a clinic.
The full amount sought by the whistleblower lawsuit is not yet determined; however, the indictment against Kilgore reveals that the government paid $15 million to Orbit Medical as a result of power wheelchair claims between 2006 and 2011.
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