. .
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MEDICARE COVERAGE OF

POWER-OPERATED VEHICLES

E1\VICEs. 
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lt""JO 
OFFICE OF INSPECTOR GENERAL 
OFFICE OF ANALYSIS AND INSPECTIONS 
JULY 1989  MEDICARE COVERAGE OF

POWER-OPERATED VEHICLES

RICHARD P. KUSSEROW 
INSPECTOR GENERAL 
OAI-02-8-'01110  JULY 1989  EXECUTIVE SUMMARY 
PURPOSE 
The purose of this inspection was to determe 
the effects of beneficiar-oriented marketing 
of power-operated vehicles (POV s) on Medicare reimbursement and to review the appropriate
ness of Medicare payments. 
BACKGROUND 
Power-operated vehicles ar thre-wheeled battery operated vehicles that resemble small golf 
car. Under its durable medical equipment provision, Medcar covers small, relatively light
tuing 
weight POV s that have a short  radius and are appropriate for home use. 
To qualify for a POV, patients must be unable to operate a wheelchair manually, and would 
otherwise be confined to a bed or chair. Medicare requirs that the prescribing physician be 
from one of four specialties, unless extenuating circumstaces exist, and that carer medical 
staff review all POV claims. 
The Offce of Inspector General (OIG) became concerned about POV reimbursement in 1987 
when abuses were brought to its attention by a local Medcare carer. This experience re
sulted in the issuance of an GIG Fraud Alert and conduct of this inspection. 
METHODOLOGY 
Two samples were utilzed: the first was a national random sample of 102 beneficiares who 
were contacted by phone to determne their responses to supplier advertising and their role 
obtaining the POY. Some physicians of these patients were also contacted for related informa
tion. The second was a sample of eight Medicare carers; these were visited to examne their 
clais. 
policies and procedures for reviewing POV 
FINDINGS 
Direct Marketing Of pov s To Beneficiaries Is Generating Demand. 
More than half of POV beneficiares intervewed reported they leared about POV s 
through television and other advertising. 
Thiry-seven percent learned about POVs from family, friends, and neighbors. 
Three-quarers of the beneficiares said it was their own or their family s idea, not that 
of a health care professional, to obtain a POV. 
ar 
Suppliers  agressively marketing POVs. As an example, one-third of the 
beneficiares claim they were told they would not have to pay anything for the POV.  Physicians are playing a passive role in prescribing POVs. This includes "going along 
with it," signing the authorizations after the POVs are delivered in one-third of the 
cases, and having little knowledge of Medicare coverage guidelines. 
Medicare Should Not Have Paid For A Majority Of POVs In 1986. 
Sixty-two percent of the POV beneficiares contacted apparently did not meet coverage 
said they could operate a wheelchai manually when they obtaned 
reuirements. They 
their POV, or they were using their POV exclusively outside their home. 
A review of carer supporting documentation showed most claims fail to document 
appropriateness. 
Six of eight carers failed to routinely utilze medcal personnel to review POV claims 
as requird. 
Thiry-one of 81 carer cases showed no information as to the specialty of the 
authorizing physician. 
A loss of $5.9 milion for 1986 is projected. 
RECOMMENDATIONS 
To reduce inappropriate payments for POVs, HCFA should: 
carrr 
I. Evaluate and strengthen as needed  implementation of Medicare coverage 
requirements and the 1987 Omnibus Budget Reconciliation Act provisions to: 
a. use medical staf to review each submitted POV claim for medical necessity, 
b. allow only certain specialists to authorize these claims or cite the reasons for exceptions 
to this rule, 
c. ensure that payments ar made only for beneficiares whose medical and/or physical 
conditions render them unable to use a wheelchair manually and who need a POV for in
door use, and 
d. prohibit payment for durable medical equipment unless suppliers receive a wrtten order 
from a physicians before the delivery of the item to the patient. 
2. Publicize Medicare coverage requirements to the medical community. This could be done 
by issuing instructions or letters to all physicians, citing Medicare restrctions on POVs. 
3. Advise carrers to develop and refer sanction recommendations to the OIG when carrers 
have identified physicians with patterns of excessive POV prescriptions.  " .
HCFA COMMENTS 
The HCFA acknowledged the existence of inappropriate expenditures for POV s as reported in 
the study but did not agree to any specific dollar amount. The HCFA also agreed with our 
three recommendations by citing actions they have taken to resolve these problems. (See 
appendix B for text of comments and OIG' s response.  . . . . . . ..  ...  .....    ...   ....    ....   ....   .....   .....    .....    .....     .....    .....    ....     .....     .....    ......    . .....      ......     ......  .   ......     .....      ......     ......     ...... .    ......     ......     ......     .......       ......   .   .......      ... ...      .......       .......       .......       ........    .  ........    .  . ......     . ..... .       ........        ........       ........        ......".       ......       .......       .......       ........        ........        ........        ........   .....
TABLE OF CONTENTS 
EXECUTIVE SUMMARY. . . . .  . . . . . . . . i

INTRODUCTION. . . . 

FINDINGS. . . . 

Direct Marketing Of POVs To Beneficiaries Is Generating  . . . . . . . . . . . . . . . .4

Demand. 
Beneficiares are takng initiative to obtan POVs ........................ 
Suppliers ar aggrssively marketing their product  . . . . . . . . . . . . . . . . . . . . . . . .4 
Physicians are playing a passive role in prescribing POVs . . . . . . . . . . . . . . . . . . . 
1986 . . 
Medicare Should Not Have Paid For A Majority OfPOVs In 
Beneficiares ' phone responses apparntly reveal most did not qualify for 
POVs ............................................................ 
Carer documents for most beneficiares fai to justiy appropriateness of 
reimbursement. . . 

Weakess noted in carer claims review procedurs

RECOMMENDATIONS 
A: 
APPENDIX-
Cost Savings Projections. 

APPENDIX-B: HCFA General Comments and OIG Response. . . . . . . . . . . . . . 
 A representative of one carrier spotted an elderly woman, accompnied by her daughler, ma
neuvering a power-operated vehicle through the aisles of a shopping mall in a western city. 
The cart had a basket filled with packages and a smll sign on the rear announcing "Medi
care paid for me," followed by the name an phone number of the local supplier of medical 
equipment. This is only one of many techniques being used by manufacturers or suppliers 
to market power-operated vehicles. 
INTRODUCTION 
PURPOSE 
The purpose of this inspection was to determe the impact of beneficiar-oriented marketing 
of power-operated vehicles (POVs) on Medcare reimbursement and to review the appropriate
ness of Medicare payment. 
BACKGROUND 
Power-operated vehicles ar thre-wheeled battery operated vehicles that resemble small golf 
car. Under its durable medical equipment provision, Medcar covers small, relatively light
weight POV s that have a short turning radius and ar easily maneuverable in an individual' 
home. This easy maneuverabilty is the primar advantage over electrc wheelchairs. Med
care wil pay for electrc wheelchairs prescribed by the physician instead of POVs when the se
verity of the patient s condition requirs it for 
greater balance and safety. 
Concerns in the Offce of Inspector General (OIG) about Medicare s reimbursement of POV s 
emerged in 1987 when the OIG New York offce was alerted by a Medicar carer regarding 
some abusive practices. As a result two carers in the New York ara completed a special pre
payment review of POV claims during a 4-month period in 1987. The carer developed ques
tionnaies which were completed by physicians and made telephone calls to Medcar 
beneficiares. Coverage denials resulted in most of these cases. In response to these fmdings 
the OIG sent an issuance to carers, urging incrased surveilance of POV reimburements. 
Medicare Coverage ofPOVs 
Claims for POV s must meet the criteria that the Health Car Financing Administration 
(HCFA) has set for all durable medical equipment: 
can withstand repeated use, 
is primarly and customarly used to serve medical puroses, 
is generally not useful to a person in the absence of ilness or injury, and 
is appropriate for use in the home. 
All of these elements must be met in order for the equipment to be covered by Medicar.  The POV models covered by Medicare are small and relatively light-weight. Medicar does 
not cover the larger POV models which are much heavier and have a  radius. 
grater turning 
The rationale is that such chairs ar used primaly outside the home and are generally useful 
as a means of trsportation in the absence of an illness or injury. Another explanation for not 
progr 
coverig such vehicles was that "the cycle chai might actually increase  costs since 
beneficiares might require one device for outside the home and another for use inside the 
home. "

Accordig to Medicare POV coverage reuirments issued in 1978, a specialist in physical 
medicine, orthopedic surgery, and neurology, and since 1988 rheumatology "must provide an 
evaluation of the patient s medical and physical condition and prescribe the vehicle to assure 
that the patient requires the vehicle and is capable of using it safely." There is an exception to 
the four-specialty requirement that applies when a Medicar carer "determines that such a 
specialist is not reasonably available, e.  , more than one day s round trp from the 
beneficiar s home, or the patient s condition preludes such travel." In these cases, a pre
scription from the beneficiar s physician (outside of the four specialty groups) can be 
accepted. 
Medicare also requires that the patient be eligible for a wheelchair (i.e., the patient would oth
erwise be confined to a bed or chair) and that the patient be unable to operate a wheelchai 
manually. These coverage requirements ar found in Section 60-5 of the Coverage Issues 
Appendix of the  arers Manual, which also states that the carer s "medical staff 
Medicar 
wil review al claims for a power-operated vehicle, including the specialist s or other 
physician s prescriptions and evaluations of the patient s medical conditions to insure that all 
coverage requirements are met. 
Reimbursement Trends 
Claims submitted by suppliers under assignment ar paid at 80 percent of the allowable charge 
recognize by Medicare. The beneficiar is then responsible for paying the 20 percent coin
surance to the supplier. Suppliers who do not accept assignment can charge the beneficiar 
the difference between their total charge and what Medicare allows. 
Based on HCFA data for a 1 percent sample consisting of 102 beneficiares, tota Medicar 
allowed charges for POV s can be projected to $13.6 millon in 1986, with an average 
allowance of $1,330 per beneficiar. The HCFA reported from its Medicar Par B procedure 
me that the total allowed charges for POVs were $12.9 millon in 1986 which is statistically 
comparable to the $13.6 milion projection. Additional information from the procedure fie 
shows a grdual increase from $9.7 millon in 1985 to $12.9 millon in 1986 to $13.3 milion 
in 1987.
 suppliers.
OBJECTIVES 
1. Describe the nature ofbeneficiar and physician responses to the marketing of POV s by 
2. Identify types of POV beneficiares for whom reimburement may have been inappropriate. 
3. Assess the carers' procedures for implementing HCFA' s requirements for POV coverage 
and claims review. 
METHODOLOGY 
This inspection was designed and cared out in conjunction with the recent OIG inspetion 
Medicare Coverage for Seat Lif Chairs  (OAI-02-88-00100). The same methodology and 
sampling procedurs were used for both studies. The fIrst was a national radom sample of 
102 beneficiares from all carers, representing 1 percent of all Medicar payments for POVs 
in calenda year 1986. Seventy-one of these beneficiares - or, in a few cases, their surivors 
were reached by telephone to determne how and why they requested a POV. They were 
asked about their abilty to use a wheelchai manually, their need for a POV and whether they 
had paid anything for it. Reasons for not contacting the remaining 31 individuals included the 
following: beneficiares with no telephone listing did not respond to letters; others who were 
deceased had no available surivor, or their surivor was not contacted; and some requested re
cords had been purged or biled electronically and the beneficiar was not contacted. 
Telephone interviews were conducted with 28 of the physicians for the 71 beneficiares, se
ascert 
lected on the basis of avaiabilty, to  their role in prescribing a POV for the patient. 
The Medicare claims and physicians' authorizations for 62 of the 71 beneficiares interviewed 
were also reviewed by a physical therapist to assess the adequacy of documentation of the di
agnoses and conditions which might justify the nee for a POV. Other analyses were made, in
cluding a comparson of POV delivery dates with physician authorization dates. 
The second sample, consisting of eight Medcar carers was originally selected for the study 
on seat lift chais. It is a judgementa sample drwn from a universe of 53 carers nationwide. 
Included were: Blue Cross and Blue Shield plans of Florida, Indiana, Massachusetts, Pennsyl
vania, and Rhode Island, Traveler s Insurce Company of Minnesota, General American Life 
of Missouri, and Prdential of New Jersey. The eight carers accounted for 32 percent of all 
dollar allowed for POV s in 1986. 
Discussions were held with 22 managers and staf personnel at the carer level. To assess 
each carer s POV claims review procedures, approximately 10 claims were randomly se
lected from 1987 paid claims and reviewed on site at seven carers (one carer had only one 
paid claim in 1986).

Discussions were also held with 'HCFA and carer offcials and non-sample beneficiares, and 
other physicians and suppliers, bringing the total respondents contacted to 167.  FINDINGS 
I. Direct Marketing ofPOVs to Beneficiaris is Generating Demand 
Beneficiaries are taking initiative to obtain POVs 
Beneficiares were initially asked how they fist leared about POVs. More than 
hal (57 per
cent) of the 71 POV beneficiares contacted said they leared about POVs though television 
and other advertising, including magazines, salespersons, mail brohures ,and demonstrtions 
at shopping mals. Thir-seven percent were told about POVs by famly, frends or neigh
bors. Only 6 percent said they leared about POVs frm a doctor or other medcal personnel. 
Beneficiares were next asked to indicate whose idea it was to obtain the POV. As shown in 
figure 1, thee-quarers of the POV beneficiares contacted said it was their own idea or their 
famly s idea to get a POV. Another 6 percent said it was both their idea and their doctor 
idea. Most of the remaiing beneficiares (15 percent) said it was the doctor s idea. 
PATIENT RESPONSES:

WHOSE IDEA WAS IT TO GET A POV?

FIGUR 1 
SelflFamiIy (76%) 
MD (15%) 
Self & MD (6%) 
yL0  Oter (3%) 
Suppliers are aggressively marketing their product 
Some beneficiares descrbe suppliers' tactics as aggrssive, such as salespersons showing up 
at the door within minutes of a phone call from a patient, the withholding of information about 
the diffculty of maneuvering or lifting the POV into a car, and implying that the POV would 
not cost anything. 
Thiry-four percent of the 71 beneficiares contacted said they were told they would not have 
to pay anything for their POV.  ,. 

........
...
Physicians are playing a passive role in prescribing POVs 
A number of practices were noted which showed the physician s role to be a relatively passive 
one.  go along with it  role in prescrbing the POVs, signing authorizations 
' These include a 
after the vehicles have been delivered, feeling pressured by the patients or families to autho
rize a POV, not following-up on patients' use of the POVs and not having knowledge of Med
care guidelines. As shown below in figure 2, when the physicians contacted were asked 
whose idea is was to obtan a POV, hal responded that the patients rather than the physician 
had suggested the POY. Only 36 percent of the physicians said it was their idea. 
PHYSICIAN RESPONSES: 
WHOSE IDEA WAS IT TO ORDER A POV? 
FIGUR 2 
Patient (50%) 
MD (36%) 
D Do'tknowC/%) 
Oter  C/%) 
A review of the 1986 claims and authorization data showed that in one-third of the claims the 
POV was delivered to the beneficiar before the authorization for it was signed by the physi
cian. Since then, the Omnibus Budget Reconciliation Act (OBRA) of 1987 was enacted. It in
cludes a provision prohibiting Medicar payment for durable medical equipment unless the 
supplier has received a wrtten order from the physician before delivery of the item to the pa
tient. 
Several physicians in this study indicate that they received pressure from patients or their 
famlies to prescribe the POV. One physician said: 
The patient asked me twice during appointments and kept insisting how useful it 
would be for him.. .and then I conceded! Patients see these advertisements and pres
sure you to get the equipment. If you don t sign the form, the patient moves on to an
other doctor.
 .. 
Over half (53 percent) of the 28 physicians contacted said they did not know the Medicare 
guidelines for POVs. Of special note: while 38 percent of the physicians outside the four spe
cialties said they did not know the guidelines, 54 percent of the  specialty physicians
approved 
said they did not know them. One physician, who did not know the POV guidelines, made the 
following suggestion:

Medicare criteria should be clearly explained more to the medical population by car
riers so the basis of ordering equipment could be better understood." 
2. Medicare Should Not Have PaidforaMajori ofPOVs in 1986. 
Beneficiaries' phone respoi1ses apparently reveal most did not qualify for POVs 
Forty-four (62 percent) of the 71 beneficiares interviewed seem to have been inappropriately 
reimbursed by Medicar for their POVs. This resulted in estiated overpayments totaling 
$59, 162 (see appendix). Projecting this to the enti Medcar program in 1986 yields esti
mated overpayments of $5.9 milion. The responses of these individuals indicated that they 
did not qualfy for reimbursement since they faied to meet either one or both of the two pri
mar 
criteria, namely that the beneficiar cannot operate a wheelchair manually and the POV 
must be appropriate for home use. Table 1 summzes the results of these interviews. 
Table 1

Reasons Why Reimbursement Appears 
Inapproprie 
Reans Why Reimbursment  Number of Beneficiares

Appes Inappropriate

(a) Beneficiaes could 
operate a wheelchai manually 
(b) Beneficiares use the POV	 30**

outdoors exclusively

(c) Either (a) or (b)	 44 (=62% of71

beneficiaes)

benefciaries contacted 
.Based on a total of  71 
These 30 cases include  beneficiaries who did both (a) and (b). 
Twenty-two beneficiares told us that they had a wheelchair in their home which they could 
operate manualy, when the POV was obtaied. They did not mention any pain or diffculty in 
using it. In 6 of these 22 cases, prescribing physician certfication documents cited an inabil
ity to operate a wheelchair manually. The carer had no apparent reason to question the valid
ity of the physician s statement, absent conflcting information in carer fies. Thirt 
beneficiares said that their POVs were used exclusively outdoors. Eight of these 30 benefici
ares told us that they could both operate a wheelchai manually and used their POV outdoors 
exclusively.  As some of the beneficiares noted, the POV s were too big or too heavy to use indoors. The 
following are beneficiar responses on when and how they used their POVs (also called scoot
ers). 
I used the (standrd) wheelchair in the house. If I go to the Mall, I use the scooter. 
The scooter was better- it would allow her to go downtown. However, it was too 
heavy. She used the wheelchair up until a week before she died. 
The wheelchair was worn out. It was the reason I asked for a POV.. .I used the 
wheelchair inside and the scooter outside. 
Only one carer had an authorization form signed by the physician which included a question 
on whether the POV was for outside use only. 
Ten beneficiares, at the time of the telephone interviews in the summer of 1988, said they 
could wal without any assistance or with the assistance of a cane, a walker or crutches. 
Carrier documents for most beneficiaries fail to justify appropriateness of 
reimbursement 
The appropriateness of reimburement for the sample beneficiares was also assessed by re
viewing supplier clais and all documents signed by physicians including authorization 
forms, medcal necessity forms, letters and prescription pad notations. Such claims or physi
cian documents were avaiable for 62 of the 71 beneficiares interviewed. We looked speifc
ally at documentation concerning diagnoses and condition to determine whether the patient 
could propel a standard wheelchai manually, or had a need for a POV. Only some forms 
signed by physicians addrssed the patient s abilty to operate a wheelchair manually. Thir
nine of the 62 cases (63 percent) had a physician-signed document, indicating that the patient 
could not maually operate a wheelchai. However, as note above, only 6 of these 39 cases 
had been judged as inappropriately reimbured based just on the beneficiar  report abilty 
to use a wheelchair manually. In four of the six cases, where there was a contradiction be
tween physician and beneficiar response, the evidence clearly supported the beneficiar 
statement. 
Some carers' authorization forms reuested information from the physician in areas such as 
upper and lower extremity strength, or abilty to ambulate with or without assistance. 
Many beneficiares in our sample were diagnosed with the following diseases or conditions: 
multiple sclerosis  muscular dystrophy 
rheumatoid arhrtis  os teoarhri tis 
cerebral vascular accident  periphera neuropathy 
paraplegia  quadrplegia 
arriosclerotic hear disease  congestive hear failure 
diabetes  cancer 
chronic obstrctive pulmonar disease  below-knee amputation  tation. 
The records were reviewed by a physical therapist who was a member of the inspection team 
and experienced in rehabiltation and evaluating patients for wheelchairs. Based on her re
view, the 62 cases were divided into three categories, depending pn the adequacy of documen
The fIrst category, with nine cases, dealt with those contaning adequate information to sup
port the need for the POV. One patient, a bilatera below-knee amputee with severe periphera 
vascular disease and poor upper body strngth clearly would appear to require a POV. 
The second category included patients for whom it was likely that there was a nee for a POV, 
but where more information was needed to support a positive decision (14 cases). Several 
these were multiple sclerosis patients, who by the natur of the disease have weakess and 
poor endurance and would likely benefit from a POV. However, there was no additional infor
mation to indicate where and how much weakess the person had or whether a wheelchair 
could be manualy operated. One case showed a person with diagnoses ofpolymyalgia 
rheumatica, rheumatoid arhrtis, and diabetes. An attached medcal note cited  limited abilty

to propel a wheelchair  and indicated that the physician wante the POV to enable commu
nityaccess. More documentation might clarfy this clai's appropriateness. It should be 
noted that only one of these 14 cases was judged inappropriate based solely on the 
beneficiar s statement that he continued to use a wheelchai manually. 
The third category consisted of those patients whose need was not clearly indica ed from the 
less than adequate information available and more compellng evidence was necessar (39 
were patients who had a cerebra vascular accident with result
cases). Several of these cases 
ing hemiplegia. Additional evidence would be necessar to show that the person could not 
propel a wheelchai with the unaffected hand and foot as is often done by hemiplegic patients. 
Indication of perceptual and cognitive disabilty would also be helpful to show whether the 
wheelchai and also whether a POV could be safely used. 
person could manually propel a 
Some of the other diagnoses, such as low back pai, arhrtis, paraplegia or hip frcture would 
not in themselves indicate inabilty either to ambulate or to propel a wheelchai manually. 
However, in some of these cases additional information from the physician might support a 
nee for a POV. 
The results of this record review matched our fIndings based on the responses of these benefi
ciares that reimbursement for a majority of beneficiares studied was lik ly to have been inap
propriate. 
Predures 
Carrier Claims Review 
Weaknes Noted  In 
The key problem noted during the on-site visits to carers was the failure of most carers (six 
of eight) to routinely utilze medical personnel to review all POV claims as 
reuired by the 
Medcare Caers Manual. 
Another problem noted was the lack of informtion in the carers' fies for the claims OIG re
viewed on site concerning the specialty of the prescribing physician. The authorizing physi
cian must be practicing in one of four specialties or specific exception requirements must be  met. In 60 percent of these claims information was lacking on whether the prescribing physi
cian met the specialty requirment and/or whether the exception criteria applied. 
There was also no documentation in the fies of any of the carers visited that they had 
checked to see if the physician specialty exception applied because the 
beneficiar was unable 
to leave home, or because the specialist is more than 1 day s round trp from the beneficiar 
home.  RECOMMENDATIONS 
TO REDUCE INAPPROPRIATE PAYMENTS FOR POVs, HCFA SHOULD: 
I. Evaluate, and strengthen as needed, carrr implementaton of Medicare coverage 
provisions to: 
requirements and OBRA  1987 
a. use medcal staf to review each submitted POV claim for medical necessity, 
cert 
b. allow only  specialists to authorize these claims or cite the reasons for exceptions 
to this rule, 
c. ensure that payments ar made only for beneficiares whose medical and/or physical 
conditions render them unable to use a wheelchai manually and who need a POV for in
door use, and 
d. prohibit payment for durable medical equipment unless suppliers receive a wrtten order 
from a physician before the delivery of the item to the patient. 
HCFA COMMENTS 
Medicare Coverage Issues Manual, Par 3, Section 60-5 released in Februar 1988 and Med
care Carers Manual, Par 3, Section 4107.6 released in December 1988 already provide for 
each of these recommendations. 
OIG RESPONSE 
We question HCFA's citing Medicare Coverage Issues Manual, Par 3, Section 60-5, as a re
sponse to our recommendation that HCFA evaluate and strengthen as needed carer implemen
tation of Medicar coverage requirements. It was beause these Manual guidelines were not 
being adequately followed by carers visited, that we made this recommendation. 
2. Publicize Medicare coverage requirements to the medical community. This could be 
done by issuing instructions or letters to aU physicians, citing Medicare restrictions on 
POVs.  RECOMMENDATIONS 
TO REDUCE INAPPROPRIATE PAYMENTS FOR POVs, HCFA SHOULD: 
I. Evaluate, and strengthen as needed, carrr implementation of Medicare coverage 
requirements and OBRA 1987 provisions to: 
a. use medical staf to review each submitted POV claim for medical necessity, 
b. allow only cenai specialists to authorize these claims or cite the reasons for exceptions 
to this rule, 
c. ensure that payments are made only for beneficiares whose medical and/or physical 
conditions render them unable to use a wheelchair manually and who need a POV for in
door use, and 
d. prohibit payment for durable medical equipment unless suppliers receive a written order 
from a physician before the delivery of the item to the patient. 
HCFACOMMENTS 
Medicare Coverage Issues Manual, Par 3, Section 60-5 released in Februar 1988 and Medi
care Carers Manual, Par 3, Section 4107.6 released in December 1988 already provide for 
each of these recommendations. 
OIG RESPONSE 
We question HCFA's citing Medicare Coverage Issues Manual , Par 3, Section 60-
5, as a re
sponse to our recommendation that HCFA evaluate and strengthen as needed 
carer implemen
tation of Medicar coverage requirements. It was because these Manual guidelines were not 
being adequately followed by carers visited, that we made this recommendation. 
2. Publicize Medicare coverage requirements to the medical community. This could be 
done by issuing instructions or letters to all physicians, citing Medicare restrictions on 
POVs.  . .
APPENDIX A 
COST SAVINGS PROJECTIONS 
The data for this inspection were pulled from the 1986 HCFA Annual Data Base (BMA) and 
represent a 1 percent sample of al POV records for that year. One hundred and eighty-two re
cords were found. These records represented bils for 102 individuals. Accordng to an analy
sis of these bils, 44 of the beneficiares had overpayment charges totalling $59, 162. This is 
an average of $580 per beneficiar reviewed (stadad error of $79.48). The number of bene
ficiares in the universe with bils for POVs is estimate at 10,200. With this information, it is 
estimate that there is approximately $5,916,204 (stadad error of $810,699) in allowed over
payments in this population of beneficiares. At the 90 percent confidence level, the lower 
cutoff point of this estimate is $4 582 603 and the upper cutoff point is $7,249,805. The over
all precision of this estimate is 22.5 percent.  APPENDIX B

HCFA GENERAL COMMENTS AND OIG RESPONSE 
The HCFA provided the following general comments on the draft report: 
The OIG' s fmdings of inappropriate Medicar expenditures was based largely on telephone in
terviews with beneficiares not on claims reviewed, developed and, where appropriate, denied 
by carers. We do not believe that an evaluation which focuses on information solicite from 
beneficiares provides an accurate assessment of carer claims processing effectiveness. 
The OIG acknowledged that in 6 of 22 cases where beneficiares reportd they could operate a 
wheelchai manually when the power operated vehicle was obtaned, physician documentation 
cited an inabilty to manually operate a wheelchai. In these situations, carer medical review 
staff would have had no reason to question the physicians s statement assuming other docu
mentation relatig to the claim was consistent with the physician s certification statement. 
We acknowledge that the OIG' s study identified the existence of inappropriate expenditues 
agr 
for power operated vehicles. However, based on the focus of the review, we cannot 
any specific dollar amount of unnecessar expenditures that would be projected nationally for 
the period in question. 
OIG RESPONSE 
In response to HCFA's comments that our review "was based largely on telephone interviews 
car
developed and, where appropriate denied by 
with beneficiares not on claims reviewed, 
ers," we would note that our statistically valid random sample of claims included a review of 
all documentation as well as the conduct of telephone interviews. In the six cases cited by 
HCFA where beneficiares reported they could operate a wheelchair manually when the POV 
was obtained, even though the physician documentation stated otherwise, we assigned grater 
probative value to the beneficiares ' information in four cases based on our consideration of 
all available information and documentation. 
We ar satisfied that our projection of inappropriate expenditures is based on proper sampling 
techniques. We also do not believe that our projection of loss should be limited only to those 
cases where the carers would have had reason to question physician statements, assuming 
other documentation relating to the claim was consistent with the physician s certification 
statement.  . -