Who oversees Medicare medical equipment benefits?

in /Ask Phil by

Jon – Ind.: I have been disabled for several years and on Medicare, and recently had to repair my wheelchair. I have gone to almost every durable medical equipment (DMW) outlet in Indianapolis. None of them will even help me order parts or cover. When I ask them if Medicare would cover a new wheelchair, all I get is a huge NO. This is the only chair that has worked for me. Just because I’m disabled doesn’t mean I do not want to be as active as possible.

Phil Moeller: I’m sorry you’ve had such a hard time. I don’t pretend to understand all the details of wheelchair standards, Medicare rules, and the craziness of DME suppliers. But I agree that the system often seems to deny the best long-term solution in the interest of saving a few bucks today.

I don’t know what kind of Medicare you have. If it’s only Parts A and B, then your claims are not handled by an insurance company but by the Medicare administrative contractor (MAC) who oversees the part of the country where you live. These businesses are hired by Medicare to handle claims, with their approval and denial process based on Medicare coverage rules.

The A-B MAC for Indiana is the Wisconsin Physicians Service Insurance Corporation. There also is a MAC for durable medical equipment. In Indiana, that MAC is CGS Administrators, LLC,.

In my experience, the actual DME suppliers are not really the decision makers here, but are only following what they’re told by the MACs. The MACs, in turn, usually point to the Centers for Medicare & Medicaid Services (CMS) in Washington as the final decision-maker. This often appears to be an effort to pass the buck, as neither the MACs or CMS can be easily held accountable by consumers.

I don’t know if you’ve been turned down for this coverage by the MAC where you live. I also don’t know if your physician(s) have prescribed this particular wheelchair as medically necessary. If you have committed doctors on your side, they can make a big difference in reversing Medicare coverage denials.

There are two Medicare nonprofits I deal with that might be willing to help you with your claim. I should warn you that they are overwhelmed with consumer demand, but perhaps they have encountered your type of problem before and can give you good advice. They are the Medicare Rights Center and the Center for Medicare Advocacy.

Please let me know how things go. I wish you the best of luck, and admire your efforts to overcome the challenges caused by your disability.