Complex Rehab Wheelchair Claims: Independent PT/OT Evaluation and ATP Involvement

Medicare fraud involving a complex rehab wheelchair can turn on a false independent evaluation or an ATP’s claimed involvement in selecting the chair. The clinician evaluates the patient’s need. The durable medical equipment supplier’s ATP participates in selecting the equipment in person. When sales staff write the clinical findings and a therapist supplies only a signature, the paperwork can describe work the clinician never did. The patient loses the clinical judgment meant to guide the choice of chair, and taxpayers pay for work that never happened.

What an Independent PT/OT Evaluation Means

An independent wheelchair evaluation comes from a qualified medical professional who has no financial relationship with the supplier. Medicare’s power mobility coverage policy requires this specialty evaluation for Group 2 power wheelchairs with power options, all Group 3 power wheelchairs and power assist systems. The evaluator can be a physical therapist, occupational therapist or another qualified licensed or certified health care professional.

The clinical work explains why the patient needs the equipment. Power mobility coverage concerns daily activities in the home, including dressing, bathing and toileting. The evaluation, the treating practitioner’s medical record and the supplier’s equipment selection each contribute something different to the claim.

For a wheelchair evaluation, a physical therapist paid by the supplier has the financial relationship the policy bars.

That division is particularly important in complex rehab. The business supplies custom power wheelchairs and seating for people with severe permanent mobility disabilities. The supplier has equipment expertise and employs technical staff. Medicare still requires the clinical evaluator’s financial independence from that business.

What Is the ATP Certification for Wheelchairs?

The ATP is an Assistive Technology Professional certified by RESNA, the Rehabilitation Engineering and Assistive Technology Society of North America. For the wheelchairs covered by this requirement, the supplier must employ an ATP who specializes in wheelchairs and has direct, in-person involvement in selecting the patient’s wheelchair.

ATP direct in-person involvement in a complex wheelchair claim means participation in the selection itself. A credential on the supplier’s staff roster does not describe what happened with a particular patient. The useful questions are who met the patient, what equipment they helped select and how that work appears in the claim’s supporting documents.

The employment relationship is part of the required arrangement: the ATP works for the supplier. The independent evaluator must have no financial relationship with that supplier.

The Supplier Template and the Physician’s Signature

A supplier template for a power mobility order may list the required elements, but the supplier cannot write the order for the treating practitioner. A physician’s signature at the end of a supplier-completed order leaves the central question unanswered: who supplied the clinical information and made the recommendation?

The same question follows the evaluation into the chart. A supplier’s proposed equipment, the evaluator’s findings and the practitioner’s order should describe the work each participant actually performed. Emails sending clinical wording for someone else to copy, evaluations prepared before the visit and different versions of an order can show how the file took shape.

In the complaint behind one of the Numotion cases, whistleblowers alleged that ATPs completed evaluation forms before therapists evaluated patients and presented the forms for signature. Another passage describes a therapist’s response when asked about the work behind her signature:

The allegation puts the problem plainly. The evaluation carried a therapist’s signature. According to the complaint, it carried none of her evaluation.

What Is a Standard Written Order?

A Standard Written Order contains six elements: the beneficiary’s name or Medicare Beneficiary Identifier, a general description of the item, the quantity, the order date, the practitioner’s name or NPI, and the practitioner’s signature. The supplier also needs the practitioner’s supporting medical documentation.

For equipment subject to the face-to-face and written-order-before-delivery requirements, the treating practitioner’s encounter must fall within the six months before the order date. The supplier must receive the order before delivery. Obtaining it afterward does not cure the earlier delivery.

The order rules changed on January 1, 2020. The former seven-element power mobility order, separate Detailed Product Description and 45-day examination window gave way to the Standard Written Order and the six-month encounter period.

The Centers for Medicare & Medicaid Services also eliminated Certificates of Medical Necessity for dates of service on and after January 1, 2023. The practitioner’s chart and supporting records still matter.

An Office of Inspector General review published in December 2009, examining claims from the first half of 2007, found that 30 percent of complex rehabilitation power wheelchair claims lacked a written specialty evaluation report. The chair had been billed, but the file lacked the report explaining the evaluation.

Where the Claim Can Break

The false account can begin in the evaluation, enter through an altered prescription or continue into delivery. The cases show why the signature, the equipment and the underlying work need to be examined together.

Numotion and Supplier-Written Evaluations

Numotion agreed to pay $13,500,000 in an August 2024 settlement resolving allegations that claims relied on patient evaluations unlawfully authored, completed or signed by its employees instead of qualified medical professionals. The settlement resolved three whistleblower cases.

The same whistleblower complaint quoted above alleged that Numotion’s software required a sales quote before the medical order could be completed. It alleged that expensive, unnecessary wheelchair components escaped medical evaluation before the order was confirmed. The accessories therefore belong in the examination alongside the chair: who selected each component, and what clinical work supported it?

A separate complaint in the settlement alleged that an ATP’s visit exposed a false delivery record. The paperwork said the patient had visited the office and signed for the wheelchair. The ATP found that the patient had not visited and had not received the chair. According to the whistleblower, a branch manager had falsified the documentation to permit billing by month-end.

That allegation shows another reason the ATP’s actual contact matters. The person who saw the patient could contradict the story in the supplier’s system.

Orbit Medical and the Altered Prescription

Orbit Medical and Rehab Medical paid $7.5 million in a May 2015 settlement over alleged alterations to power wheelchair and accessory documentation. Two former Orbit employees brought the whistleblower case and were to receive approximately $1.5 million of the settlement.

The government alleged that sales representatives changed dates on prescriptions and chart notes, changed prescriptions to establish medical necessity, created or altered supporting records, and forged physician signatures. They also allegedly added fax stamps to make documents appear to have come from physicians’ offices.

The fax stamp mattered because it supplied an apparent history for the document. The government’s allegations reached both what the prescription said and the appearance of when and where it originated. A signed page alone could conceal those changes.

Prior Authorization and Proof of Delivery

Prior authorization is a condition of payment for items on Medicare’s required list. The evaluation, order, supporting documentation and delivery requirements still apply to the claim. An authorization decision does not perform the independent evaluation or establish that the supplier delivered the billed equipment.

The supplier must retain proof of delivery. Medicare’s documentation requirements also prohibit a supplier, its employees or another person with a financial interest in the delivery from accepting the item and signing on the beneficiary’s behalf. The person selling the equipment cannot sign as the patient’s representative accepting it.

In its sentencing announcement in a wheelchair supplier’s criminal case, the Justice Department reported that the owner billed for a more expensive type of wheelchair while providing cheaper scooters or less expensive wheelchairs. The equipment delivered supplied a different story from the equipment billed.

For an insider, this connects the clinical file to the actual chair. The order identifies the equipment, the supporting records explain the need, and the delivery record accounts for what reached the patient. We examine the decisions behind those records with you, including who created or changed them.

Complex Rehab and Competitive Bidding

Congress excluded certain complex rehabilitative power wheelchairs and their accompanying accessories from Medicare competitive bidding. The competitive acquisition law later extended the exclusion to complex rehabilitative manual wheelchairs and specified other manual wheelchair categories.

The exclusion changes how Medicare buys the equipment. The independent evaluation, ATP involvement and supporting medical records still determine whether the claim meets the clinical requirements.

Does Medicare Pay for Wheelchair Repairs?

Medicare pays for covered wheelchair repairs, and accumulated repair claims can expose problems after the original delivery. In a July 2023 nationwide audit, the Office of Inspector General identified $30.1 million in potentially unallowable repair payments for enrollee-owned capped-rental wheelchairs within their five-year reasonable useful lifetime.

The audit examined $91.1 million in repair payments from January 2016 through December 2021. The questioned payments came after accumulated repairs exceeded a federally recommended limit of 60 percent of replacement cost. The Office of Inspector General said the excessive costs could indicate unreasonable repairs or substandard chairs that would not remain serviceable through their expected lifetime.

The Office of Inspector General recommended review of accumulated costs and system edits to flag repair claims for examination. For a supplier insider, the connection is the chair across its life: what was selected, what was delivered and what the business later claimed to repair.

When the Evaluation Does Not Describe the Work

If you are a therapist, ATP or supplier employee who knows how an evaluation became a claim, speak with our whistleblower experts about the work behind the signature. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. We work with you from the first conversation through the case, bringing in Medicare fraud whistleblower lawyers who know complex rehab wheelchair claims and building the strongest case your evidence supports.