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Perplexing Power-chair Policies

Reprinted from PN August 2008

Rapid changes are taking place. It's time to raise your voice and be heard!

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These are some difficult and confusing times for people who use powered mobility devices and for the clinicians and suppliers trying to help them obtain the most appropriate mobility. The sweeping changes implemented by the Centers for Medicare and Medicaid Services (CMS) will also likely be adopted by many private health-insurance companies. Unfortunately, consumers may be the biggest losers in the drive to reduce costs, under the auspices of providing adequate mobility, decreasing fraud, and improving the quality of services.

Let’s take a short step back a few years. Previously, CMS essentially had three commonly used, broad categories of electric-powered wheelchairs. The lowest one provided very basic mobility with only limited seating options, and limited or no programmability. These chairs were largely provided to older people with mobility limitations. The other two categories were commonly called “rehabilitation products” and provided to people with various disabilities. The middle one allowed a range of seating options, power bases, and programmable features.

The upper category included expanded outdoor mobility, complex power seating functions, sophisticated user interfaces, greater controller programmability, and accommodation for such things as respirators. In some cases, this category was used for larger people weighing more than chairs in the other categories could support.

This system worked for years but had two serious faults. The first was that most powered wheelchairs grew to be lumped into the middle category even though their features and quality could vary greatly. The second was that no face-to-face assessment by a licensed, certified medical professional was required in many situations other than just a prescription and certificate of medical necessity signed by a physician. Therefore, cases began to grow where people received their powered wheelchairs without proper assessment. Hence, more individuals started receiving wheelchairs that did not meet their needs. This was further compounded by a surge in use of powered mobility devices partially due to direct-to-consumer advertising and pockets of fraudulent provision by unscrupulous suppliers and physicians.

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Reform was arguably necessary. Therefore, CMS held a series of hearings, hired a number of consultants, and started to create new categories and subcategories. The goal was quite logical: provide a clearer system so beneficiaries receive the technology they need.

The Centers for Medicare and Medicaid Services (CMS) introduced the following primary coding groups for power chair

Group 1:

Minimal performance of mobility-related activities of daily living, these provide only captain’s-style seat option and are intended for limited or intermittent use

Group 2:

Intended for continuous use, within specific user weight subcodes, and offer a captain’s seat or a solid seat frame. Must offer single or multiple power-seat options (tilt, backrest recline, elevating legrests).

Group 3:

Have performance characteristics intended for continuous use by active people and offer the same seating options as Group 2. These chairs are linked to specific diagnoses codes.

Group 4:

Power wheelchairs with even greater mobility performance characteristics primarily directed at increased outdoor mobility. Because the expanded functions address mobility not essential for in-home use, Medicare provides similar payment for Groups 3 and 4 devices.

While not perfect—few systems are—the new approach to coding is in principle a step in the right direction. In the grand scale, powered wheelchairs were divided into four categories. This was accomplished by essentially splitting the middle category into three groups. The upper category was tweaked, and some of the configurations were incorporated into Group 3; other products with enhanced outdoor capabilities were placed into Group 4 and are not covered by Medicare and many other payers due to the “in-the-home” use policy restriction.


On the surface, it looks simple enough. Three categories became four, and the bottom one was eliminated or upgraded, depending upon your perspective. The new system also includes a large number of sub-codes (64 unique ones) in order to precisely specify products. (We won’t go into the subcodes here.)

CMS addressed the issues of face-to-face assessments by requiring that a qualified clinician see a client in person and make a recommendation. For a time, CMS proposed recommending defining clinicians’ qualifications as holding the Assistive Technology Practitioner (ATP) credential from the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) in order to obtain more complex power wheelchairs. However, during the public comment period, this definition was replaced by “a licensed or registered therapist or physician.”

The face-to-face assessment with a therapist does not apply to basic Group 1 powered wheelchairs or scooters, as they are thought to be simpler and used by people who are less impaired than users of the other category electric-powered wheelchairs. Beneficiaries, however, must be seen by a physician (face-to-face) for an assessment related to mobility issues in order to qualify for any Group of powered mobility devices. A therapist’s assessment is needed only for more complex equipment, and the new policy requires that complex power chairs be provided by a supplier with the RESNA Assistive Technology Supplier (ATS) credential.

Bidding Wars?

As these things go, a new coding system also includes a new payment structure. The payment structure seeks to reduce the reimbursement across the categories and attempts to stratify payment across them. In 2006, reimbursement was reduced 8–25% depending on the Group and code. A growing concern is that people with disabilities will be unable to get a Group 2–4 electric-powered wheelchair or, more likely, will receive a lesser-quality product as manufacturers and suppliers attempt to maintain profit margins. Therapists and physicians are compensated for their time for the services they provide, whereas suppliers and manufacturers must recoup their costs through the price of their electric-powered wheelchairs.

In order to once more minimize costs, CMS has started to implement competitive bidding in various regions throughout the country. From the viewpoint of an insurance provider, obtaining an electric-powered wheelchair from the lowest bidder may make sense—but it also assumes the majority, if not all, of such chairs are in most respects the same.

Of course, this is not true. Simply try comparing the driving performance of a front-wheelchair-drive to a center- or a rear-wheel-drive base. Each has unique performance characteristics and meets the needs of different individuals. The same is true for seating systems. Some are more appropriate for certain users than others; similarly with controls.

Competitive bidding also makes the implicit assumption that all chair suppliers are the same. Anyone who has used a wheelchair for any substantial length of time knows this is not true. Suppliers vary in expertise, service, experience, and commitment to their customers and the profession. As many of you know all too well, the supplier is a critical link for adjusting, servicing, and maintaining your electric-powered wheelchair.

In May 2008, the U.S. House of Representatives Ways and Means Subcommittee on Health Care held a public hearing on national competitive bidding for selected durable medical equipment prosthetics, orthotics, and supplies (DMEPOS), which includes the type of equipment many people use and depend upon:  scooters, standard and complex power wheelchairs, and seating and positioning components.

Because many suppliers who submitted bids were disqualified, quality is not well defined, and access to qualified suppliers by consumers is a concern, the committee and its chair, Congressman Pete Stark (D–Calif.), posed a number of questions to Acting CMS Administrator Kerry Weems regarding implementation of the program. They even went so far as to say it may need to be revisited and perhaps abolished due to the flaws.

 Peter Thomas, of the ITEM [Independence Through Enhancement of Medicare] Coalition and CCD Health Task Force, provided some excellent testimony on behalf of several disability organizations and the impact competitive bidding would have on people with severe disabilities. Tom Ryan, an American Association for Homecare member, offered well-thought testimony on the impact competitive bidding will have on suppliers and the way beneficiaries will be served.

At the end, Congressman Stark indicated legislation may be needed to resolve the issues of competitive bidding. However, he said the means to achieve this may be for the industry to absorb a $6-billion reduction in CMS reimbursement over the next five years, as this is what CMS has estimated the competitive bidding program will save.

The challenge remains to get legislation through the House and Senate to recognize the expertise required for complex rehab equipment and to serve people with severe disabilities and exempt complex rehab equipment from competitive bidding. H.R. 2231 is intended to address the issues of competitive bidding for people with disabilities who need complex rehabilitation equipment (such as active-use wheelchairs and electric-powered wheelchairs for those with severe disabilities). However, as of press time, the bill still needs cosponsors in the House. The Senate has introduced a companion bill, S.2931. For those of you who do not believe Medicare policy affects you, keep in mind that this program will have a rippling effect across all payers and all providers in the United States.

Veterans’ Advantage?

If you receive your electric-powered wheelchair from the U.S. Department of Veterans of Affairs (VA), you may have greater flexibility in equipment choice. VA is not bound to follow CMS policies and currently has more enlightened guidelines for the provision of electric-powered wheelchairs. The department implemented competitive bidding for wheelchairs several years ago but included an exemption for complex rehab equipment and for people with severe disabilities such as spinal-cord injury, traumatic brain injury, polytrauma, and limb amputation. This allows eligible veterans to receive the full range of devices to meet their mobility needs.

However, CMS purchases considerably more electric-powered wheelchairs than VA does, and many private insurance providers follow CMS’s lead in developing their policies. Therefore, veterans could be impacted simply because of market pressures that may reduce the availability of complex rehab wheelchairs.

For example, if the number of units sold drops precipitously, a manufacturer may discontinue the product. This is likely to occur at least in a few cases, especially since manufacturers already discontinued and introduced new products or at minimum redesigned products in response to CMS code changes.

Rapid changes are taking place regarding electric-powered wheelchairs, and it is time for consumers to raise their voices and be heard. Whatever your opinion, you’re likely to be impacted in some manner.

Contact: Human Engineering Research Laboratories, www.herlpitt.org.

 

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Perplexing Power-chair Policies

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