Access to complex rehab technology — medically necessary, individually configured wheelchairs, seating systems and components — continues to be threatened by Medicare reimbursement cutbacks. Because private insurance companies tend to use Medicare policies as guidelines, this affects all wheelchair users. Yet there is a widespread misconception that complex durable medical equipment is overpriced. People sometimes compare the price of high-end power and manual chairs and components to cars and bicycles. Quite simply, these are apples-to-oranges comparisons. To clarify the issue, we looked at some of the expenses involved in bringing complex rehab DME from original concept to the end user.
Research, development and design is the first step in creating equipment that addresses the orthotic support, proper fit, and skin protection that is so important to wheelchair users every day. “Complex rehab products are not commodity items that you pull off a shelf,” says C5-6 quad Josh Anderson, vice president of marketing for Permobil and former head of product management and marketing for TiLite. “Whether it’s a manual chair custom made for an individual or a custom-fit power chair where you can dial everything in to an exact fit — like a controller or a headrest that is specific to a person’s needs — the design of each part is about maximizing ability. It has to fit the person like an orthosis.”
Most people with SCI sit in their chairs an average of 11 hours per day — ranging from five to 16 hours. Neither cars nor off-the-shelf bicycles are designed to custom fit and support a person so intimately and uniquely. Car seats, for example, do not provide the skin protection that many wheelchair users need, so we have to sit on our wheelchair cushions while driving to avoid dangerous pressure sores. As for bikes, the most appropriate comparison to complex rehab manual chairs are custom-fit bikes, which start at around $3,800.
Economy of scale is another huge difference. “Permobil U.S. and TiLite produce approximately 20,000 power chairs and 20,000 high end manual chairs respectively per year,” says Anderson. “These quantities are not enough to bring the price down.” For comparison, in 2013 GM alone had U.S. vehicle sales of 2,700,000. That same year over 18,000,000 bicycles were sold in the U.S.
Product testing and FDA approval is another costly and lengthy manufacturer expense. Wheelchairs must pass testing by the Rehab Engineering and Assistive Technology Society of North America that represents five years of use. John Goetz, government affairs manager of Permobil, says RESNA testing includes loading test chairs to maximum weight capacity and rolling 200,000 cycles on round drums with half-inch metal curbing built into them. Also, the chairs are dropped from a height of 6 inches 6,666 times. Power chairs must pass additional tests, including speed, braking, stability, obstacle-climbing and numerous electrical system trials, including battery and controller tests. Test results and design documentation are then submitted to the FDA for review. A chair can’t be marketed until it gets FDA approval.
Then there are the ongoing costs of running a business, which include — besides the usual daily overhead costs — paying accountants, attorneys, and employees like Goetz, who must stay abreast of all the latest legislation and CMS (Medicare and Medicaid) requirements.
What the Dealer Does to Get Your Chair
When a wheelchair product is ready to sell, DME dealers that specialize in complex rehab products must provide extensive customer service that goes above and beyond other types of retail stores.
An assistive technology professional must work with wheelchair customers to make certain they get the most appropriate custom rehab equipment. RESNA requires a lengthy apprenticeship before an ATP can qualify to take a four-hour 200-question test on knowledge of disabilities, complex rehab equipment, diagnosis, and funding. Continuing education is also required. “Under Medicare guidelines, basically any piece of complex rehab equipment has to be delivered by an ATP,” explains Dave Kruse, an ATP employed by Bellevue Healthcare in Portland, Oregon, who is in his 40th year supplying complex rehab DME to clients.
“It takes a huge amount of time, driving and paperwork to get a piece of equipment to a client,” says Kruse. “For each ATP, we employ three full-time office support people.” This includes a direct support specialist who knows insurance coding, how it is handled, what documents are required, and what each type of insurance will and won’t pay for. Also, a funding coordinator, and a reimbursement specialist.
“Per Medicare guidelines, if a wheelchair user needs a cushion, back, ultra-lightweight manual chair or power chair, an ATP must attend an assessment with the wheelchair user at a seating clinic done by a physical or occupational therapist,” says Kruse. The average seating clinic eval is 1.5 hours plus drive time. Following the evaluation, the ATP writes up notes on the equipment that the therapist has determined, then gets price quotes from manufacturers, which all goes in a file.
“For a manual or power chair we are required to do a home assessment which means measuring to make sure the chair fits in doorways, etc.,” says Kruse. “If it is a first-time wheelchair user or they are getting a different model of chair, I take a demo to the client’s home for them to try — for anywhere from an hour to a few days — to make sure the chair fits and works in and around the home.” After this, the ATP’s documentation is turned over to the direct support specialist.
The direct support specialist checks documentation and contacts the physician — to get the client’s history and chart notes — and the therapist for their notes on why they need the specific equipment. The specialist also requests a prescription and/or letter of medical necessity explaining in specific detail why they need the equipment, then reviews the documentation, particularly the letter of medical necessity to make sure the wording is exact so insurance doesn’t deny the claim. The specialist may need to request additional documentation or a rewrite of the physician’s letter. At times follow-up calls and paperwork go back and forth between the doctor three or four times before it is right.
The funding coordinator then receives the documentation file and re-checks everything and writes up the information. If the client has private insurance, documentation is submitted along with a request for pre-authorization — to guarantee payment. If the request is denied, the reimbursement specialist reviews everything and submits paperwork to request a hearing to reconsider. “Medicare generally doesn’t do a pre-auth,” says Kruse. “It is the reimbursement specialist’s job to make sure all the documents support the coding requirements, which are kept on file in case the claim is denied. Medicare can deny payment after receiving the invoice, or years later they can audit invoices and if the documentation isn’t perfect, Medicare can make the dealer return the payment.”
After many hours of work by different full time DME specialists, including constant reviewing of all information and paperwork, the ATP goes over the order with the client, explaining any co-pays or items that aren’t covered. Documents are signed and the order is placed. “With Medicare there is a bond of trust that the client will cover the 20 percent co-pay and a leap of faith that all of the paperwork is perfect and Medicare will pay for it,” says Kruse. “But co-pays can be difficult. If the client doesn’t have the money up front, you can set up a payment plan, but other times we have done all the legwork and paperwork to get approval, and then the client decides they can’t afford the co-pay.”
Delivering the Goods
When the equipment arrives at the DME dealer, it is then set up for delivery. Manual chairs often require minimal set up, but a power chair with a complex seating system such as power recline and/or tilt-in-space requires time-consuming assembly by a technician. The final step is delivery of the wheelchair to the client’s house for final set up and adjustment by the ATP — and getting the client’s signature before a bill for payment can be submitted.
After this lengthy, time-consuming process of customer service, jumping through hoops, and checking and re-checking documentation, it is not uncommon for payment to be denied by Medicare or private insurance. Of course this means appeals and more paperwork. “You can spend just as much time fitting and getting funding for a small piece of complex rehab DME, say a headrest that may cost a few hundred dollars, as you do on a wheelchair,” says Kruse. “You are probably never going to financially recoup your time, but it makes all the difference for the client, and that is what this business is all about.”
After equipment is delivered, customer service continues in the form of maintenance. “Clients generally don’t realize how dedicated people in the industry are,” says Kruse. “If I get a phone call from a client who needs a repair or has a flat tire on a power chair, I will go fix it after-hours or on a Saturday because I know they won’t be moving until I handle it. This usually costs me, not only time away from my family, but also because Medicare doesn’t reimburse calls to fix a flat tire. Other insurance companies require a preauthorization — how do you get a pre-auth on somebody’s broken down chair on a weekend? This is an industry you get into because you care about helping people. You aren’t going to get rich, but like any job, you have to make a living, which is becoming more difficult as funding continues to get cut.”
When you consider all of the expenses involved in getting the correct complex rehab DME to wheelchair users, prices for equipment that is so important to us are very reasonable. Continued pressure to reduce reimbursement is a very real threat to not only gaining access to wheelchairs, but also a threat to our health and mobility.
• ATP Eligibility Requirements: www.resna.org/get-certified/exam-eligibility-requirements
• Manual Wheelchair Use: Bouts of Mobility (sitting time per day): www.hindawi.com/journals/rerp/2012/753165/
• National Registry of Rehabilitation Technology Suppliers: www.nrrts.org
• Characteristics of Power Wheelchair Use (sitting time per day): www.scireproject.com/book/export/html/1252
• What is Complex Rehab Technology (CRT)?: www.nrrts.org/pages/what-is-complex-rehab-technology-crt