What can you do to help fix Funding for DME.

The item coalition, as well as NRRTS, RESNA, NCART, and countless other groups and manufacturers have been fighting a battle for the mobility challenged community. For years, it has been up to our industry to police itself, and there have always been a few bad apples that have ruined our system, reducing our credibility and have forced CMS to take action. As a long time supplier, I remember the signs “FREE LIFT CHAIR”, which providers abused until Medicare blocked the code, and made it difficult for consumers to get these items.

Over the past few years, since powered wheelchairs have become fashionable and attractive; suppliers had found a loop hole which could be very lucrative. We have all seen the people who receive powered wheelchairs, but can still walk. We have also recently witnessed many providers becoming indicted for billing for this equipment and never providing it to their patients.

I have repeated over the years, to my congressman, to organizations, consumers, and professionals; that the only solution is to rid the industry of its bad apples. The problem stems from the manufacturers, who see increased demand of their equipment through outlets who do not offer service, customization, or any choice to the consumer. If manufacturers demanded their suppliers were credentialed, and provided adequate service with the capacity to follow up the product; our industry would be very professional and respectable. Instead today, suppliers are looked at as people you cannot trust; and only in it for the money.

There is a genuine concern about the competitive bidding program that Medicare is initiating. As a supplier my concern is that to put something out for bid in an industry which is already providing (in many cases) substandard equipment; the allowable for equipment will plummet. Competitive bidding means that in a community all providers bid their lowest price they can provide a service for. Since many suppliers are providing non-US equipment, the price ceiling would most likely be set for these lower imported products.

The obvious concern here is that when reducing costs so much, what happens to the service. What many individuals do not understand is that most equipment that is provided (by responsible providers) requires an assessment from the provider, with a team consisting of a physician, therapist, and family to provide the best solution for the patient. When you set a capped amount on equipment, both the choice of equipment and the specialty of customizing, and fitting a mobility product will disappear.

What most people don’t know, is that most physicians and therapists are not familiar with equipment and depend on the supplier they are working with to recommend the most appropriate equipment. In reality the equipment that is being prescribed, is left up to the supplier to choose. When you reduce the funding, and reduce the choices, you will lose the specialty providers; and have only a delivery system. Would you rather a delivery person drop off your equipment, or a specialist who can instruct, train, adjust, modify and make suggestions to you?

The competitive bidding issue still has a long battle ahead, as there are too many uncertainties; like if you award a company a particular demographic; and they turn out to be a bad provider; what is the recourse. When you award one provider the work for an entire area, you will certainly force many of the other providers out of business. So how do you replace a provider that fails to perform?

The larger picture may be that by providing cheaper products that will be outsourced to non US countries, our Gross National Product declines. To spend billions of US dollars on healthcare for most of that revenue to be sent outside the US , is not good for our country. Even worse, is the amount of unemployed, skilled workers from local equipment suppliers, and from national manufacturers.

Now is the time to get involved, voice your concerns to legislators; tell them of the importance of local providers who can supply, fit, repair and customize products. Nothing in this world is free, when you see these ads for free power wheelchairs, no cost to you, qualifying people who can still walk- turn them in to Medicare. We cannot be blind and turn away as this problem is not going away; and when you need Medicare benefits they are not going to be there.

This article was provided by Carey Britton, seating and mobility specialist for Active Mobility Center. He can be reached at 954-946-5793 or at cbritton@wheelchairguys.com

What Can You Do to Help Make a Positive Change

If you know me, you know that I attempt to do the very best at whatever I choose to do in life.  In regards to my work, I am passionate about helping others through Seating and Mobility.  Over the past few years, there has been an attack by CMS/Medicare on this small industry that positively affects so many people; allowing them to live a more productive and independent life.  With the help of Active Mobility, I have been able to spend time advocating and lobbying for access to these services.

The number one (1) complaint that we here at Active Mobility Center, is that it takes too long to receive new equipment, and that the hoops needed jump through are unbearable.  As an industry we have done a poor job educating the public on how to advocate for themselves. We, as a collective group, always want to satisfy our customers, avoiding all the negativity of the increasing pressures.  When there was more of a margin/profit on medical equipment, we could hire more staff and facilitate equipment faster; however now with these changes- we have to do more with less.

These increased funding pressures, combined with the amount of requirements now to qualify and prior authorize equipment is making this process much more lengthy. CMS/Medicare had created new watch dogs who are bounty hunters only profiting by finding errors in paperwork, so suppliers have to spend much more time on the details; than the actual equipment provision.

Over the past few years, you may have heard of a program called competitive bidding. This program, no longer only a Medicare problem; has been finding it's way into the private sector; and if Obama's plans go into affect in 2015, will affect state medicaid programs. 

As of April 1st 2014, Manual Tilt in Space wheelchairs as well as some other DME products will become capped rentals. Many providers have already voiced their concerns that they will no longer be able to accept this and will no longer provide these services.

Equipment providers can no longer afford to be the sole Advocate for the users of medical equipment. The pressures exerted have taken the profit out of the system and where equipment users will need to get involved to avoid access to these services.  There are many ways that you can get involved, from contacting CMS/Medicare, your state and local representatives, or attend lobby groups to show how important this is to you and others.

Staying in touch through NRRTS.org, NCART.us or other similar organizations can help guide you and help your voice be heard.

This article was written by Carey Britton, ATP/SMS, CRTS for Active Mobility Center. He can be reached for comment at cbritton@wheelchairguys.com or at 954-946-5793.

Powered Wheelchairs and Medicare Guidelines

Medicare Guidelines for Powered Wheelchairs

Let's start by stating that Medicare (CMS) is operated by the Federal Government, they set codes and fee schedules to all Medical Equipment and Services.  They determine what is appropriate and necessary based on reported information about the patient.  With any government agency there are requirements to meet their determination of medical necessity.  All other insurance providers follow the governmental plan, so everyone should be concerned when Medicare makes a change.

Mobility Related Activities Of Daily Living

This is a fancy way of saying what you do in a day. MRADLs as they are commonly called, need to be reported to any insurance as this is how someone at Medicare can create a mental picture of the beneficiary needing the equipment.  Although Medicare is diagnosis driven, there is a lot of variance within a diagnosis. One person with MS (Multiple Sclerosis) maybe ambulatory, and the other in a multiple function powered wheelchair. Mobility Related Activities of living is a list of items that you can and cannot provide without the equipment being recommended.

For an individual who cannot ambulate, getting around the home is a challenge. Additionally they may or may not be able self feed, toilet, transfer, get out of the home, or some other activity of living.  These items help justify or deny the new equipment needed.

Medicare Hierarchy of Equipment (Complexity)

You may have heard Least Costly Alternative to solve medical needs. This is true with Medicare andstandard wheelchair, then light weight wheelchair, then ultra light weight wheelchair, then scooter and finally a powered wheelchair.   The powered wheelchair is on top of the mountain and as such requires the most documentation to support the need.
all insurance providers. They have created a chart, from basic to complex equipment that is easy to follow.  If you cannot ambulate, you may use cane, if a cane does not provide enough support, maybe a walker or crutches will help. I this does not allow you to perform your activities of daily living, then a

A Good Medical Equipment Supplier

This has never been as true as it is today.  In the past your supplier was just that a company who provided and serviced the equipment. With all the new rules/requirements,  your equipment company will navigate the system and reduce the amount of time involved.

Documentation Requirements

This is where you need a good team to help you. Documenting and Submitting a request to Medicare is a challenging process, and over the past few years has gotten much more difficult. You will need to find a supplier that will help guide you through this process.

Medicare now requires a Face to Face (F2F) visit for all powered mobility equipment. This requirement will soon affect most other medical equipment as well.  The Face to Face is a visit with
your physician where you are present, and where the reason for the visit is to discuss Seating and Mobility Equipment.  The physician must document what he does in a normal visit; vital signs, list of conditions, list of needs, etc.  The physician must document your ambulatory status, your need for assistive technology ranging from the cane, walker, wheelchair, scooter or powered wheelchair.  He must document how you presented to him in the office.  If you physician has a challenge with the level of documentation required, they may refer you to a physiatrist (physical medicine doctor), or a physical or occupational therapist who can further describe your conditions.

In today's medical model, most physicians are not familiar with seating and mobility equipment, so after they provide the Face to Face document, and 7 Element Prescription, they generally refer a patient to a physical or occupational therapist. 

During this therapy evaluation, the equipment supplier should be sending their RTS (Rehab Technology Supplier) to be present to be part of the team who assesses and recommends the most appropriate equipment to fulfill your mobility needs within the Insurance Guidelines.

The therapist is responsible, through their letter of medical necessity (LMN) to paint the picture of the mobility and functional status of the patient. They will document the patent's range of motion, their posture, and ability to reach and perform daily activities of living.  This document will be very detailed and is what the insurance reviewer will be looking for to approve or deny the equipment requested.

From this point, the RTS will print out all the manufacturer order forms, and create a detailed product description. This lists all the equipment the patient requires, based on the assessment, and lists the insurance code that references the item. This report will be sent to the therapist who will ensure that the LMN discusses each item listed, and will send their LMN back to the supplier.  The supplier will send the LMN, along with their reports back to the physician for review and signature.

Once all documents are received, they are sent to Medicare for prior authorization.  When Medicare responds, it is either with an approval, denial or request for more information.  If approved the equipment is ordered, of denied, an appeal can be submitted. If more information is requested, the supplier with the beneficiary's help can gather more information from the physician and/or therapist.

Time Line

This can be a lengthy process as there are many professionals involved. Beneficiaries need to have patience through this process.   Prior to the F2F requirement equipment was evaluated, and approved within 30 days.  Unfortunately this is no longer the case.  Physicians are busy, and getting an appointment can take weeks, waiting for the documentation from the physician can take time, if they send you to a specialist; between scheduling and reporting this can take weeks.  Waiting for an authorization has taken up to 30 days. Additionally several weeks;  ordering, assembling and scheduling for delivery.

Provider Certifications

Medicare requires a minimum certification to assist with Powered Mobility Equipment evaluations.  This requirement is expected to be increased; and at the time of this article it is a ATP; Assistive Technology Provider. This staff member must be present and involved through the evaluation of the equipment.  You should know that there are providers who have higher qualified and trained individuals above the ATP.  These individuals are the SMS and CRTS  SMS stands for Seating and Mobility Specialist, where they have went beyond the ATP and trained to the highest standard.  The CRTS, Certified Rehab Technology Supplier, is harder to receive, and shows the commitment, dedication and experience.

Five Year Rule

Like most insurance providers and DME (Durable Medical Equipment), the life expectancy of the usefulness of the equipment is five years.  This means that Medicare will not fund a replacement for this term.  There are exceptions to every rule, however short of a theft, or natural disaster; a beneficiary will wait five years to receive new equipment. In the event the equipment you have no longer solves your mobility equipment, you may be eligible for equipment that his more complex.

Service and Follow Up

With any mobility equipment, your supplier needs to be your friend. They will be needed for maintenance, service/repair, and for modifications to your equipment over the five years. Prior to several changes, it was easier to switch providers after receiving the equipment. Since the equipment supplier has the documentation sent to Medicare for support that the beneficiary needs the equipment, a new supplier may require to you go back through the process as Medicare audits all providers. If the service provider cannot prove the equipment the beneficiary is using is medically necessary (has all the documentation from the doctor/therapist/etc), then Medicare could recoup the funds. 

All Insurances are following these guidelines, and for this reason beneficiaries must be more involved and aware of this process. There has been a lot of change, and continues to be changes at Medicare that affect your ability to receive quality equipment.

This article was written by Carey J. Britton, ATP/SMS, CRTS with Active Mobility Center. He can be reached at cbritton@wheelchairguys.com or (800) 326-4463.

Is a Wheelchair is a Medical Failure ?

I was appalled when I first heard that a Wheelchair is a Medical Failure. Apparently in the Medical Model, it is taught that when resorting to long term use of wheelchairs and other mobility devices, that you have given up.

It is not surprising then, that the community perspective is that a person in a wheelchair is lame, an invalid, or handicapped....all negatively describing a person's DISABILITIES. This is also why that Prosthetics are much more acceptable, even when they are not as functional.

It may come at a surprise, but mobility equipment is provided not for mobility or independence but to reduce the medical costs associated with an individual stuck in bed. It is clear that a bed bound individual will cost the Health care system more than what it costs to get them out of bed.  Cushioning and Positioning is not for the comfort of a wheelchair user, but to reduce injury, reduce skin breakdown and to reduce contracture and deformity.  We look at this equipment to increase function, independence and quality of life, but the funding sources (all based on Medicare's policy) does not.

Therapy services for individuals with long term mobility challenging conditions are limited. It seems that the Medical Model if there is not documented gain in function then therapy services are not needed. After spending over 20 years in this industry, the question should be without therapy services how much loss will occur. 

Medicare who creates Medical and Equipment Standards, approves equipment based on use within the home and has little flexibility about looking at equipment for recreation and vocation. 

In my 20+ year career, I have seen huge change.  I am concerned with the changing policies that more equipment users need to voice their challenges and their victories.  Not unlike the Women's Rights Movement, where women didn't have a voice, and where they were stuck in the home; equipment users deserve the same. 

If this article has moved you, I encourage you to look at www.usersfirst.org, or www.ncart.us and get involved, share your story, and be heard.  You can reach Carey Britton, Seating and Mobility Specialist at Active Mobility Center at 954-946-5793 or cbritton@wheelchairguys.com .

One More Reason to be Angry with Medicare !!

If you are a user of DME and Mobility Equipment, here's another reason for you to be upset !It's official, Medicare has reclassified Tilt in Space manual wheelchairs, powered assist wheels, and pediatric wheelchairs as capped rentals.  This was released late on Friday....Happy Thanksgiving?

This will, if implemented, certainly affect access and the quality of equipment provided to people with significant special needs. 

Tilt in Space Wheelchairs- many of you know that tilt in space wheelchairs, are specialty wheelchairs, that require a face to face visit, a specialty evaluation from a therapist and an ATP to be involved. These tilt in space wheelchairs involve specialty seating and positioning equipment and require a high level of technical experience from the equipment supplier to ensure the most appropriate equipment is provided.

The costs associated with having ATPs and Technicians to provide and support for this equipment have now tipped the scales.  Tilt in space wheelchairs are near $3000, with all the documentation, and expenses required to provide this equipment, suppliers will now be forced to accept ~ $250/month.  How many equipment suppliers can wait 7-9 months to recoop their investments on wheelchairs that are custom ordered and fitted to a individual?

Most specialty providers have already been excluded out of  much of the DME program (Durable Medical Equipment), where the new round of competitive bidding recently gave access to all standard wheelchairs to winning bidders.  This was a huge blow, as the winning bidders of this equipment do not (in most cases) have ATP certified technicians, leaving these companies to determine which wheelchair is right for which person. In the past month, we have already heard nightmares about people receiving inappropriate equipment, which is negatively affecting lives and function.  Tilt in Space wheelchairs in the rental market will cause suppliers to rent used equipment, or inferior equipment to fit an allowable and not the person.

Powered Assist Wheels- are a low utilized technology allowing powered assist wheels to be added to a manual wheelchair when a user has difficulty propelling a manual wheelchair. These powered options are near $5,000.00, suppliers will likely not be able to afford providing and waiting nearly a year to recoop their capital investment.

Pediatric Wheelchairs- are generally not covered under Medicare with few exceptions. Any individuals who fall into this area may lose access entirely.

I encourage you to watch this development closely and speak out before it is too late.  Medicare has already ruined much of DME program. What happens with Medicare becomes standard with private insurance and medicaid. Babyboomers should be very scared, as they are watching services disappear.

With Medicare's war on DME, it is curious to see what is left in 2014.  There are less than 50% of the quantity of providers of this equipment only 2 years ago.  This new round of bidding that goes into affect January 1st will likely reduce the number of providers again by 40-50%.  Choice of equipment and choice of a provider are rapidly ending as providers who have the knowledge, experience, and infrastructure are not able to compete.

This article was provided by Carey Britton, Seating and Mobility Specialist for Active Mobility Center. He can be reached at 954-946-5793 or cbritton@wheelchairguys.com.

Wheelchairs, Medicare and the Five Year Rule

As is a theme in Durable Medical Equipment (DME), there are established guidlines for how long equipment needs to last and how often in can be replaced. In this article we will be discussing Seating and Mobility Equipment guidelines; it is important to know that all equipment has a usable and functional life and is listed in the fee schedule. 

Ultra Light Wheelchair

CMS/Medicare generally set's the standard for all other insurance companies follow their guidelines, it is after all easier to copy than create your own standards; and if it is good enough for the government than it is safe for other insurance companies to follow.

Seating and Mobility Equipment has a five (5) year usable life expectancy.  Until a few years ago, it was an expected entitlment that after five years you get a new wheelchair, scooter, powered wheelchair or seating system.  Although it is the eligaiblity requirement, due to over utilization, there are new guidelines that require an equipment provider detail why the equipment is no longer working, too costly to repair, is discontinued, is outgrown, or no longer provides for some other need; even after the five year term.


Scooters

It is also important to know that Medicare allows for condition progression and will consider new equipment if a patient has changed and where the current equipment no longer provides function and independence.  An example may be a patient receives a wheelchair, and loses the ability to self propel. With adequate documentation, this patient may then qualify for a scooter or powered wheelchair depending on their needs; prior to using the equipment for five years.


It is also a requirement for much more documentation to support the need coming from a physician 

Power Wheelchairs

and/or clinician. 

If you have questions on the Five Year Rule, or if you are having problems with your currently equipment, contact Carey Britton, your guide to Seating and Mobility. Carey is the resident Seating and Mobility Specialist at Active Mobility Center. He may be reached at cbritton@wheelchairguys.com or (800) 326-4463.

Why Care what Medicare Does?

Living in the United States, unless you are over 65 you probably do not care about what Medicare does. What may surprise you is that decisions that are made at CMS/Medicare affect what private insurer's and Medicaid does.  Private insurance uses what Medicare does on the Federal level as a guideline of what minimum services they need to offer.

CMS uses SADMERC, a group that determines coverage, and coding of all DME (Durable Medical Equipment). These codes are universally used by all insurance/funding groups.  Medicare establishes a fee schedule and longevity of each product code which is published.  Once a fee schedule is published it is accessible by all other insurance providers.

Generally private insurance PPO's use a formulary that offers higher fee's paid to service providers (Doctors, Clinicians, and Equipment Suppliers).  Private Insurance HMO's use a fee schedule closer to what Medicare offers. Medicare HMO's use a fee schedule lower than the Medicare fee schedule as they generally package other benefits into their program and uses the lower fee schedule to offset the additional benefits.

Presently in the DME industry, there are three (3) important battles shaping up......

Competitive Bidding

The First major issue is competitive bidding, which was introduced in 2010, and was trialed in 10 metropolitan areas. Although it hasn't been a total failure, it has caused a huge reduction in access. In the first year of 2010, almost 1/3 of the winning providers went out of business unable to perform under the agreed contract.  In 2012, the Scooter Store was closed down by the Government, and had contacts in all contact areas.  In 2012, the 2nd round of competitive bidding starts in July, if not stopped, will affect the entire United States.

What is Included in Competitive Bidding?
Most DME equipment including; wheelchairs, scooters, group 1 and group 2 powered wheelchairs, beds, mattresses, patient lifts, canes, walkers, oxygen and respiratory products and many other supplies.  Not one company won all the bids, so it is possible if you need multiple products, you may have different suppliers for each one.

Less providers equal less access. You know when you have a problem with FPL or ATT, that you are stuck. You cannot switch your business to another provider.  Once these companies are struggling and do not have adequate funding to survive, will they care about unsatisfied customers?  If they have limited reimbursements, less options, and less quality products and services will be offered. Since DME has a life expectancy of five (5) years, if the equipment is not as durable, will beneficiaries become stranded if the equipment is of less quality?

Further we have seen from what occurred with the Scooter Store, that beneficiaries of equipment have become stranded. It is not recommended to provide service to a customer whom you did not provide their equipment and do not have the supporting documentation in your files. As you will read shortly, in an audit from the initial company, if CMS/Medicare finds that the equipment was provided inappropriately, not only will the money for the equipment purchase be recouped, but also will any services provided for that equipment. When additional suppliers of DME disappear, their customers are severely disadvantaged and will most likely have to personally pay for services, or go back through the process gather medical documentation to support the need for their equipment.

Several economists have shown that this system will fail. A system where you force an industry to bid low or no longer be able to stay in business does not foster competition, it creates fear, and survival instinct. Many companies bid low, not because it was a sound business decision, but a way to keep their business alive. There are many in Congress that have been trying to stop Medicare/CMS from moving forward with the competitive bidding program; however Medicare/CMS continues to boast huge savings; overlooking the destruction of businesses, the loss of customer choice, and reduced access to equipment and service.

The Second major battle are the audits. If it were not bad enough that CMS/Medicare created competitive bidding, they also hired companies, bounty hunters, to audit DME companies to ensure that they were billing properly and to avoid fraud and abuse.  This is where it gets interesting....Most recognize fraud and/or abuse by the providing of equipment to people who do not need it or billing equipment that was not provided.  Medicare determined that if they reviewed a file, even if there was medical need, if a date was not proper, or a signature not clear, that the claim could be deemed improper and money can be recouped from the provider.  I say again, it is not because the patient did not need the equipment, they are looking for a technicality to reclaim money from the equipment supplier. They do not go after the Physician, or Clinician, but the supplier.  This has cause these bounty hunter companies to become aggressive- they get a percentage of money recouped, so it is to their benefit to find things wrong.  If they find claims wrong they can extrapolate back several years based on a percentage of claims found not be correct and demand money back.  It is up to the supplier then to hire an accountant and attorney to dispute this, in most cases the company declares bankruptcy. As you can imagine, more and more companies are leaving the Medicare program to avoid these unfair audits.


Many private insurance companies are now looking a these types of audits.  The underlying question is whether these audits are for supplier integrity, or whether it is to recoup funding back to the insurance provider.  

The Third battle is over Complex Rehab Technology (CRT).  Complex Rehab Technology is described as equipment that is specialized and customized for an individual with mobility challenges. This level of equipment requires a greater knowledge, higher skill set and certification.  Currently these are the specialized companies who are the experts in your community.

The only current certificate required is an ATP- Assistive Technology Provider, which was set to be a
minimum qualification and is for general assistive technology.  There are other certifications currently offered (not yet required), Seating and Mobility Specialist  (SMS) and Certified Rehab Technology Supplier (CRTS).  With all the pressure from competitive bidding, many companies who did not receive a contract (winning bid) are trying to keep their businesses and are trying to migrate to providing complex rehab equipment.

An ATP certification requires only passing a test, it doesn't say you are qualified or good at providing CRT. An ATP who passes the exam on Monday is now on an equal playing field as an ATP who has been providing this level of equipment for 10 years. Would you want a Surgeon who just passed their board exam to perform your surgery or the Surgeon who has experience?

There is legislation in Congress and in the Senate attempting to separate CRT from DME.  This legislation has been years in the making, and spearheaded by NRRTS, NCART and United Spinal. These group are very concerned that the industry, filled with knowledge and experience, may soon disappear if not protected.  You can sign a petition for HR-942 and support CRT.

Tying this back together, what occurs with Medicare will carry over to Private Insurance and Medicaid. If/when you need equipment, unless you know how to fit yourself, and  know what is important, pro's and con's of different equipment and are handy to fix your own equipment; you need this industry to survive.  Many insurance companies are watching closely to these Medicare programs, and many have already adopted parts of the program.

Many manufacturers of Assistive and Rehab Technology Equipment have already frozen research and development- No further Innovation or Advancement.

It is short sighted not to care just because you do not need this equipment now. We are all aging and living longer, and it is inevitable that we will need some piece of adaptive equipment to continue with the quality of life we desire.  Baby Boomers are coming of age and this huge population will depend on Assistive and Rehab Technology to continue to live independently in their homes.  Without a unified effort, we may lose this industry, and lose the local service provider who will assist you when you have a need.

If you are motivated, you can contact your legislator and let them know how you feel. You can find you local representation by clicking here.

Carey Britton, ATP, SMS, CRTS, works for Active Mobility Center, and has been committed to lobby congress, and participate in the Advocacy of people requiring CRT.  Carey can be reached at (954) 946-5793 or emailed at cbritton@wheelchairguys.com