Winning Strategies for Tough Funding Scenarios
Making a Case for Ultralight Chairs, Standing Chairs, Non-Coded Technology & Power Mobility for the Very Young
- By Lois Brown, Tara Gentile, Jim Stephenson, Eli Anselmi, Paul Komishock
- Jul 01, 2008
When it comes to getting funded, not all rehab technology is created equal. Sometimes, coverage criteria are stacked against a certain category of product. Some products inherently cost more to manufacture. Some technology may be new and unfamiliar to payors. In all of those cases, providers may have a tough time getting the equipment funded — which can be frustrating to rehab professionals who know a certain piece of technology could do wonders for a specific client.
We asked manufacturers for their advice on creating winning strategies for four tricky rehab scenarios. Have you had difficulty getting a certain type of assistive technology funded? Tell us about it by e-mailing MM editor Laurie Watanabe at firstname.lastname@example.org
Funding for Non-Coded Technology
By Eli Anselmi, Director of Sales & Customer Service/Product Specialist
Editor’s Note: While Eli’s advice could apply to other non-HCPCS-coded equipment, he used the Kids Rock mobility system with Active Seating as a concrete example. The chair’s dynamic seating system does not currently have a code.
Tip 1: Expect to invest more time and effort on your case if the product is not coded.
(For the Kids Rock system) there is no HCPCS code for it, so pretty much everywhere we go, (suppliers) are having to use the K0108 miscellaneous code. The challenge with the K0108 is that it does require considerable time invested on the supplier side. In some states, the therapists are the ones writing the additional letters of justification for the equipment; in some states, that falls on the supplier. It does vary depending on the state that you’re in, but it does require additional documentation, which takes considerable time.
In general, what we’ve found is suppliers need to submit it under the K0108 with additional documentation, and because it’s a miscellaneous code, it gets outright denied. Then they have to resubmit with additional documentation. It’s going to take time and effort to get it funded.
Tip 2: Wording is important. As you’re filling out the paperwork, know the coverage criteria.
The challenge comes in because the state Medicaids are funding for positioning and mobility. Dynamic seating is not only positioning and seating, but it’s also therapeutic as well. The trouble is that you cannot use that word in most of those states, because they don’t fund for a therapeutic benefit. From a manufacturer’s point of view, we have to go to the suppliers and educate them on how to properly word the benefits page. (For instance, they need to be) looking at “seating tolerance” instead of “comfort.” We’re talking semantics here, but that’s a good example of wording they may need to use to get funding.
We fought hard to get the very first chair funded in Florida. We met with (the Medicaid representative) in Miami, and she was not very receptive. She said, “This is not medically necessary, it’s not coded. We don’t want to be guinea pigs.” You name the scare, and she had it.
After we sat down with her and presented the case and gave her the clinical trial information, finally she said, “OK, we’ll pay for it.” But even then, she was very clear at the end of the meeting. She said, “Just remember, we pay for positioning and mobility, not for therapeutic benefits.” She was basically saying, “Submit this as seating & positioning, and we’ll pay for it.” Tip 3: Ask manufacturers to help you fight.
I have taken it on myself to support the suppliers, to spend some time with the state Medicaid agencies that are willing to sit down and listen to the medical reasoning. Not all of them are open, but I talk with the key suppliers in the state, and I will have them contact their local Medicaid agency and set up the appointment. And I will come and support them.
The smaller (manufacturers) are the ones who are bringing a lot of technology out there. I don’t know of a small manufacturer who would not be willing to get on a plane and support that supplier, especially when it becomes challenging to get funding. If it comes to the point where educating the funding agency and supporting the supplier will make the next request for funding easier — I don’t know a single manufacturer who would not go out and do that. That’s something I think a lot of suppliers are not aware of. Remind the local manufacturer’s rep first — bring the problem to them. That local rep will eventually engage corporate or the product specialists at the company to come and support them. It is to the manufacturer’s benefit that new technology is getting prescribed and getting funded.
Tip 4: Pass your passion on to the funding source.
When you’re dealing with new equipment, be receptive to it. And then really become passionate. Because if you can carry the passion to the funding agency, and really speak to them in a manner which they understand, and involve the manufacturer to support you, it will facilitate steps down the road.
If it’s new technology and there’s clinical data to support it, don’t be afraid to try it. It’ll still be an uphill battle the first couple of times that you do it. But it will make it easier, and the ultimate beneficiary is the end-user. They’re really the people who will benefit from it.
Funding for K0005 Ultralightweight Manual Chairs
By Jim Stephenson, Reimbursement & Coding Manager, Rehab Department
Tip 1: You can lower your K0005 anxiety.
A K0005 chair, from a cost perspective, is fairly significant to where if things don’t go in (your) favor, it’s a lot to lose.
For the base itself, before you start talking about options and accessories, you’re talking $1,000 or better that’s at risk.
The thing, though, that is advantageous to doing a K0005 is you can get your ducks in a row to do it, and then you can do it as a purchase to where you get paid up front, as opposed to waiting 13 months to get all your money.
Tip 2: For Medicare claims, consider using an ADMC.
K0005s with Medicare are a little on the difficult side, just because most people in that geriatric population don’t have high-end need. Not that there’s nobody out there that needs it, but the majority all-day need (for seniors) is “Get me from A to B.” They don’t need fancy tires, extra dump or axle adjustment. They just don’t need that stuff, typically. So Medicare is sometimes a bit of a challenge.
You can find out if (the client has) medical necessity met before you even put yourself out on a limb. Then at least you’ll know if you have medical necessity covered, which is typically the primary culprit as far as the denial is concerned. ADMC (Advanced Determination of Medicare Coverage) doesn’t guarantee payment in any sense of the word, but at least it takes out the biggest culprit in the case of denial. It gives you the option of knowing before
you buy, so you don’t invest the money in it, then go through the process and realize, “I’m not going to be able to get this funded.”
If you get an affirmative ADMC back, then the only types of things that you have to worry about are if maybe the client switches to a Medicare HMO, or if they pass away. (A post-ADMC denial would have) more of an administrative denial reason as opposed to medically related-type denials.
Tip 3: Differentiate the K0005 from lesser equipment.
Typically for Medicare, if you can prove the necessity for axle adjustment, that’s the one kicker that gets somebody a K0005 more times than not. That goes for all funding sources. An adjustable axle is not available on anything but a K0005.
What does the client need that’s only available on a K0005 and can’t be accommodated on a lesser chair? You get better propulsion efficiency with a K0005, and you can do things to make them more efficient: camber, tilting the wheels in and out, etc.
One of the key tips across the board is identifying the patient’s routine on a day-in, day-out basis and identifying why they can’t function independently in a lesser chair. The weight difference between a K0001 and a K0005 can be 10 lbs. or more — that’s a lot when you’re trying to propel one versus the other, and a lot for the older population.
Tip 4: With private payors and younger clients, do a great assessment of day-to-day activities, and help payors to think about how a K0005 could prevent future problems.
Private insurances are typically more receptive to (funding) this type of a chair, because they’re dealing with a younger population. And they realize that when they’re dealing with an ultralightweight chair, they’re going to have to deal with lesser costs for shoulder repairs and things of that nature from all the propulsion issues. So they typically understand.
And a K0005 is typically a more durable kind of chair. Younger folks are typically working or they’re college students who have to get across great distances.
Medicare is looking at whether this patient is going to need a chair even 12 months from now. The allowable for a K0005 is $1,850 or so with Medicare. And they don’t want to shell out that kind of money if their needs can be accommodated with something less. That’s basically their motto.
Funding for Power Mobility for Very Young Children
By Lois Brown, Clinical Education Manager, & Paul Komishock, General Manager of Government Affairs
Pride Mobility Products/Quantum Rehab
Tip 1: Independent mobility is critical to a young child’s development, but payors need to be educated about that.
Lois: I think funding sources tend to immediately look at the child’s age. I think they look at this as, “You’re asking us to give a piece of equipment that would allow (the child) to be mobile, but yet when they reach point B, they would still need assistance to retrieve or to participate or to do things.” And so the inherent mobility itself is not being honored.
Therapists are mostly sharing that they’re being asked to document complete independence (of the child) before submitting even a letter of medical necessity. I think that it’s important to help those funders to understand the meaning of independence. Independence is the ability to maneuver themselves within the environment. Any child of that age would require supervision for general safety. If we were to limit that sense of mobility, then we are limiting their actual development.
The research that is coming out now talks about lack of movement affecting sensory motor development, their cognitive development and their social behavioral development. If you can’t move through your environment, you don’t develop spatial relations in reference to objects moving around you and you moving past things in your environment. And that specifically affects your ability to develop language skills, your ability to understand how things relate to each other.
Unless you have that independent mobility before the age of 2, your brain’s sensory motor development is actually altered.
No child at that age should be crossing streets and maneuvering through dangerous situations. We encourage them to move across the room, but we protect them and give them a safe environment to do that.
RESNA has just completed research on pediatric power mobility.
Tip 2: Learn about the funding source’s coverage criteria.
Paul: (Coverage) also depends on how specific or non-specific (the payor’s) policies are. With pediatric cases, a lot of times it’s a little more open-ended than with standard power or geriatric or things like that. And so they may not have a hard, fast rule as far as the policy is concerned.
If they do, then it’s an issue simply of whether or not the patient’s going to qualify based on what the insurance company’s policy is. If they don’t have a set policy per se, then the stuff Lois talks about becomes much more important because you’re allowed to make a case a little bit more freely than if you’re held to specific coverage criteria.
Tip 3: Emphasize that early intervention is crucial, regardless of how the child’s mobility continues to evolve. Using a power chair doesn’t mean all attempts at walking will necessarily stop.
Lois: A lot of parents don’t want to see their kids go immediately into power mobility. But you still have the ability to remediate a skill like walking. In other words, the child that we just did (as an early-intervention case study for power mobility) is still working with a walker, and still trying to facilitate some large-extremity movement. But that movement is literally laborious, step by step. And he’s not getting that same sensory motor development that you get by moving at a fairly normal rate through the environment, just like any other child, to gain spatial relationships.
They’re still going to work on that walking ability. But sometimes funding sources say, “Well, maybe (power mobility is) premature. We don’t know, maybe he’s going to become a walker.” If you can’t maneuver through the environment (on your own), you need to be introduced to power mobility, even if you eventually, wonderfully transition out of it.
Paul: Other funding sources don’t demand that you’re in that chair 24/7. That same train of thought should be considered when you’re funding for pediatric power.
Tip 4: Get support from others who interact with the child, such as teachers and therapists. Consider including research results and multimedia examples with your documentation.
Lois: Special educators are able to document and talk about lack of problem-solving or language expression and tie in again that cognitive development is attached to inherent movement. A lot of therapists will attach (research/white papers) to their letters of medical necessity. Others will reference them within the letter itself.
Paul: A picture’s worth a thousand words. I don’t know if I’d make (videotaping) a regular part of every case, but in a situation where your documentation may not speak real well to the case, or you have an unusual circumstance — for any client that you would say, “I wish you could see a picture of this kid in this chair, and how good he is in it” — I think it couldn’t hurt. I think the provider would have to weigh the cost benefit of that, maybe not do it for every case, but I wouldn’t be afraid if I were a provider to do that if it could help the case.
Tip 5: Show payors you’re sensitive to their parameters by choosing systems that can grow. But emphasize that pediatric systems require a high degree of customization.
Lois: If you can document that you have chosen a base and a seating system that can grow to accommodate the child’s weight growth and size and shown some fiscal responsibility up front, then you’ve shown them you’re working with the system.
Paul: Growing a chair is an important feature that funding sources look at. One thing that providers need to remember is that, according to the HCPCS codes that are out there now, there are very few products that are specifically coded as pediatric chairs. Pediatric chairs are only defined as (having) up to a 125-lb. weight capacity. So when funding sources are considering what to pay for, (providers should consider) that there are other bases out there that have pediatric applications, but they’re not coded as a pediatric chair, per se. Don’t limit yourself to those, and don’t be afraid to explore other bases.
Lois: There are times because of a child’s neurological or orthopedic status, you need to seat them in a very specific position with controls placed in a way that, without it, they wouldn’t be successful. Sometimes we talk about, “Why at this age can’t we just use demo stuff that’s given to the schools or that the provider brings in?” Well, a lot of times they won’t achieve success unless it is custom fitted for them in order to control their tone, etc. That’s why we want them to fund a specific piece of equipment for that child, not just rely on demos.
Paul: There may be other ways to save money if this client is provided equipment that can help them. If they’re provided a power chair, maybe the home health nurse doesn’t need to visit as often. Or they’re not going to have to go to the doctor or therapy quite as often. They’re able to get to therapy independently, as opposed to by ambulance that the funding source is going to have to pay. There are ways other than the base itself that the funding source may be able to save money if they pay for a power base for a child.
Funding for Standing Wheelchairs
By Tara Gentile, Funding Manager
Tip 1: Understand the roadblocks you may encounter (but yes, standing wheelchairs can be funded!).
The first roadblock is the assumption that standing wheelchairs are not covered at all. In general, standing wheelchairs have been more challenging to get funded, but actually can be reimbursed through some funding sources. The Medicare local coverage policy states that standing devices are “not primarily medical in nature” and therefore will be denied as non-covered. This blanket statement is the root of the problem that needs to be addressed, either at the local or national level.
Also, a power wheelchair with a standing system is inherently more expensive than a standard power wheelchair because of the added capabilities. Due to the lack of extensive knowledge regarding standing system capabilities, options, medical benefits and equipment, some suppliers and funding sources may be apprehensive about investing in such equipment. Funding sources may be reluctant to reimburse for standing systems for reasons which may include lack of education on the medical benefits of standing, costs, complexity of equipment or fear of increased risk of repairs.
Tip 2: Educate payors via research and by teaming up with clinicians.
Therapists and suppliers need to find the most appropriate equipment for their patients. If a standing wheelchair has been determined to be the most appropriate technology, then the supplier should use all available resources, including assistance from therapists, physicians, caregivers, manufacturers, etc., to help document the need. The documentation should prove medical need, but show the functional benefits of how a standing wheelchair can improve independence and the overall quality of life. The documentation should create a visual for the reviewer.
Suppliers should work with therapists, physicians, caregivers, end-users, manufacturers and others to collect pertinent information that strengthens the case. In addition to the required forms and documentation, examples of additional resources that may be useful include pictures or video testimonials of the client in the chair; letters from therapists, physicians, and/or end-users describing the medical benefits of the standing system; and the RESNA position paper on wheelchair standing devices. These supplemental documents will strengthen the documentation.
Tip 3: Paint a “complete picture” of a standing system’s benefits to show its cost-effectiveness.
Incorporate any and all appropriate resources as mentioned above. If the standing system is initially denied, follow the proper procedures specific to the funding source to file a timely, organized and detailed appeal.
Suppliers may also submit relevant cost comparisons on alternate treatments or products. This analysis may prove the cost-effectiveness of the equipment and added medical benefits of the chosen treatment plan over alternatives. Be sure to specify the medical benefits for that individual patient, citing research articles to support claims. Discuss functional benefits that will improve MRADLs (mobility-related activities of daily living) and other self-care tasks, which will potentially reduce funds required for personal-care attendants. Describe vocational benefits for the user, specifically if they are involved with a vocational rehab program.
Tip 4: Consider alternate funding sources.
Finally, don’t underestimate the end-user’s ability to raise funds for non-covered items. Philanthropy organizations, church groups, fundraisers, etc., have helped many individuals pay for features that were not covered by insurance. Always give the patient the option of trying to raise funds.
This article originally appeared in the July 2008 issue of Mobility Management.