What Lies Ahead for Complex Rehab in 2009 and Beyond…

This has certainly been a monumental year for the complex rehab industry. After years of advocating for an exemption from DME competitive bidding, the exemption became law on July 15.

Unfortunately, Congress included complex rehab with the other items subject to competitive bidding that will incur a 9.5-percent payment reduction on January 1, 2009. While that level of reduction more than pays for the cost of excluding complex rehab from competitive bidding, the fact that Congress has now recognized the difference and excluded these highly customized and service-intensive products from competitive bidding provides a strong position to move forward from next year. The focus of the complex rehab segment of the industry will largely be in the following areas based on the latest assessment of the legislative and regulatory environment.

Parallel exemption from 9.5-percent reduction for complex rehab power — These efforts will continue into next year on multiple fronts with increasing support continuing from consumers, providers and clinicians. The support generated this fall has put Congress on notice that this impending reduction is a critical situation that will result in negative outcomes for all stakeholders, most importantly Medicare beneficiaries.
The Simon School of Business (University of Rochester, N.Y.) conducted a financial analysis of the complex rehab industry that indicates that pre-tax profits from a complex rehab company are between 3.44 and 6.87 percent, which does not provide room to absorb a 9.5-percent reduction without significant restructuring. In addition, an industry survey designed to identify the specific changes companies that provide complex rehab power chairs will be making indicates that there will be significant changes to the products companies offer, a reduction or elimination of the services that they will provide, and a reduction in staff necessary to process an order in a timely manner. It is important that industry stakeholders continue to convey to senators and representatives the impact this reduction will have on the ability to continue to provide complex rehab power wheelchairs and the necessary services to Medicare beneficiaries after January 1, 2009.

Competitive Bidding — While complex rehab has been exempted from competitive bidding, the exemption only includes Group 3 power chairs, and does not include Group 2 power chairs with single or multiple power options defined by Medicare policy as complex rehab, or any manual wheelchairs. The effort to broaden the exemption to apply to all complex rehab and assistive technology will likely continue next year.

The legislation introduced in the House and Senate (H.R. 2231 and S. 2931) to exempt all complex rehab and assistive technology will likely be modified and reintroduced next year to secure a broader exemption that includes these products, should a modified competitive bidding program go forward. In addition, it will be important to support the broader industry efforts that will be moving on parallel tracks — legislative and regulatory — to kill or modify the competitive bidding program.

Support has been built within the key committees in Congress to develop legislation that would eliminate competitive bidding. The main area of debate within the industry and Congress will likely be how to “pay for” the cost of eliminating the program. Hopefully this can be achieved through savings via enforcement of tougher anti-fraud measures.

On the regulatory track, the focus will be on modifying the structure, processes, and procedures of the competitive bidding program to make it the best possible framework should the program go forward, albeit without Group 3 complex rehab power chairs. There were positive changes mandated in the Medicare Improvements for Patients & Providers Act (MIPPA) that was signed into law in mid-July that will also need to be closely monitored to ensure congressional intent is followed and these protections are provided — one of which is allowing providers the opportunity to submit missing bid information prior to being disqualified from participation in the program. Under the previous rules, a provider could be disqualified without warning or explanation regarding missing or incomplete information.

Fraud & abuse — The industry is continuing to work with Congress on the development of anti-fraud provisions to help guide CMS on the establishment of rules and regulations utilizing their current authority under the law, and providing additional authority if necessary to change the negative perception of the DME, and specifically the power wheelchair industry, and get out from under this cloud in a proactive, positive manner. Legislation based on industry-recommended anti-fraud measures will likely be introduced early next year.

Manual wheelchair codes — The new PDAC (Pricing, Data Analysis and Coding) Contractor that took over from the SADMERC on August 18 is now in charge of this project, and it is currently unclear whether the PDAC will adopt and move forward with the work product in the early stages of development by the SADMERC or start from the beginning on the development of new manual wheelchair codes. It has been confirmed that this project has transitioned to the new contractor, but no clear timeframe has been established for release of new proposed codes. Movement on the development of new codes is expected in 2009, and this will be followed by the establishment of a new coverage policy and pricing for the codes. This is an initiative that the rehab industry will continue to be engaged in to help ensure the best possible framework is developed.

As stated at the outset, this has been a monumental year for complex rehab. Strengthening relationships with legislators and continuing to educate them on the unified message on these issues is the best way to help make 2009 another positive year.

This article originally appeared in the November 2008 issue of Mobility Management.

About the Author

Seth Johnson is the vice president of government affairs for Pride Mobility Products Corp. He is a board member of the National Coalition for Assistive and Rehab Technology (NCART), a former chairman of the American Association for Homecare's Complex Rehab and Mobility Council (CRMC), and is active within several state associations and various other industry stakeholder organizations and coalitions. He can be reached by voice at 1 (800) 800-8586, or online by visiting www.pridemobility.com.

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