Pediatric Funding

They’re Probably Scrutinizing a Little More

• By Laurie Watanabe
• Aug 01, 2010

The assistive technology adage used to be that when the client is a child, doors of opportunity seem a little quicker to open. But as the economy continues to labor, payors of all types, including state Medicaid programs, have had to cut back — even when kids are involved.

“I think that they’re probably scrutinizing a little more,” says Pride Mobility Products’ Jay Doherty, OTR, ATP, when asked about funding sources for pediatric seating & mobility. Doherty emphasized that he is not intimately familiar with current funding policies for all Medicaid programs. But as an example of what he has seen happen, he says, “If a chair can be grown, they want a cost comparison a lot of times. How much are the parts and labor going to cost to grow the chair to the size it needs to be, and how much is a new manual chair going to cost? Are there other repairs that need to be done? If the chair is in disrepair so it needs significant repairs and also needs growth, what are the cost benefits to repairing versus replacing? Are they better off replacing because of mechanical issues that are going on or repairs that have consistently been a problem with the chair?”

As with any complex rehab technology client, providers who can back up their requests with documentation and justification will probably stand the best chance. Doherty says, “You need to talk about why the system’s not working anymore, that the growth has been maxed out... You eliminate that the chair can be grown further: ‘We’ve maxed out what this frame can provide to this child and therefore we need to go to another size because we can’t swap these parts out.’ Side frames, when you start swapping them out — it gets relatively expensive.”

Altimate Medical’s Nancy Perlich, COTA, ATP, says policies for how long standers are expected to last “vary greatly from payor to payor. The most restrictive end of the approval range is one stander per lifetime, i.e., Wisconsin Medicaid. Three to five years is average coverage frequency for most stander policies, but there is always an exception per client medical necessity. For example, a male youth who has grown 9" in a year has the potential for a medical-necessity change. You can only look into your crystal ball so far.”

This article originally appeared in the Pediatric Handbook August 2010 issue of Mobility Management.