Automotive Accessibility

Funding Essentials: The Reimbursement Side of Crash-Test Standards

• By Julie Piriano
• Nov 01, 2011

Change can be a slow and gradual thing — and it’s often an evolutionary process rather than a bolt from the blue.

So it goes, perhaps, with funding for wheelchairs and seating systems used as seating for passengers in motor vehicles.

Securing wheelchairs inside motor vehicles isn’t new; neither is having motor vehicle passengers and drivers remain in their wheelchairs during the ride. Funding for such crash-tested WC19 and WC20 systems, however, hasn’t kept pace across the board.

Julie Piriano, PT, ATP/SMS, director of rehab industry affairs for Pride Mobility Products, acknowledges that crash-tested systems often aren’t reimbursed by payor sources.

“From a payor perspective, especially when you’re looking at state and federal dollars, they’re required to pay for what’s medically necessary,” she says, pointing out funding similarities between crashtested systems and other products such as bath safety equipment. “So when it comes to components like this, they have benefits for the individual that’s using it, but being medically necessary — it’s difficult to cross that threshold so that (payors) would be mandated to fund transit options and systems like this.”

Another funding hurdle: Medicare’s antiquated policy of reimbursing for DME only if it’s medically necessary for use within a beneficiary’s home.

“The in-the-home restriction is still applicable from a Medicare perspective; that throws a monkey wrench into it, too,” Piriano says. “So with the separate benefit initiative for complex rehab, now we’re looking at home and community mobility, not too dissimilar from what state Medicaid programs are required to do. That’s why a lot of the state Medicaid programs, while they still won’t fund transit options on the device, they’re looking at it from a prior authorization perspective.”

Piriano says that many Medicaid programs require consideration of a wheelchair’s transportability as part of the entire consideration process for purchasing DME.

“(In) a lot of states, you have to submit information with regard to how the device is going to be used, how it’s going to be transported, if this occupant is going to be in this device when it’s going to be transported,” she explains. “They’ll deny prior authorization unless that information is presented.”

Once that information is presented, Medicaid programs then expect the DME order form to include an indication of a transit option for the wheelchair that the supplier is looking to provide. “They’re not funding it,” Piriano acknowledges, “but in all likelihood, they will deny authorization if the transit option isn’t checked, even though they’re not going to pay for it.”

ABNs for Transit Option Situations

Furthermore, Piriano suggests providers use an Advance Beneficiary Notice of Noncoverage (ABN) in Medicare beneficiary situations.

“From a provider perspective, if it’s a Medicare beneficiary, you have the option of utilizing an ABN, even if it wouldn’t be necessary to do that because it’s not a covered item,” she says. Such a discussion with the beneficiary could enable him or her to make a more informed decision about spending their own funds. Piriano suggests talking with consumers about a transit option, if it’s available: “What it’s for, what it will do for them, what it’s going to cost them, letting them know the payor is not going to fund it. They then can make an informed decision as to how that chair will be equipped upon ordering it and what their financial commitment would be.”

A similar upfront discussion with private payors about transit options can also be ultimately helpful. Piriano suggests “submitting that with a prior authorization request, again informing the payor of what it is, why it’s necessary, some information about how often the individual travels. Will they be able to return to work if this option is funded and remain involved as an active, independent citizen? Providing that information with the prior authorization request is enormously important, because if that funding source denies it, there’s an appeal process that can be utilized.”

Effecting an Evolution

And just because a payor is likely — or even certain — to deny funding for transit options is no reason to shy away from asking for it and explaining the value of such systems, Piriano says.

“The information is going in, whether it’s Medicare, Medicaid or a non-government payor,” she says. “The request has been submitted, the rationale has been submitted. If the payor denies it, the payor denies it.”

Depending on the individual circumstances, the provider may still be able to receive payment for the transit options “through the appeal process or some financial decision-making between the provider and the consumer,” Piriano says. But just as importantly, the need for crash-tested seating & mobility systems will continue to be trumpeted if ATPs on the front lines continue to tout their enormous value, both from safety and independence standpoints. And that’s why providers should continue to include transit option information to payors and ask for reimbursement, Piriano suggests.

“If we don’t ever ask for it and indicate why it’s necessary, how it will be used, why it’s important for that individual — we’re never going to make any headway in bringing this to the forefront,” she says. “The further we move down the path with crash-testing and standards surrounding crash-testing, (funding) has to run in parallel. If a payor source doesn’t see it as something of value, they can’t even consider funding it. If we don’t ever submit it, they’re never going to see trends in terms of requested utilization or funded utilization.”

Piriano makes a comparison to today’s automotive seatbelt laws.

“When I was a kid, there weren’t even seatbelts in cars,” she notes. “And now seatbelts are mandatory. Studies were done and the efficacy was realized, and then it became mandatory.”

Perhaps ATPs will one day be able to say the same thing about crash-testing for wheelchairs and seating used in motor vehicles.

This article originally appeared in the November 2011 issue of Mobility Management.