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
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
“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
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
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.
About the Author
Julie Piriano, PT, ATP/SMS, is VP, Clinical Education, Rehab Industry Affairs & Compliance Officer for Pride Mobility Products.