Funding Essentials

A Real Opportunity for Complex Rehab to Move Ahead?

The complex rehab and mobility industry is starting 2012 in a better position than the previous year. The industry ended 2011 with some positive developments on the competitive bidding front, particularly in the complex rehab segment, and a delay in the Power Mobility Device demonstration project.

While this year is an election year, and Congress will have a more compressed legislative schedule, there will be continued opportunities to advance better outcomes for the industry. The good thing about an election year, especially a presidential election year, is that legislators are much more attuned to the concerns of their constituents.

While this year will certainly include its share of challenges, the complex rehab segment seems very well positioned to continue to advance, and opportunities exist for the mobility segment as well. So let’s evaluate the opportunities and threats for the complex rehab and mobility industry this year and identify what actions are necessary in order to move the industry forward in 2012.

Competitive Bidding, Round 2

Late last year, the Centers for Medicare & Medicaid Services (CMS) agreed to remove three complex rehab codes from the standard wheelchair category to be used for bidding both power and manual wheelchairs in round two of Medicare’s competitive bidding program. The codes — K0005 manual wheelchair, E0986 push-activated power-assist wheels, and E1030 gimbaled vent tray — were strongly advocated for removal by the industry, consumer groups and Congress. The complex rehab industry was given more good news early this year, when CMS also eliminated the four adjustable skin protection cushion HCPCS codes (E2622– E2625) from round two, which completed the industry’s request.

While those changes largely protect complex rehab from competitive bidding, manual and standard power providers are now in the middle of the bid window for round two of those products included in the program.

Despite significant and continuing DME industry eff orts to replace competitive bidding with the more practical Market Pricing Program (MPP), the round-two bid window was scheduled to open as of press time. At the writing of this article, the industry remained focused on advancing the MPP alternative in the SGR/Doc fix legislation that must pass by March 1 in order for physicians to avoid a 27.4-percent reduction in their Medicare payments. Congress passed a two-month temporary fix in late December, which provided the industry an opportunity to include the MPP in legislation early this year.

While all legislative efforts remain on advancing the MPP alternative, other efforts will continue on the regulatory front to modify the process and procedures CMS utilizes in evaluating the bid information and making determinations on which providers are offered contracts. While securing changes after the close of the bid window will be difficult, options should continue to exist to modify the processes or stop the program prior to implementation.

Power Mobility Device Demonstration Project

The industry was given some very good news on Dec. 29, when CMS announced it was delaying implementation of the pre-payment review and prior authorization demonstration in seven states, which together account for 43 percent of the Medicare market. The delay was the result of a very strong and unified message being carried by all power mobility device (PMD) stakeholders — providers, consumers, physicians, clinicians, and manufacturers — that the demonstration needs to be stopped prior to implementation.

Congress and the stakeholders encouraged CMS to move toward the development of a prior authorization process similar to the one included in legislation (H.R. 3399, section 204) introduced last year by Rep. Peter Roskam (R-Ill.). The legislation calls for the development of a comprehensive face-to-face examination template for physicians or clinicians to document specific criteria to determine medical necessity. The template would need to be developed and approved with stakeholders before implementation of prior authorization.

Even though the length of the delay remained unclear at the writing of this article, the industry now has an opportunity to work with Congress, CMS and other stakeholders on the development of a properly structured prior authorization process. Th is will move Medicare away from its outdated and inefficient “pay and chase” model, and toward a real-time prior authorization process. Such a process, if properly designed, would be in all stakeholders’ best interest, including Medicare’s.

A Separate Benefit for Complex Rehab

Late last year, the complex rehab technology (CRT) industry received some very good news from Rep. Joseph Crowley (D-N.Y.): a commitment to introduce legislation to create a separate benefit category for complex rehab. This is a very big milestone on the road to securing the separate benefit. The goal now is to get the bill introduced prior to this year’s NCART/NRRTS CELA Conference to be held April 17-19 in Washington, D.C.

For those not familiar with the separate benefit initiative, the objective is to improve and protect access to CRT products and services for individuals with significant disabilities and medical conditions. The introduction of the bill early this year will provide an opportunity to build support and get this legislation passed this year to further protect the industry from future reductions and provide a formal mechanism for future payment increases.

Medicaid Under the Microscope

Challenges will continue to present themselves at the state level, as state legislatures continue to look for ways to reduce expenditures or slow the growth of their Medicaid programs.

The industry is much more organized and had some positive outcomes in certain states last year due to increased industry efforts on Medicaid issues. Th is year, many state legislators will also be up for re-election, which should result in them being more attuned to concerns or issues raised by constituents. They will be looking for ways to help, and there are certainly things they could do to help establish improvements within the Medicaid program.

Since all states have somewhat unique and individual Medicaid programs, the best resource for the latest information is your state association and organizations like NCART on the complex rehab front. Each has resources to get stakeholders more involved in helping protect Medicaid coverage and payment policies that may be under discussion for further reductions.

Clearly it is going to be another busy year, rife with opportunities to further advance positive outcomes for the complex rehab and mobility industry. If the industry continues to build on the significant educational and lobbying eff orts with policy-makers, legislators, consumer groups, clinician groups, and other stakeholders, I am confident 2012 will be a better year for the industry.

This article originally appeared in the March 2012 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

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