A Real Opportunity for Complex Rehab to Move Ahead?
- By Seth Johnson
- Mar 01, 2012
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
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
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.
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.