Regarding repairs for complex seating and wheelchairs, stakeholders seemingly agree on one thing: The process takes too long, leaving wheelchair riders without the technology they depend on to optimize their function and independence.
From consumers and caregivers to clinicians, providers, manufacturers, researchers, legislators and policy experts, stakeholders agree that repair reform is desperately needed. But the problem itself has many causes.
A worsening problem
Wayne Grau is the executive director of the National Coalition for Assistive and Rehab Technology (NCART).
“The process has been broken for a long time,” he said. “It’s just gotten worse. As more managed care companies have come in, there’s been a lot more emphasis on prior authorization and a lot more on regulations and so forth.
“The gist of it is consumers want their equipment fixed quickly. That’s incredibly reasonable. However, it’s not a cash market. It’s not like a washing machine market or appliance market. It is controlled by insurance companies, and they have very specific things we’ve got to do to take care of that consumer. And that is what, in a lot of cases, is slowing everything down.”
Julie Piriano, PT, ATP/SMS, is NCART’s senior director of payer relations & regulatory affairs.
“It’s a consumer-initiated process without a consumer-driven solution,” she said of the current system. “Consumers identify the need, but can’t just make a phone call and get their equipment fixed, because the financial transaction isn’t between the consumer and their provider. There’s a middleman in there.”
One of the common requirements from middlemen — i.e., many funding sources, but excluding Medicare — is prior authorization for repairs to equipment that’s already been approved and provided as medically necessary.
“We understand that third-party payers have a fiscal responsibility to ensure that the money going out the door is appropriate, especially state Medicaid programs,” Piriano said. “As a taxpayer, there’s a part of me that says, ‘I’m glad they’re making sure the expenditures are accurate and appropriate.’ That makes sense, and in conversations with third-party payers, we’re not saying, ‘Eliminate prior auth for the initial investment of the equipment.’ But once it has been determined that the equipment is necessary for the person as a lifetime medical need — because they have a permanent disability — then it’s understood that that equipment will require periodic maintenance and repair to keep it safe and operable for its five-year reasonable, useful lifetime.’”
Piriano added that because consumers typically are the ones who report that their chairs need service and are wary of being without them for any length of time — removing prior authorization requirements would not open the door for provider fraud or abuse.
“[Service] isn’t a cash cow,” she said. “People don’t call up and say, ‘I need my chair repaired’ unless they really do. Suppliers aren’t calling their customers saying, ‘Hey, do you need your chair fixed? I’ve got some parts here that I’d like to sell you.’ None of that occurs. So concern for the financial resources expressed by the insurance company, state Medicaid programs, and the MCOs [managed care organizations] is really unfounded. Yet they’re hesitant to consider alternatives, like the elimination of prior authorization for repairs to Complex Rehab, because they’re afraid that they’re either going to lose control over the expenditures, or they won’t have the necessary accountability for those expenditures.”
As a clinician, Piriano knows the consequences of a repair system that can deprive wheelchair riders of their equipment for months.
“Obviously, when the initial chair is spec’d out, it is designed to fit and function for that one person, based on their diagnosis, presentation, body shape, size and configuration,” she said. “When you think about the provision of Complex Rehab, it’s not just identification of need, prescription and delivery. There’s a lot that happens in between. Then once the chair is delivered, it’s fit, adjusted and individually configured the rest of the way for that person.”
She gave an everyday example of how personal configurability impacts function: “I wear a size-six shoe. Not a lot of people can fit into my shoe. Could you make it work? Could you put part of your foot in and use it temporarily? You could, but bad things are going to happen to your foot if you have to use it for days or weeks, waiting for shoes that fit your feet to be fixed and returned to you.”
Piriano added that an identically configured wheelchair to use on a loaner basis “isn’t readily available. It’s not standard DME [durable medical equipment], used for a minimal number of hours a day so a standard size would work. With CRT, the intimate fit of the device is what’s critical. And when you try to make do, preventable secondary complications and adverse occurrences can happen pretty quickly.”
Consumers borrowing a power chair not configured to their specific needs could fall out of the chair; develop a pressure injury; have cardiac, respiratory or circulatory issues, or problems with chewing, swallowing and digestion; or experience bowel and bladder complications in a short amount of time, Piriano noted. If drive controls aren’t precisely mounted where they need to be or aren’t programmed as needed, the consumer could have difficulty using them, thus impacting independence and the ability to engage in their activities of daily living.
“It’s duplicative,” Grau said of prior authorization requirements. “They’ve already approved the medical necessity for the chair; this is a repair. The insurance companies know that repairs are going to be needed, so why make people jump through hoops and wait for paperwork to be collected and requests to be approved to get it done?”
Without prior authorization requirements, he added, “In some cases, we could get things fixed pretty quickly. Like a set of batteries: Most [service] drivers have extra batteries in their vehicles. They could go out [to the client’s home] and say, ‘Yep, you’ve got bad batteries. Here are new ones. Thank you. Bye.’”
The added cost of making house calls
In explaining why repairs frequently take so long, Grau said, “A lot of [consumers] don’t have access to transportation. Those wheelchair-accessible vans are not cheap. There’s very limited funding and coverage for people to take public transportation. With non-medical transportation, they can take it to go to the doctor or the dentist, but they’re not allowed to take it to come in for a [wheelchair] repair.
“So that means we have to go to the person’s home — which we’ll do when necessary. There are going to be some people who cannot get into our facilities. But if we can get additional people to come into our facilities, where we have more parts and we have all the tools, we can get it done quickly. I’ve worked on a power chair before. When it’s on the ground, it’s not easy. It’s a lot easier and quicker to bring it into a shop, lift it up and do all the work.”
Doctors no longer make house calls because they can treat more patients by seeing them in the office. But Grau said currently, 82% of repairs, on a national basis, are done in consumers’ homes.
“We have to protect those consumers who need service in their homes, absolutely we do,” he said. “But if there was funding for medical transportation to our facilities, as part of the continuum of care, I think a lot more consumers would prefer to come in and have their chairs repaired quicker and in a setting where we can check out a lot of different things to make sure everything is operating properly.”
But doing more repairs at provider locations only improves the process if prior authorization doesn’t stand in the way.
“Even if the consumer can bring their wheelchair in, and the diagnostics can occur right there, and all the things that are needed to fix it are right there — the repair cannot be done because the provider has to get a prescription and documentation that the person still has the disability, still needs the wheelchair, and is still using it,” Piriano said. “Then everything needs to be submitted for prior authorization, and we have to wait for the payer to determine if they will cover and pay for the repair, when you could literally fix it and send [the consumer] out the door in an hour. Unfortunately, they have to either leave their chair and go home with one that does not have the same intimate fit, or go back home with a chair that’s in need of repair. So yes, coming in is advantageous, except that you can’t do anything once they come in, and that’s a problem too.”
Provider perspectives: Inventory challenges, funding gaps
Even in the much more straightforward worlds of washing machine or automotive repair, dealers don’t stock every replacement part in existence. The same goes for complex wheelchair providers.
“We’ve got five major manufacturers of [power wheelchairs] out there, and they all have a lot of different parts,” Grau said. “There are some similar parts — batteries, for instance, and casters. But there are 75,000 different SKUs. There’s no way [a provider] can carry 75,000 parts.”
Most providers, he added, “will carry the top 25 to 40 parts across the board. They’ll have them in stock: battery chargers, batteries, casters, arm pads. But for anything like a motor, they’re going to have to order it. And motors change over time, too, as they get better. That’s why providers carry a lot of parts, but they can’t carry everything.”
From the provider perspective, another problem is lack of funding for critical portions of the repair process, such as commuting to the consumer’s home and, once they arrive, diagnosing the wheelchair’s problem. Unlike appliance technicians who charge service call fees to drive out and examine a homeowner’s dishwasher, wheelchair techs aren’t reimbursed for that time or expertise, even if the commute is long and needs to be repeated once the prior authorization comes through.
“Reimbursement is not there for us to be going to consumers’ homes, and it’s not there for the repair assessment time,” Grau said.
Mixed messages for manufacturers?
Complaints about the repair process regularly point fingers at manufacturers, especially power chair manufacturers, who are called upon to produce more durable products with longer warranties (see sidebar) … though without, of course, higher reimbursement rates for providers.
Piriano said manufacturers are, in fact, producing devices to high standards as required by the Centers for Medicare & Medicaid Services.
“For the chairs — at least in the power mobility space, which is where this typically comes up — to be code verified, there are dedicated, independent testing requirements in place,” she said. “They validate that chairs will last a five-year, reasonable, useful life.
“For the testing protocol — and especially when it comes to the drop and drum test, the strength and fatigue testing — the chairs literally get dropped 6,667 cycles. They’re run through the ringer. So the concept [that manufacturers should be making] better chairs — I can’t wrap my head around that, because they are required to be made to a standard that is pretty high.”
Piriano acknowledged that even rigorous testing can’t always duplicate real-life usage — the fact that some wheelchair riders stay mostly indoors, while others are in their chairs 12 to 18 hours a day and riding over rocks, gravel, concrete and other rougher terrains. That doesn’t mean chairs that need repairs weren’t built durably; it simply means they are being used.
“When you go through the doorway and you shear off your joystick because you cut it too close, that has nothing to do with ‘The manufacturer didn’t make it strong enough,’” she said. “They’re not tanks. You could add a whole bunch of different structural materials and welds and make it a really heavy beast of a chair that now won’t fit on the lift, right?”
Grau agreed: “We can make you a tank with a seating system, but you’re not going to be able to take it anywhere.”
Finding the way forward
The mainstream media has been quick to blame manufacturers and providers for repair problems — at least in part leading to right-to-repair movements in multiple states. But Grau and Piriano are hopeful that stakeholders can come together to effect change.
“The system was not set up by us or the consumer,” Grau said. “We’ve tried to reach out to payers and explain this to them. You’re seeing a spotlight being put on prior authorization overall in D.C. — not just for us. It’s time that insurers make common-sense changes. If a person has ALS [amyotrophic lateral sclerosis], they know [service must] be expedited. But for CRT in general, it has to be expedited because consumers could be stuck at home otherwise.”
Educating stakeholders is key.
“Trust users of the chair to know when something’s not operating properly,” Piriano said, advocating for “training them how to be good, first-class noticers. For wheelchair users, when it’s not sounding right, operating properly or not going the distance, they need to able to articulate that, instead of waiting until it dies to say, ‘My chair needs to be fixed.’
“But they’re very hesitant. They know they can’t be without their chairs. We’ve got to work to fix the problem and start regaining their trust, so that if something’s amiss, they’re not afraid to make the call.”
Grau added that the more that legislators and their staffs learn the complexity of the issue, the better they’ll see the entire challenge.
“If there’s anything we need to learn, it’s that all stakeholders need to work together,” he said. “It’s not just the providers or the consumers or the manufacturers or the clinicians or the academics. It’s everybody.”
Grau pointed to a hard-won 2023 funding victory. “We got one great thing done by working together, and that was seat elevation,” he said of Medicare’s coverage decision. “That took a long time, but we got it done because everybody was rowing in the same direction. Everybody wanted the same thing.
“This is that same issue. We want the same thing: quick repairs for wheelchairs. We’ve got to stop looking at each other and saying, ‘What’s your fault?’ Let’s work together to get this thing done. Because if we can do this, this is going to be fantastic for the consumers. It would be win, win, win for everybody.”
Piriano said the key is educating all stakeholders. “When we think about legislators and regulators who aren’t really part of the process — this has to be well defined and communicated. Then our group gets bigger, because legislators and regulators are, in fact, part of the process. They then influence the laws and the regulations that govern how this moves forward. It’s kind of exciting.”
Editor’s note: This story originally appeared in the August digital edition of Mobility Management.
