ATS Requirement Still Murky, Stakeholders Say

ATLANTA–A CMS regulation regarding assistive technology
suppliers is still evoking concern and confusion, even though it
was implemented April 1, industry stakeholders said last week.

The new regulation requires that Group 2 single- or
multiple-power option power wheelchairs and any Group 3 or Group 4
PWC or a push-rim activated power assist device for a manual
wheelchair come from a supplier employing an ATS “who
specializes in wheelchairs and who has direct, in-person
involvement in the wheelchair selection for the patient.”

The ATS must be certified by the Rehabilitation Engineering
& Assistive Technology Society of North America (RESNA).

While industry stakeholders applaud the requirement, saying it
is a mark of professionalism, there has been some confusion over
how the ATS can be employed: as a W-2 employee or as an independent
contractor. Concern heightened in January when CMS issued its
proposed supplier standards. In a change to existing standard No.
1, the agency is proposing that suppliers providing licensed
services not be allowed to contract out those services.

“We’ve had a number of questions as to whether you
were allowed to contract, and all were submitted to CMS because the
[Local Coverage Determination] did not provide anything
greater,” said Anjali Weber, director of certification for
RESNA.

Perhaps to address that and other questions, on May 5 the DME
MACs issued an FAQ on the subject. In its clarification of the word
“employ,” the document reads: “The ATS must be
employed by a supplier in a full-time, part-time or contracted
capacity as is acceptable by state law. The ATS, if part-time or
contracted, must be under the direct control of the
supplier.” (According to the FAQ, the term “ATS”
refers to either an ATS or an assistive technology practitioner,
ATP.)

Still, the issue is confusing, said Tim Pedersen, ATS, president
and CEO of WestMed Rehab in Rapid City, S.D.

“The [DME MAC] medical directors don’t feel that
they are the ones that should be deciding what the status of the
employment arrangement is. But they have said the ATS must be under
the clear control and direction of the supplier,” Pedersen
said.

Both he and Weber said they have concerns about contracting an
ATS.

“The LCD says it has to be documented in the client file
that a RESNA-certified ATS working for a supplier is directly
involved, not just signing off. But the requirement is there only
for the recommendation,” Weber explained. “CMS is not
requiring that the same person come back for the delivery.
It’s an issue of continuity of service, optimizing that
equipment and making sure that the equipment is operating
effectively.”

Pedersen agreed. “I have always been a believer in best
practices. Best practices dictate that the ATS should be a full
employee of that organization and not merely a hired gun,”
said Pedersen, who has three ATSs on his staff beside himself.
“I think we encourage proper compliance when we have an ATS
who is a full-on employee of an organization.”

Jerry Keiderling, president of U.S. Rehab for Waterloo,
Iowa-based VGM, said he, too, believes the ATS needs to be on
staff.

“You tend to lose control over marketing or referral
sources [if personnel is contracted],” he said. “I
would want full control over my employees.”

Stakeholders said that questions have also surfaced on whether
there would be enough ATSs to meet demand.

Weber said that beginning last year, RESNA stepped up the number
of times it offered the test for the credential. “We made a
real effort in the last 18 months to make the exam available in
every part of the country,” she said, noting that it was
offered 56 times last year and at least 20 times so far this
year.

“Because of the April 1 deadline, we had a surge in the
providers sitting for the exam,” she noted. But not everyone
passes, she said. The certification requires, among other things,
that the person taking the exam be employed for two years in the
field.

“Because they don’t have the formal training or
don’t have the experience, there are those who are not
passing,” Weber said.

Still, business has been brisk. “We’ve certified
3,800 so far,” Weber said. That number is up from 2,812 at
the end of October 2007, when there were 1,138 ATSs and 1,674 ATPs
in the country.

But are the 3,800 enough to meet demand? Stakeholders said they
aren’t sure.

“I don’t know if that is calculable,” Pedersen
said, adding he doesn’t believe there is a shortage.

Cody Verrett, ATS, national sales director of Quantum Rehab for
Pride Mobility Products, Exeter, Pa., also couldn’t say if
there was a shortage, but he noted another concern.

“I think we are going to see some attrition in complex
rehab,” he said, adding that providers who have in the past
supplied such equipment but who now do not have an ATS will be
unable to service those same clients.

That business will move to well-established, long-term
providers, he surmised.

Providers supplying the pertinent equipment without the ATS are
in jeopardy, said Keiderling.

“If you don’t have an ATS at the time of the
evaluation and the billing, that is actually fraudulent
billing,” he pointed out.

How that is going to be policed hasn’t been stipulated.
According to the FAQ, “the medical directors have not
mandated how suppliers document compliance with the ATS …
requirement.”

However, it continues, “There must be evidence in the
supplier’s file of direct in-person interaction with the
patient by the ATS in the wheelchair selection process. Suppliers
must document how the ATS is involved with the patient.”

Even with release of the new FAQ, there is still enough gray
area in the regulation for concern, stakeholders said. But Pedersen
said he believes some of the gray could become clear if quality
standards were in place.

“I do believe that this is another reason we need the
quality standards in place,” Pedersen said, specifically
referring to the contracting issue. “The quality standards
could be a method of addressing this through the accreditation
bodies.”

Calling the CMS system “backwards,” Pedersen noted
that “we have accreditation requirements but no quality
standards. They can’t hold us accountable to draft standards.
There are no rehab quality standards in existence today except in
draft standard form.”

Meanwhile, as they wait for these issues to clear up,
stakeholders are hopeful that providers will continue to send
employees to take the certification exam.

One ATS employee may not be enough, Keiderling said, because the
certification stays with the person, not the provider. “What
happens if that person starts seeing the grass as being greener on
the other side and they leave?” Keiderling asked.

He knows it can be expensive and that has likely stopped some
providers from sending multiple people to take the test. The
200-question exam is $500 the first time, he pointed out, $250 the
second and third times. Sometimes, travel is required to the
location where the exam is being administered. That means
transportation costs, hotel and meal expenses.

Weber said RESNA is working on cutting those costs; it expects
to institute computer-based testing in 2009.

And that, said Verrett, “is definitely going to make it
easier for providers to get tested and be compliant. It will
definitely make it easier to become certified. That’s a good
thing.”

Julie Piriano, PT, ATP, director of rehab industry affairs for
Quantum Rehab, said the computer-based test would offer another
plus: quick results. Currently, Piriano said, it can take as long
as eight weeks to get test results. “With computer-based testing,
[people] will know right away and be able to go forward and see
patients,” she said.