Playing by New Rules

As CMS seeks to hammer out a new way of doing business with the mobility market, a number of industry and advocacy organizations are trying to ensure that mobility providers, manufacturers and end users have some say in the crafting of new rules and regulations.

Among them, the American Association for Homecare’s Rehab and Assistive Technology Council, the National Coalition for Assistive and Rehab Technology and the Restore Access to Mobility Partnership have each sought to rally providers, educate legislators and establish a stronger working relationship with CMS. At this juncture, it appears these groups and others are making progress, albeit slow, in breaching a communication gap between the mobility industry and the agency — and in harnessing support from at least some legislators.

As Seth Johnson, chair of AAHomecare’s RATC notes, “2005 certainly ended better than it began, and 2006 promises to be a year of opportunity for this segment of the DME industry.”

Last year, Johnson says, the mobility industry got a “new and improved coverage standard that eliminated the archaic ‘bed or chair confined’ standard.” In addition, he says, delay of the Interim Final Rule until at least April 1 allows time for physicians to become educated on what is needed to substantiate medical necessity for power mobility devices.

Also, he believes, “the industry will have an opportunity to work with the government on the development of a modified final rule that addresses the remaining issues with the IFR, new power mobility device codes, fee schedules and a Local Coverage Determination that ties the new codes to the National Coverage Determination.”

Sharon Hildebrandt, executive director of NCART, describes the current mobility climate as being one of instability. “There’s a lot of change that has gone on, with the IFR that was issued then rescinded, and the power wheelchair codes that were put forth and then pulled back, so there is a lot of confusion and frustration.

“I guess ‘instability’ would be a good word to use. It’s hard for our members to know what to do.”

Still, she is encouraged by the reception to industry input from CMS and congressional legislators. “They’re very willing to meet with us and to work with us, and for that, we are very grateful,” she says.

“The clouds should lift for the mobility segment of the industry,” according to Johnson, who adds the caveat, “as long as the industry is united in our strategies and solutions to address these issues.”

And that, say organization members, is what they are all about. While there are overlapping issues, each group has managed to carve out its own niche within the larger mobility arena.

Here’s a snapshot of each entity, their goals and current focus.

AAHOMECARE’S RATC

The RATC is comprised of AAHomecare members who are manufacturers, providers and others active in both the HME and home health industries. Its goals, says Johnson, are to:

• Work with CMS to ensure a smooth transition period between now and the implementation of a new final rule that replaces the IFR;
• Assist CMS in developing a final rule that ultimately is in the best interests of Medicare beneficiaries and is supported by the industry, Congress and CMS;
• Advocate for the appropriate development of new power mobility device codes, a Local Coverage Determination and fee schedules that do not diminish beneficiary access to medically necessary PMDs;
• Continue educating CMS and Congress on the reasons why PMDs should not be included in competitive bidding; and
• Continue to educate suppliers on the evolution of the PMD benefit, and advocate for all mobility suppliers to get involved with developing these important policies.

“The RATC will continue to utilize its relationships with CMS officials, members of Congress, consumer groups and other stakeholders to achieve these goals,” he says. “In addition, the RATC plans to partner with other coalitions and stakeholder groups that share our goals and are interested in preserving access to medically necessary rehab and assistive technology.”

Johnson and his team aren’t naïve about the challenges that lie in the way of meeting RATC’s goals.

“The main challenge,” he says, “continues to be working on these interlinked issues independent of one another, since a change to one area — codes, for example — has the potential to impact another area, such as coverage.

“Another challenge,” he adds, “is keeping legislators and CMS officials up-to-date on the status and position of the industry as policies impacting providers and beneficiaries move through the process.”

NCART

NCART is a consortium of providers and manufacturers of high-end rehab products and services. The organization’s overall goals are twofold, says Hildebrandt:

• To provide some stability in the changing environment; and
• To maintain accessibility to rehab equipment for beneficiaries.

“We probably can’t increase access for beneficiaries,” says Hildebrandt about the latter goal, “but we would like to maintain access. It’s hard in this environment of cutbacks to increase accessibility, but we want to make it more equitable and reasonable if we can.”

To do that, NCART has lobbied legislators and forged a relationship with key CMS personnel, according to Hildebrandt.

In February 2005, the group sponsored a legislative “show and tell” on Capitol Hill to educate lawmakers about the what’s, how’s and why’s of rehab equipment and individual technology assessments.

With clinicians and therapists from throughout the country participating, NCART set up various stations at the Hill’s Rayburn Office Building to demonstrate how different pieces of equipment can help make people more independent.

One focused on the technical assessment a rehab technology supplier performs. Another featured seating and positioning technology, while others showed alternative positioning and standing devices. Hildebrandt believes the one-of-a-kind event was valuable for the 50 congressmen and staff aides who attended.

“They had no idea rehab and assistive technology was as [complex] as it was,” she said after the fly-in. Before the event, she said, “they just thought ‘a power wheelchair is a power wheelchair is a power wheelchair.’”

Currently, she notes, “We’re meeting with people at CMS [and] offering our assistance … particularly in the area of the IFR face-to-face exam, and providing them information on developing fee schedules.”

Hildebrandt explains that the methodology CMS uses to come up with new fee schedules “has not served the industry well. It has underpaid companies for many products.” To correct that, NCART is providing the agency with pertinent information that would help in setting more appropriate fees, she says. (See “Industry: Gap-Fill Just Won’t Work” on page 16.)

In addition, Hildebrandt says the organization is working with CMS to come up with transition policies related to the IFR and also on the final rule itself.

“Another thing we are trying to do,” she adds, “is to help our members establish HCPCS codes for products [such as standers, head supports, etc.].” NCART is also putting together a task force that will focus on manual wheelchair codes, she says.

But while much positive work is being done, there are challenges.

For example, Hildebrandt notes, “Competitive bidding [guidelines] are to come out any time now for implementation in 2007. That has very dire consequences for rehab technology suppliers because their clients are so individual.

“The kind of equipment they use is so specialized and so customized that trying to do any kind of competitive bidding on this would not give [beneficiaries] the equipment they need, nor would it cover the cost of rehab technologies.”

But the biggest challenge, she says, is trying to educate lawmakers and regulators about the rehab sector of the industry. If officials could understand that, perhaps the problems with competitive bidding, fee schedules and the like would disappear, she believes.

Currently, these officials seem to view rehab equipment the same as any other durable medical equipment, Hildebrandt says. “But it’s not like a hospital bed where you provide the product and you don’t have to do anything with it,” she says.

“With rehab, you’ve always got to follow the client. If they develop a decubitus ulcer or their posture starts to sag, they call on the supplier to help them. Often, the supplier is more familiar with the patient’s condition than the physician because [the suppliers] follow them for years.”

NCART is attempting to get that concept across. “We’re trying to educate lawmakers and people at CMS as to what rehab and assistive technology really is,” Hildebrandt says. “There doesn’t seem to be a good understanding … It’s up to us to educate them.”

RAMP

With members including AAHomecare, Invacare Corp., The Med Group, Mobility Products Unlimited, Pride Mobility and Sunrise Medical, the organization has called on industry stakeholders to communicate with CMS, the U.S. Department of Health and Human Services and congressional members on numerous issues, including the mobility NCD.

In addition, it has, both publicly and in correspondence to CMS, issued specific recommendations, such as urging that Congress delay implementation of the IFR.

RAMP applauded the rule’s subsequent delay, and has since asked CMS to take the time before the implementation date of April 1 to listen to the recommendations and concerns of industry stakeholders, as well as to educate physicians about the requirements for documentation that will substantiate medical necessity for power mobility equipment.

In a RAMP statement, Michael Hammes, Sunrise Medical chairman and CEO, said, “RAMP is very supportive of many of the changes, including the face-to-face exam rule requiring that a physician examine a Medicare beneficiary before power mobility equipment is prescribed.

“But our continuing concern … has been the confusion that exists among prescribing physicians and suppliers regarding the new documentation responsibilities of the respective parties. We urge CMS to use this additional time to provide prescribing physicians and suppliers with more detailed information to facilitate the necessary understanding.”

In addition, RAMP has recommended to CMS that it:

• Issue instructions clarifying that physicians may respond to a series of questions that are based on the May 5, 2005, National Coverage Determination for mobility assistive equipment, as long as the physician provides all responding information. In many cases, the organization notes, physicians are not educated on the coverage criteria, and suppliers typically are bearing the burden of providing that education to prescribing physicians.
• Work with national and state medical groups by providing articles explaining the new coverage policy and physician documentation responsibilities, as well as host seminars at their meetings.
• Create a Web-based education program to explain the new coverage policy, regulations and physician documentation responsibilities.
• Extend the time frame between the date of the face-to-face physician exam and the date that the physician provides the supplier with supporting documentation from 30 days to 60 days. Oftentimes, the group says, the 30-day time frame is not feasible.

RAMP has also stressed the importance of having CMS affirm that the documentation expectations outlined in the IFR will not be applied during a pre-or post-payment audit on claims for services provided during the transition period from Oct. 25, 2005 (when the IFR originally went into effect), to the effective date of the new regulation.

Hitting Too Close to Home

Medicare currently restricts the coverage of mobility devices to those that are medically necessary within a beneficiary’s home. But one thing most HME stakeholders agree on is that the restriction needs to be addressed. In addition to current priorities, both AAHomecare and RAMP have urged lawmakers and regulators to reconsider the coverage policy’s “in the home” language.

For example, HME advocates point out that a consumer who may not need a mobility device to function at home but needs the equipment to get to work, school, doctors or a place of worship would not be eligible for a wheeled mobility device. “Congress originally intended this restriction to differentiate between mobility devices that were used in an institution such as a hospital or skilled nursing facility and those needed outside an institution and, therefore, separately reimbursable under Medicare Part B,” explains an AAHomecare statement.

While many in the industry are pleased with CMS’ new National Coverage Determination for mobility, many also say they are disappointed the policy continues to limit wheelchair coverage to beneficiaries who need the equipment primarily in the home. But as CMS points out, the restriction comes from Medicare statute, so It would take an act of Congress — literally — to change it.

A number of mobility providers responding to HomeCare’s 2006 Mobility Survey (see page 8) have their own thoughts on the matter. As usual, they span a wide range of sentiments. Following is a sample of those expressed regarding “in the home.”

“Ask one of those making the rules, ‘Does your grandma or grandpa go out of their house with any item of equipment or service provided by Medicare?’ Of course the answer will be ‘Yes, if at all able.’ The ‘four walls’ is a dumb law, unless you want the walls to close in on your loved one at home.”

“I don’t know of a single client who only uses [his] wheelchair in the home. In fact, the wheelchair is needed mostly outside of the home.”

“If the equipment is needed by the patient, it should be provided without restrictions.”

“Too many people are excluded [who] need equipment.”

“I am not sure how CMS would draw that line so this is not abused. Changing the restriction, I feel, would definitely draw a lot of fraud.”

“It is widely known that patients who are able to leave the home by utilizing their mobility equipment are encouraged to do so by their physicians, caregivers, etc. Ignoring this … is unrealistic.”

“Patients have the right to use their power wheelchairs how and where they want. They shouldn’t be restricted to a walker. CMS needs to realize that a power chair is cheaper than a broken hip.”

“We are trying to make rules from the ‘30s fit into [a] 2006 lifestyle. Family life, general health and support systems have changed since Medicare was established.”

“CMS should put themselves in the patient’s shoes. Would they want the ‘in the home’ restriction for themselves or their loved ones? Quality of life is very important — inside and outside the home.”

“It’s absurd that 10 years after the Disability Act … our patients cannot get equipment to use outside the home, but that our community has made all of our buildings wheelchair-accessible.”

“The aim to improve quality of life and exclusion of use outside the home are contradictory.”

“People should have the right to mobility everywhere.”

“This interpretation of Medicare law was invented … as a means of restricting coverage for POVs.”

“We are encouraging people to stay active and to become employed, yet we are not providing them with the equipment they need to be able to accomplish these goals.”

“A patient who can walk a few steps to the bathroom and who might be able to do without a wheelchair in [his] own home becomes homebound, depressed and sicker when restricted to [his] home only due to lack of coverage for a wheelchair that would enable [him] to leave and interact within the community, i.e., church, shopping, senior centers, etc.”