Living Without the First-Month Purchase Option: ‘We’re not Thrilled’

ATLANTA — Medicare’s elimination of the first-month purchase option for Group 2 power wheelchairs is entering its third week, and already problems are surfacing that reach beyond the bottom line, according to mobility providers and others.

CMS implemented a new reimbursement model on Jan. 1 that effectively turns standard power wheelchairs into rentals. Rather than getting paid up front for the expensive products, providers must now wait 13 months for the full payment.

Even though it is early in the game, stakeholders are reporting issues ranging from beneficiary access to clear guidance on provider compliance requirements.

“We’re not thrilled with the process,” said Jim Greatorex of Black Bear Medical in Portland, Maine. “The problem we are seeing is not so much financing, although we are certainly going to have to limit our choices as to what people get. The biggest issue is catching the clients who go into skilled nursing facilities and having to take [the wheelchairs] away from them.

“We’re having to be the bad guys. We’re going to have clients furious at us for taking their power wheelchairs away … We’re talking about a very emotional thing here.”

He’s also disturbed that patients who go 60 days without the benefit because they are hospitalized or in another facility will have to be re-evaluated all over again to prove medical necessity once they are released.

“Again, who is going to be the villain in this?” Greatorex asked. “Those are extremely negative experiences we are going to have with our clients.”

“There is more than a payment methodology change,” acknowledged Julie Piriano, director of rehab industry affairs for Pride Mobility Products in Exeter, Pa. “There is some concern with regard to effectively managing through the long-term, 13 months of capped rental.”

Documentation is relatively clear for static situations, Piriano said, but beneficiaries are rarely static. They move around. They travel. They go in and out of hospitals and nursing facilities. Once released, they might go to a relative’s home for a time rather than their own home.

“There is no clear guidance once it gets complicated,” Piriano said. “The logistics of the documentation and the condition of the equipment are really of concern … When there is a break in service like that, this is expensive equipment and you can’t keep track of where it went or who took it. That’s a high-value asset to lose.”

The issue becomes even murkier if beneficiaries live outside a competitive bidding area and travel into a CBA.

“Grandfathering rules do not apply,” Piriano said. “So again, there are a lot of down-in-the-weeds compliance issues that providers are grappling with because they do want to provide the equipment, but they want to make sure that once they receive the money, they will get to keep it and not have to give it back because of a technicality at the start of the program.”

That has caused providers to be very wary in providing standard PWCs, she said. “Some companies are hanging back a little, not wanting to have too much risk and liability,” Piriano said. “Some have indicated that they can’t make the transition at this time, at least in the short term, until they see what the lay of the land is economically.”

Medical directors for the four DME MACs are aware of the problems, she said, and are working to come up with some solutions. “But the need for guidance is pretty immediate,” she said.

Meanwhile, there is the beneficiary access issue.

“It is pretty early, but some things are becoming evident,” said Tim Pederson, ATS, president and CEO of WestMed Rehab in Rapid City, S.D. “We are taking a hard look at who we are providing service to and under what circumstances. And we are looking at the type of equipment we are providing. If it is a high-risk situation and is going to come back in pieces, we’re probably not going to provide it.

“I see us being very selective under a rental [program],” he said. “I think the mindset is different from when we provided a power wheelchair that people own at the outset.”

Pederson said he has heard of some companies getting out of the Medicare standard power wheelchair business altogether. “And that is always a possibility for us, as well,” he said. “We are concentrating on the complex side and less on the noncomplex.”

Greatorex said he, too, must limit his standard power wheelchair business. “We are not probably going to be able to help people with their bariatric products,” he said. “You’re looking at a client whose health stability is probably not very good. Usually, the wear and tear on those products is pretty high. We are really seriously having to look at every one of those and we are not taking them all.”

Darren Tarleton, president and CEO of Mobility Warehouse in Stockbridge, Ga., said he has pared down his Medicare business so it comprises only about 20 percent of his revenue. So the elimination of the first-month purchase option is not affecting his business too much.

Still, he is not in favor of the policy and he doesn’t believe it will achieve what CMS is projecting: cost savings for Medicare.

“I really don’t see it saving money in the long run,” he said. “The average person is going to live longer than 13 months. There are much bigger problems in the system and I think [CMS is] focusing on something that in the short term looks like it will save money.”

Stakeholders said they weren’t holding out a lot of hope that the policy would be repealed. “It’s a terrible policy, but I wouldn’t be surprised if we’re stuck with this,” Greatorex said.

That could happen, said Seth Johnson, vice president, government affairs, for Pride. “Legislative options to delay [elimination of the] purchase option at this point are very remote,” he said, adding, “We are continuing to work with CMS and its contractors to secure additional guidance and clarification to assist providers in transitioning to the [new program].”