Is It DME or Complex Rehab? Separate Benefit Proposal Shaping Up

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BUFFALO, N.Y. — The project steering committee continues
work on development of a separate Medicare benefit for complex
rehab and, according to Don Clayback, committee chair, they’re
making progress.

“It’s all about access to the products that fall under the
complex rehab technology banner,” Clayback said. “As providers
know, as individual clinicians know and as consumers know, there
are some barriers that prevent these products and services from
being provided, and we’re looking to address those.”

The group began work
on the concept last year, and since has held conference calls,
Webinars, a panel discussion at Medtrade and in-person meetings in
St. Louis and Nashville to gather input from stakeholders across
the HME mobility sector.

“It’s a very big project with a lot of details and nuances that
need to be addressed,” said Clayback, executive director of NCART,
during a Jan. 22 update. Each of the three major components that
will shape the separate benefit proposal — coding, coverage
and payment — takes thought from every angle, including how
any changes might impact the current system, “and we don’t want to
rush through,” Clayback said.

The massive effort is paying off, he believes. Past identifying
the big-picture objectives for a new rehab benefit — among
them recognition of the services involved with providing complex
rehab — the group is now working on fixes in five specific
areas: fee schedule, coverage and conditions for payment, coding,
claims processing and provider qualifications.

Details of the proposed changes will be finalized at a committee
workgroup meeting Feb. 1 and 2 in St. Louis, and the results will
be incorporated into a draft white paper to be released at the
committee’s next Webinar, scheduled for March 4.

Coding is a particular challenge “because CMS has had such a
tendency over the last five years or so to bundle items,” noted
committee member Rita Hostak, vice president of government
relations at Sunrise Medical. “The industry has suffered a lot
financially by these groupings,”  she said, “so what we did as
a coding workgroup was to take a step back and list everything that
is potentially HCPCS-related to wheeled mobility and seating under
a benefit category called complex rehab.”

That includes not only bases but also accessories, said Hostak,
and that gets into a discussion about “what is DME vs. what’s truly
complex rehab … Anybody that can provide complex rehab could
provide DME, but the opposite may not be true.” Hostak said her
workgroup put together a matrix to sort it all out “that gave us a
different way to look at these codes.”

Discussion of a draft code list will continue at the workgroup
meeting next week.

The committee is also looking at the best structure for coverage
changes in terms of power mobility, manual mobility and seating,
Clayback added.

The steering committee is “really looking at finding the right
balance” between making changes “that will get the improvements
that we desire while at the same time not adding any unnecessary
complexity or cost to the system … A lot of variables come
into that analysis, and that’s where the discussion is now,” he
said.

Related issues, such as elimination of the “in-the-home”
restriction, provider standards and credentialing and service and
repair are also being considered. “There have to be safeguards to
make sure consumers are getting the right services and right
evaluation,” Clayback said.

In the end, he said, one of the “intangibles” he hopes to come
from creation of a separate benefit “will be a greater appreciation
for the role and the services that a complex rehab provider gives
to their community.”

A recording of the Jan. 22 update should be available shortly,
Clayback said. In the meantime, comments to any member of the
steering committee are welcome:

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