Observation Deck

Ensuring a 'Sure Thing' Stays Sure

Is the separate benefit threatened by competitive bidding and complex rehab as capped rental?

• By Julie Piriano
• Sep 01, 2013

If the industry has anything to say about complex rehab’s position in the Medicare program, we are on the right track for a successful outcome despite some new and ongoing threats that came to light at the beginning of July. Our voice is strong, our message is clear and unified, and Congressional support is building for H.R. 942 and S. 948, the “Ensuring Access to Quality Complex Rehabilitative Technology Act of 2013.” We are continuing to identify consumer, clinician, and provider constituent leads in order to form 435 advocacy teams across the nation to communicate with members of Congress about complex rehab technology (CRT) on a regular basis. So, what could possibly threaten the viability and success of complex rehab?

On July 1, Medicare’s competitive bidding program went into effect. While complex rehab has been and remains exempt from inclusion in this fatally flawed program, much of the fallout from its impact is threatening complex rehab providers that previously offered the full spectrum of products and services in their local communities. Many individuals with chronic medical conditions, complex medical needs, and disabilities rely on their local provider to supply not only their complex rehab manual or power wheelchair, but they also rely on them to provide the other products and services necessary to be discharged home. A hospital bed and mattress or support surface, oxygen, CPAP, BIPAP or respiratory assist devices, enteral nutrients, and diabetic supplies are all critical components of the homecare spectrum that allow individuals who use complex rehab technologies to remain in their homes rather than be forced into an assisted living facility.

For those providers who did not win a contract to continue providing the items and services that are included in Round Two of the competitive bidding program, this is a significant hit to their business and severely threatens their ability to continue providing complex rehab technology.

In addition, many independent complex rehab providers relied on the cash flow of their standard manual wheelchair and Group 2 powered mobility business to support the small percentage of labor intensive complex rehab business they have, especially in the urban and rural areas of the country. Since these providers were able to grandfather their patients in over the course of the rental cycle, there is a window of opportunity to save their businesses as they fight, in lock step with the rest of the industry, to stop the current competitive bidding program and replace it with the market pricing program (MPP) industry alternative. Without these local, independent providers’ ability to service their standard manual and power DME customers in the future, there will be an increased burden placed on complex rehab providers, who still have their doors open, to repair the abandoned patients’ beneficiary owned equipment.

On July 2 there was a proposed rule from CMS posted in the Federal Register regarding a “Clarification of the Definition of Routinely Purchased Durable Medical Equipment (DME)” that includes complex rehab codes. The proposed rule asked for comments on the reclassification of 80 HCPCS codes from the inexpensive or routinely purchased payment category to the capped rental category.

The list included 51 codes related to manual and power wheelchairs, options, accessories, and repair parts, most of which are complex rehab items. Converting these items to rentals is impractical at best. For example, the rule proposes that a breath tube kit (E2326) used for a sip and puff drive control system become a rented item.

As a reminder, complex rehab power mobility bases already fall into the capped rental category, but retain the first-month purchase option for beneficiaries who elect to have the claim processed in that manner. It should be noted that the proposed rule does not eliminate the purchase option for these bases, but it does propose to change how power seating functions, alternative drive controls, and the electronics used to operate them, most of which were clearly identified as complex rehab technology, would be paid if this proposal is allowed to go forward as outlined.

The proposed rule not only threatens the provision of tilt in space (E1161) manual wheelchairs, it also recommends that all pediatric manual wheelchairs (E1232 – E1238) become rental items. While the combined utilization of all seven pediatric HCPCS codes under Medicare is less than 400 units annually since they were first implemented in 2003, the ramifications of this change on the provision of these products under the Medicaid program are significant. The proposed rule also listed HCPCS codes that can only be billed to the Medicare program after the beneficiary already owns the equipment. These codes include push rim power assist wheels (E0986) as well as motors, gear boxes, actuators, controllers, and pneumatic tires. These replacement parts are not necessarily complex rehab items, but they are used to repair mobility assistive equipment that allows beneficiaries to retain their mobility and remain safe and independent in their homes and communities.

Many national organizations, providers, and manufacturers were working together as of press time to submit strong comments in opposition to this proposal in a very succinct, targeted, and coordinated manner, prior to the Aug. 30 due date. While we wait to see how CMS responds, we must come together and continue the advocacy efforts necessary to ensure the legislative language outlined in the “Ensuring Access to Quality Complex Rehabilitative Technology Act of 2013” is included in a bill that moves this fall. This effort cannot be accomplished without the dedicated efforts of every stakeholder involved in the provision of complex rehab technologies.

Consumers, caregivers, clinicians, physicians, providers, and manufacturers are working together, as constituents, to convey their message not once, but in an ongoing effort to their members of Congress. Every one of us has a compelling story about what we do, why we do it, and why it is critical that we secure passage of legislation to create a separate benefit category for complex rehab technologies under the Medicare program.

If you have not been contacted yet about participating in this effort, and are willing to contribute a small portion of your time, please contact NCART and visit www.access2crt.org. There are dedicated individuals who are working tirelessly to build their advocacy teams, putting them in motion, and making headway with their legislators. They cannot do it alone. They need each and every one of you to get involved to advance this initiative and overcome the threats to its success.

This article originally appeared in the September 2013 issue of HME Business.