Business Solutions
Complex Rehab: Adapting & Overcoming
As a segment of power mobility, complex rehab continues to face stormy seas, yet it continues to work so that it can rise above those challenges and thrive.
- By David Kopf
- Sep 01, 2016
Power mobility is one of those sectors of the HME industry that
has been beset by a number of challenges: competitive bidding, the removal
of the first-month purchase option, and the application of competitive bidding
pricing to accessories for complex rehab devices that were thought to be
protected from competitive bidding.
These changes are not minor. For instance, the removal of the first-month
purchase option completely upended the standard power mobility industry,
and forced those providers — as well as their vendors — to completely reinvent
the space.
Currently, power mobility’s struggles are personified by the complex rehab
component of the market. The CRT segment is doggedly pursuing legislative
options to improve the situation for its vulnerable beneficiaries, while still
continuing to provide them the products and services that they need.
Let’s take a look at where things currently stand and what CRT providers must
do to ensure they continue to adapt and ultimately thrive.
Protecting Complex Rehab
The industry is looking to address two key issues through legislation: To protect
wheelchair accessories from competitive bidding prices, and to finally make
complex rehab a separate benefit.
When it comes to accessories, they were temporarily protected from bid
As a segment of power mobility,
complex rehab continues to face
stormy seas, yet it continues to
work so that it can rise above
those challenges and thrive.
pricing for 2016 by legislation that was passed in late 2015. This was intended
to give the providers time to work on a permanent fix to protect those items,
but the temporary fix wasn’t instant and for the first six months of the year CRT
providers and patients had to endure the lower reimbursement rates.
“The intent was for the one-year delay to be implemented Jan. 1, 2015,
and carry CRT providers through the end of this calendar year,” explains Seth
Johnson, vice president of government relations for Pride Mobility Products and Quantum Rehab. “Medicare said, ‘Congress can’t expect us to implement a bill
that they passed late in December that quickly. It takes us time from a systems
perspective to get things in place and operational.’
“So it took Medicare until July to get everything right in their system,” he
continues. “But there is a mechanism in place for providers to go back and bill
back for the additional amount, because they would have been paid at a lower
amount for any claims that they filed prior to the July 1.”
Needless to say, the irony of saying it needed more time was rich. Regardless,
the industry used the time to advance legislation that would fix things for good.
There are two bills that aim to permanently protect patient access to complex
rehab wheelchair accessories from CMS’s competitive bidding program: H.R.
3229, which Rep. Lee Zeldin (R-N.Y.) launched in the House, and S. 2196, which
was introduced into the Senate by Sen. Robert Casey
(D-Pa.). Both bills aim to nix CMS’s plans to apply
competitive bid program pricing to complex rehab
wheelchair accessories.
Under the title of “To amend title XVIII of the Social
Security Act to provide for the non-application of
Medicare competitive acquisition rates to complex rehabilitative
wheelchairs and accessories,” the bills do just
that: ensure that competitive bidding is not applied to any
wheelchair accessory, cushion, or back when furnished in
connection with a complex rehabilitative manual or power
wheelchair.
As of press time, the bills are in good shape with the
House bill backed by 136 co-sponsors and the Senate
bill garnering 24 signatures.
That’s an immediate need, because we did get a partial
delay last year,” says Don Clayback, executive director of
the National Coalition of Assistive & Rehab Technology
(NCART). “But that expires at the end of this year, so we
continue to push for a permanent fix this year.”
The fact that Medicare applied competitive bidding
to CRT accessories has been a sore point for most in
the industry. For providers that might recall, a provision
of 2008’s Medicare Improvements for Patients and
Providers Act (MIPPA) was supposed to protect complex
rehab from competitive bidding.
Most thought that naturally included accessories, but
CMS decided to apply very strict interpretation of the
law — at least on that day — and has been working to
competitively bid rehab items such as aftermarket seat
backs, which fall under the broad definition of “accessories.”
Trying to understand why CMS would use its
authority to apply those rates to CRT items, when the
beneficiaries of such items has resulted in equal parts
puzzlement, frustration and consternation.
“CRT was carved out,” says Packer, president of the
U.S. Rehab division of VGM Group. “We still believe
that CMS wasn’t accurately reflecting Congress’ wishes.
They are playing with technicalities and they are playing
with patients’ lives. … So we’ve moved into the realm
of following the legislative method, versus trying to sit
down and communicate strategically with CMS to solve
problems — because they’re not listing.
“So we as a company in VGM and me as the president
of U.S. Rehab have taken the stand that we will fight to
protect patient access to complex rehab equipment
that is not like standard equipment that is out there,” he
continues. “It requires much more training, it requirement
much more thought and fitting and customization.
And we believe that Congress is on our side.”
“To me CMS was overreaching,” Clayback says,
trying to parse CMS’s argument. “Their position is that,
‘Well, some of these codes were competitively bid.’ So,
because some of those codes were competitively bid
that permits them to apply competitive bid pricing.
“Our counter argument is that some of these codes
may have been bid, but the complex rehab accessories
were not part of the competitive bidding program,” he
continues. “So the information you received for some of
these codes really were for the standard items that were supplied under those codes, not the complex items.”
Clayback underscored the point by noting that CMS had been paying the
traditional reimbursement rate for those items under those codes for CRT for six
or seven years prior. In any case, the industry must prioritize the legislation and
leverage the fact that it is so widely supported in order to get it passed sooner
rather than later, says Tom Powers, director of SML at Government Relations for
VGM Group.
“I think it’s important to mention as well that there are more than fifty some
organizations that are closely association with this arena, that have sent letters of
endorsement for this legislation,” he notes. “It has large bipartisan support, large
coalition groups that are supporting this legislation, and it’s time to pass it.”
Separate Benefit
The ongoing need is to make complex rehab a separate benefit. The House
bills working to advance that agenda is H.R. 1516, which was reintroduced by
Rep. Joe Crowley (D-N.Y.) and Rep. Jim Sensenbrenner (R-Wisc.), the members
of Congress, who introduced a CRT separate benefit bill to the previous, 113th
session of Congress. The Senate companion is S. 1013, which was introduced by
Sen. Thad Cochran (R-Miss.) and Sen. Chuck Schumer (D-N.Y.).
The bills quit simply call for revising Medicare so that complex rehab technology
(CRT) a separate benefit category under Medicare. CRT be separate
benefit under the DMEPOS umbrella, in the way that orthotics and prosthetics
are separate. This would help protect CRT from any future funding threats.
Presently, 169 Representatives back H.R. 1516 and 18 Senators back S.1013.
However, the effort to make CRT a separate benefit is in a bit of a holding
pattern, as Clayback mentioned, in order for the industry to focus on protecting
accessories from bidding.
“That really is the longer term solutions, because once these items are properly
recognized and separated, it enables Medicare and CMS to develop better
coding and more specific coverage policies, and to raise some of the standards
for providers of this more specialized equipment,” Clayback says.
What Should Providers Do to Help?
Right now, the front burner item is obviously trying to get H.R 3229 and S. 2196
passed in order to protect accessories.
“The message is that providers need to make sure that all three of their
members of Congress have signed on,” Clayback says, noting that NCART has
created a “three-start CRT advocate” status that it gives to members who have
their Representative signed onto H.R. 3229 and both Senators signed onto S.2196.
“We need to continue to create the co-sponsors for the bill, which will further
heighten the awareness and the priority that Congress needs to be giving that.
To supplement that, NCART and other advocates continue to have meetings
with committee staff, and Clayback say that they are making progress, but the
Capitol Hill efforts are nothing with grassroots support turning up the noise
level on the issue. Reason being is that Congress will have a laundry list of issues
it needs to address, while sandwiched between the summer recess and the
coming election.
“We need more co-sponsors, given Congress’ very busy agenda and the very
short period of time they are going to be in session, because only the things that
have the highest priority are going to get attention,” Clayback says. “The more
members we can get signed onto our bill, that provides evidence to the leadership
in Congress that these bills have a broad base of support across the country.”
“But the most needy [legislative effort] is to get everyone to call their members
of Congress in support of H.R. 3229 and S. 2196,” Powers says. “We have strong
bi-partisan support. It’s looking positive, and the GAO report was pretty positive,
so we’re feeling good that we can expect some kind of legislation to pass.”
That Government Accounting Office report was a crucial bit of help the
industry needed to build it’s case. Released in June, the study showed that the
bidding expansion cuts, which CMS implemented on July 1, will sharply reduce
funding for needed complex rehab wheelchair accessories. This provided a
strong argument for supporting H.R. 3229 and S. 2196.
The report, “Medicare: Utilization and Expenditures for Complex Wheelchair
Accessories” (gao.gov/products/GAO-16-640R) showed that accessories for
Group 3 CRT chairs, which are needed by those patients in order to properly
use the chair and function, accounted for an outsized amount of wheelchair
spending, and would be greatly cut by the July 1 cuts.
Of the 603,000 wheelchairs CMS supplied in 2014, 13,000 of those chairs were
Group 3 wheelchairs. This accounted for approximately 2 percent of the total
number of wheelchairs purchased, but accounted for 22 percent of total wheelchair
expenditures — approximately $69 million of the $620 million CMS spent
on wheelchairs.
Furthermore, accessories used with those Group 3 accounted for 18 percent
of all accessories provisioned and 51 percent of all accessory expenditures
— roughly $159 million) of all accessory expenditures.
Also, the report showed that Medicare expenditures on accessories used
with Group 3 chairs were concentrated in a small number of accessories, with
the top accessory being a combination tilt and recline power seating system.
That single accessory accounted for an estimated $56 million, or 35 percent of
total expenditures on Group 3 accessories. But, while the data showed that the
majority of Group 3 patients need these accessories, it is estimated that reimbursement
for them will be cut by 10 percent to 34 percent the full competitive
bidding adjusted rates are implemented on July 1, according to analysis by the
American Association for Homecare.
If providers can use data like that to steadily help support the legislation, then
it will be in a good enough position that the industry’s champions in Congress
can identify a larger piece of legislation the could attach the legislation to in
order to move it through the legislative process. At least that’s the goal.
“It’s a challenges, because Congress is only going to be in session for part of
September, and there are a lot of other distractions that are going on with the
election, but that remains our objective,” Clayback says. “If not, then we go to
Plan B, which is when Congress comes back from elections and they’re going
to be in the Lame Duck session, there is definitely going to be some year-end
legislation, and we would work to get included in that like we did last year, only
this time it would be the permanent fix.”
In addition to that, Clayback suggests that in the same way that providers
constantly work to educate their federal lawmakers on the value of CRT and the
importance of protecting patient access to it, that they should also communicate
those same messages to their state legislatures in order to protect
Medicaid funding.
“I think that from a provider perspective, if they can continue to support
their associations and help educate their state legislators, because … with the
challenges some state legislatures face with their budgets, this idea of carrying
on the CRT message is important,” he says. “CRT providers need to make sure
they’re active on the advocacy front.”
But for right now, the call is out to support H.R. 3229 and S. 2196 this month,
because of the timing and because providers might have an even stronger case
to make.
“Based on conversations with House and Senate champions, they’re looking
at the earliest opportunity, and there might be an opportunity to advance that
in September, so that’s what we’re focused on right now,” Pride’s Johnson says.
“ … We’ve also been told that the GAO might be updating their report that they
released in June with the payment data that Medicare released in late June that
went into effect July 1.”
That would be released this month, Johnson says, adding that, “We’re
hopeful that would underscore the need to pass legislation for the permanent
protection of complex rehab wheelchair accessories.”
This article originally appeared in the September 2016 issue of HME Business.