Don’t reduce K0011 reimbursement for true rehab

Saturday, January 31, 2004

C. Amortegui

It is no secret that the total dollars reimbursed by Medicare for the K0011 power wheelchair has increased substantially. CMS obviously wants to reduce this figure, so the easy way seems to be to lower the allowable for the code. The problem is that by doing this, they are only looking at the big picture and not what a lower reimbursement can truly mean.

The current allowable for the purchase of a K0011 ranges from $4,502 to $5,296.50. In a perfect world, this would cover the basic cost of the wheelchair and its delivery. In the real world this is not the case. When it comes to true rehab, many costs are hidden from those funding our claims.

Take a look at the basic steps performed by a rehab provider when supplying a client with a K0011. First, a representative of the company performs a wheelchair evaluation of the client. In many cases, this is completed with a therapist at a clinic. These evaluations will typically take anywhere from one hour to a half-day or more for those clients requiring specialty controls or seating systems. Once the proper product has been selected, the provider begins collecting and verifying information. This may include, but is not limited to,the CMNs, letters of medical necessity and progress notes. Once everything is received the product is ordered from the manufacturer(s). After its arrival, a second appointment is made with the client. This appointment is crucial. This is when all items are fitted to the exact needs of the client. This can be as basic as adjusting a footrest or properly adjusting the specialty controls and/or seating system to allow the client to safely use the wheelchair. Many do not realize that if a person is not seated appropriately, the wheelchair can actually do more harm than good.

In defense of current reimbursement levels, I am making a justification for true rehab companies - not for those who handle the bulk of their business over the phone. I do not consider a wheelchair evaluation to be a measurement of the client’s hip width and femur length, or even the frighteningly basic questions of height and weight. True rehab is far more complicated. My fear is that CMS is basing its decision on the “consumer market” delivery method. The wheelchair market needs to be viewed in two separate segments - consumer and rehab or seating & positioning. CMS needs to understand that if they base their decision on only one side of the story they will alienate a very large percentage of the population.

Medicare beneficiaries who qualify for a power wheelchair under the Medicare coverage criteria should have, at minimum, fairly complex clinical needs. This requires a specific level of expertise. What CMS must realize is that if they reduce the allowable, they are only hurting beneficiaries. Those providers that have the expertise required will no longer be able to provide such service, as the allowable will not cover all of the costs.

What worries me is that many beneficiaries who have received product from a supplier who “skips” all the steps have called other providers for help. This has been everything from wheelchairs that do not fit properly, to those that are unsafe. True rehab providers end up completing (and even sometimes starting) a job that should have been done by the provider that filed the claim and received payment.

Finally, if Medicare wants to use pricing information from other sources they cannot ignore the claims filing requirements and work required therein. A claim filed to Medicare is always more costly to file than to any other insurance. If they want to lower the reimbursement, they need to review the claims filing process and requirements. Clearly, this is an opportunity for Medicare to take cost out of their system and improve the turnaround time and hence, the cash flow of the equipment provider.

If the concern is lowering the overall dollars they may want to look at the actual claims that are paid that do not truly qualify under their coverage criteria. CMS needs to recognize that the medical needs of the beneficiaries requiring these items are typically complex. They just need to ask themselves a simple question. If your parent was diagnosed with ALS or was rendered a quadriplegic would you just want someone to “drop-off” their wheelchair at their doorstep and never look back? The statement “you get what you paid for” will hold true.

- Business consultant Claudia Amortegui is president of The Orion Group.