Separate benefit for complex rehab

Monday, April 5, 2010

BUFFALO, N.Y. - Industry stakeholders dedicated March to collecting comments on their discussion paper detailing a separate benefit for complex rehab. What did they hear about most? A decision tree that they created to help providers determine whether or not a Medicare beneficiary needs a complex rehab evaluation.

Some providers worry that it may be too far-reaching.

"The intent is to keep it to a finite group of beneficiaries," said Don Clayback, executive director of NCART, which is leading efforts to create the separate benefit. "Everyone who needs a power wheelchair doesn't need to go through the process."

(See below for an outline of the decision tree.)

Another worry: The yet-to-be determined "additional requirements" needed beyond RESNA's ATP certification to provide complex rehab products and services. Possible requirements: RESNA's new seating and mobility specialist (SMS) certification and NRRT's CRTS credential (albeit an enhanced version).

"We don't want to add an unnecessary burden on the supplier," Clayback said. "But we are looking to tighten up some of the standards."

Industry stakeholders plan to respond to the comments they've received so far and make clarifications in an upcoming FAQ.

All in all, however, providers have been relatively mum on efforts to create a separate benefit.

"I don't think anyone would accuse us of not being open and transparent, yet we're not getting the volume of comments that we expected," said Tim Pederson, a member of a steering committee working on the separate benefit. "That's a concern."

Industry stakeholders plan to hold another Webinar this month, updating providers and giving them another opportunity to comment. They also await a report from Avalere Health Group providing a legislative and regulatory roadmap for making the separate benefit a reality.

In the meantime, at NRRTS's Continuing Education and Legislative Advocacy Conference (CELA) in Washington, D.C., later this month, providers plan to prime the pump.

"It's going to be THE ask-for," said Simon Margolis, the group's executive director. "We want to tell lawmakers, 'When the complex rehab benefit package passes your desk, we want you to support it.'"

Decision tree for complex rehab

Does the beneficiary have a permanent need for wheeled mobility? If no, the beneficiary doesn't have to go through a complex rehab evaluation.

If yes, does the beneficiary have a qualifying diagnosis (for example, multiple sclerosis or muscular dystrophy)?

If yes, the beneficiary has to go through a complex rehab evaluation. If no, does the beneficiary use the wheelchair for more than four hours per day and have a condition that hinders his ability to perform aids to dialing living (ADLs), or propel or control a wheelchair, or maintain a stable seated posture (for example, a neurological impairment)?

If no, the beneficiary doesn't have to go through the evaluation. If yes, the beneficiary has to go through the evaluation.