Fla. Medicaid halts downcoding

TALLAHASEE, Fla. - Rehab providers have successfully lobbied the state to stop applying standard codes and prices to custom wheelchairs and components, a policy providers say has cost them hundreds of thousands of dollars and kept beneficiaries, mostly children, without appropriate wheelchairs. In January, providers say the Agency for Health Care Administration (AHCA), which administers Medicaid, began "scratching off" the codes and prices they had submitted for prior authorization and placing standard codes and prices in their place. "Providers didn't know what to do," said Bruce Bayes, president of Largo, Fla.-based Custom Mobility, which does up to 60% of its business with Medicaid. "When they downcoded, they dropped reimbursement by a couple of thousand dollars, and providers couldn't do the chairs anymore." And that's when AHCA processed prior authorizations at all, providers say. While the policy reduced Bayes' Medicaid business by 25%, Donna Batelaan estimates her company lost $350,000 in possible business. "Our AHCA office stopped processing claims altogether for four months," said Batelaan, part owner of the Lake Worth, Fla.-based Action Mobility, which does about 35% of its business with Medicaid. "It stopped our Medicaid business overnight." In a conference call last month, however, AHCA agreed to suspend the policy, largely due to numerous complaints from providers and families whose children's wheelchairs were denied or delayed. Bayes had even started a Web site, www.custommobility.org, to garner support for stopping the policy. Yet Mary Pat Moore, assistant deputy secretary for Medicaid Operations, said AHCA instituted the policy because it believed there was a need for a more uniform and accurate way to determine medical necessity for custom equipment and components, and it still stands by that belief. She said AHCA's currently putting together a work group to look at that need again. This time, though, she said it'd include providers in the process. "Unfortunately, we made these changes without their input before, and that put off a lot of concern and frustration," Moore said. Moore said AHCA instituted the policy because, while providers considered some equipment and components custom, nurses considered it off the shelf. In those cases, ACHA would request providers submit additional documentation, and providers had trouble doing that, she said. "There were questions of whether some of these claims were just standard chairs with some custom components or custom wheelchairs," Moore said. All agree that inadequate rehab codes exacerbated the issue. AAHomecare's Re/hab and Assistive Technology Council (RATC) is in the process of overhauling rehab codes. It just submitted 22 code applications for pediatric mobility base and wheelchair products and accessories, but they won't go into effect, if approved, until next year. Bayes said he knows the struggle's not over, but he's happy providers and families will have a hand in forming any upcoming policy. "They don't understand rehab and how adaptive equipment helps people," he said. "They just think that they're spending too much money on luxury wheelchairs, Cadillacs." Bayes said he tried to break down that misconception, as well as put "a face on rehab," with the Web site. It featured images of children in both standard and custom wheelchairs to show the importance of specialized equipment and components. He also posted dozens of letters to the site from people in the industry and families with disabled children. (At press time, the Web site had received more than 5,500 hits.) "We want to put together a group nationally and have this kind of information remain available on the Web," Bayes said. "Anyone experiencing a similar issue could use it as a resource." HME