The Centers for Medicare and Medicaid Services (CMS) is operated by the Federal Government, they set codes and fee schedules to all Medical Equipment and Services. They determine what is appropriate and necessary based on reported information about the patient. With any government agency there are requirements to meet their determination of medical necessity. All other insurance providers follow the governmental plan, so everyone should be concerned when Medicare makes a change and their requirements.
Mobility Related Activities Of Daily Living-MRADLS
This is a fancy way of saying what you do in a day. MRADLs as they are commonly called, and need to be reported to any insurance; as this is how a medical reviewer can create a picture of the beneficiary needing the equipment. Although Medicare is diagnosis driven, there is a lot of variance within a diagnosis, which needs to be documented and explained. One person with MS (Multiple Sclerosis) maybe ambulatory, and the other in a multiple function powered wheelchair. Mobility Related Activities of living is a way of explaining what an individual can/cannot do, and explain why seating and mobility equipment is being recommended.
For an individual who cannot ambulate, getting around the home is a challenge. Additionally they may or may not be able self feed, toilet, transfer, get out of the home, or some other activity of living. These items help justify or deny the new equipment needed.
Medicare Hierarchy of Equipment (Complexity)
You may have heard Least Costly Alternative to solve medical needs. This is true with Medicare and their reviewers look for information in the medical records that explain why the individual cannot ambulate, why they cannot use a cane/walker, then they look at a standard wheelchair, then a light weight wheelchair, then ultra light weight wheelchair, the scooters and finally a powered wheelchair. The powered wheelchair is on top of the mountain and as such requires the most documentation to support the need.
A Good Medical Equipment Supplier
This has never been as true as it is today. In the past your supplier was just that a company who provided and serviced the equipment. With all the new rules/requirements, your equipment company will navigate the system and reduce the amount of time involved.
This is where you need a good team to help you. Documenting and Submitting a request to Medicare is a challenging process, and over the past few years has gotten much more difficult. You will need to find a supplier that will help guide you through this process.
Medicare requires a Face to Face (F2F) visit for all powered mobility equipment. This requirement now affects most other medical equipment as well. The Face to Face is a visit with your physician where you are present, and where the reason for the visit is to discuss Seating and Mobility Equipment. The physician must document what he does in a normal visit; vital signs, list of conditions, list of needs, etc. The physician must document your ambulatory status, your need for assistive technology ranging from the cane, walker, wheelchair, scooter or powered wheelchair. The physician must document how you presented to them in the office. If you physician has a challenge with the level of documentation required, they may refer you to a physiatrist (physical medicine doctor), or a physical or occupational therapist who can further describe your conditions.
In today’s medical model, most physicians are not familiar with seating and mobility equipment, so after they provide the Face to Face document, they generally refer a patient to a physical or occupational therapist.
During this therapy evaluation, the equipment supplier should be sending their RTS (Rehab Technology Supplier) to be present to be part of the team who assesses and recommends the most appropriate equipment to fulfill your mobility needs within the Insurance Guidelines.
The therapist is responsible, through their letter of medical necessity (LMN) to paint the picture of the mobility and functional status of the patient. They will document the patent’s range of motion, their posture, and ability to reach and perform daily activities of living. This document will be very detailed and is what the insurance reviewer will be looking for to approve or deny the equipment requested.
From this point, the RTS will print out all the manufacturer order forms, and create a detailed product description. This lists all the equipment the patient requires, based on the assessment, and lists the insurance code that references the item. This report will be sent to the therapist who will ensure that the LMN discusses each item listed, and will send their LMN back to the supplier. The supplier will send the LMN, along with their reports back to the physician for review and signature.
Once all documents are received, they are sent to Medicare for prior authorization. When Medicare responds, it is either with an approval, denial or request for more information. If approved the equipment is ordered, of denied, an appeal can be submitted. If more information is requested, the supplier with the beneficiary’s help can gather more information from the physician and/or therapist.
Time Line -Through Insurance is Realistically 2-3 Months
This can be a lengthy process as there are many professionals involved. Beneficiaries need to have patience through this process. Prior to the F2F requirement equipment was evaluated, and approved within 30 days. Physicians are busy, and getting an appointment can take weeks, waiting for the documentation from the physician can take time, if they send you to a specialist; between scheduling and reporting this can take weeks. Waiting for an authorization has taken up to 30 days. Additionally several weeks; ordering, assembling and scheduling for delivery.
Medicare requires a minimum certification to assist with Powered Mobility Equipment evaluations. This requirement is expected to be increased; and at the time of this article it is a ATP; Assistive Technology Professional. This staff member must be present and involved through the evaluation of the equipment. You should know that there are providers who have higher qualified and trained individuals above the ATP. These individuals are the SMS and CRTS. SMS stands for Seating and Mobility Specialist, where they have went beyond the ATP and trained to the highest standard. The CRTS, Certified Rehab Technology Supplier, is harder to receive, and shows the commitment, dedication and experience.
Five Year Rule
Like most insurance providers and DME (Durable Medical Equipment), the life expectancy of the usefulness of the equipment is five years. This means that Medicare will not fund a replacement for this term. There are exceptions to every rule, however short of a theft, or natural disaster; a beneficiary will wait five years to receive new equipment. In the event the equipment you have no longer solves your mobility equipment, you may be eligible for equipment that his more complex.
Service and Follow Up
With any mobility equipment, your supplier is your support center. They will be needed for maintenance, service/repair, and for modifications to your equipment over the five years. Prior to several changes, it was easier to switch providers after receiving the equipment. Since the equipment supplier has the documentation sent to Medicare for support that the beneficiary needs the equipment, a new supplier may require to you go back through the process as Medicare audits all providers. If the service provider cannot prove the equipment the beneficiary is using is medically necessary (has all the documentation from the doctor/therapist/etc), then Medicare could recoup the funds.
All Insurances are following these guidelines, and for this reason beneficiaries must be more involved and aware of this process. There has been a lot of change, and continues to be changes at Medicare that affect your ability to receive quality equipment.
This article was written by Carey J. Britton, ATP/SMS, CRTS, he can be reached at email@example.com or (954) 821-7322.