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.

Complex RehabPower 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” ( 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.

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