What's Around the Next Corner?
- By Nikolay Voutchkov, Melissa Jackson
- Nov 01, 2006
Scooters or power operated vehicles (POVs) often make the difference between whether a client can be mobile, independent and maintain a quality of life to which he or she is accustomed. POVs are even thought to reduce hospitalizations by reducing the number of falls that occur in the home. Not only can POVs significantly improve activities of daily living such as grooming, dressing and eating, but POVs often bring the freedom of the outdoors to clients who wouldn?t venture outside otherwise.
In addition to their practical usage, the design of many POVs is now sleeker, and with a multitude of fun colors, clients are less likely to view a needed POV as a clinical-looking medical device, and are more likely to use it. That is not to say that POVs should be viewed lightly, one of the most significant changes in the POV market is that POVs are becoming more durable and rugged.
CMS clearly needs to create an objective tool that physicians can consistently use as a guide that helps capture the necessary information. CMS is looking for to justify medical necessity. Right now, the standard is totally subjective and allows CMS to hold all the cards to fairness in the process. Mark Leita, The SCOOTER Store.
Estimates of POV sales are steadily increasing as Medicare estimates that more than 18,000 scooters were reimbursed in 2005. A total of 45,000 scooters are sold per year under private pay insurance and Medicare combined. And that doesn't even account for the number of cash sale POVs.
When the requirement for a specialist to prescribe a POV was lifted, POVs became more accessible to the people who need them as any physician now can prescribe them, that is, as long as the client qualifies.
POVs also have to meet testing requirements by an independent testing laboratory and beneficiaries can benefit by the assurance that they will be receiving quality products. The downside for manufacturers, however, is that testing their products is not an inexpensive process. Some manufacturers are concerned that it won't level the playing field if foreign imports don't have to meet the same testing specifications and standards.
Local Coverage Determination Street
The Centers for Medicare and Medicaid Services (CMS) issued the new Local Coverage Determination (LCD) for power mobility devices in mid August and then revised it and reissued the LCD Sept 15, while industry members were attending Medtrade in Atlanta.
The LCD defines the 64 Healthcare Common Procedure Code System (HCPCS) codes, provides information on documentation, orders and funding, and lists basic coverage criteria to determine whether beneficiaries qualify for power-operated vehicles (POVs) or power wheelchairs.
In order for clients to meet basic coverage criteria, beneficiaries must have "a mobility limitation that significantly impairs his or her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in the home."
Beneficiaries also must have mobility limitations that cannot be adequately or safely addressed by using canes or crutches, and must lack the upper-extremity function, strength, range of motion, endurance or freedom from pain needed to use a manual wheelchair to accomplish MRADLs.
To qualify for a POV, beneficiaries:
- must be able to transfer on and off a POV safely
- be able to operate a tiller-style steering system
- be able to maintain posture and position while operating the vehicle
- have the cognitive and physical abilities to operate the POV safely
- have a home environment that accommodates the POV
- be willing to use the POV
- ability to perform MRADLs must significantly improve through use of the POV
Suppliers must receive orders for POVs within 45 days of the completion of the face-to-face examination conducted by the prescribing physician.
The order must include:
- the beneficiaries name
- description of the product being ordered
- date of the face-to-face exam
- diagnosis or condition related to the need for the PMD
- length of time beneficiary will need the PMD
- physician's signature
- date of the physician's signature
- suppliers need to date stamp to document the receipt date
The implementation date is now set for Nov. 15, but after the allowables showed drastic cuts in reimbursement, many industry members are asking CMS to delay the implementation date in hopes that CMS will reconsider the proposed cuts to the allowables.
Uphill Road: Fighting Drastic Price Cuts
Mark Leita, director of public affairs for The SCOOTER Store says, "CMS points the finger at utilization going up by 2,700 percent. That is yet a new number from CMS to justify hurting this great benefit. I'd remind CMS that payment does not parallel utilization. And the very industry that CMS is trying to hurt was the one that tried to warn CMS of spikes in payment in 2002 and 2003 only to be ignored."
The proposed fee schedule calls for cuts to power mobility devices that are 30 to 40 percent lower than current pricing. "These severe reductions are scheduled to go in to place in five weeks, Leita says. "It is unfortunate that the new fee schedules were derived from gap filling methodology that has been commonly referred to as flawed, even by CMS' own admission."
The cuts are so drastic that many industry players are concerned that it will pur some providers out of business. "We are extremely concerned that the 30-40 percent cuts will be the final nail in the coffin to companies large and small who have helped the Medicare program save over $10 billion dollars over the last eight years," Leita says. "Hundreds of mobility businesses across the country will be forced into bankruptcy, and thousands of U.S. manufacturing jobs will be lost. And, the most devastating issue will be that Medicare beneficiaries will find that access to mobility products will become more difficult, if not impossible. Without adequate mobility, most of these seniors will be forced into institutional care at a huge expense to the taxpayer," Leita says.
Randy Riecks, national sales manager for Ranger All Season Corp., George, Iowa, says he's unsure of what will happen in the POV market due to competitive bidding and the Medicare allowable coming in lower. "It is typical government bureaucracy, going from one extreme (higher allowable for power chairs on the old codes) to the other (lower allowable on new codes). This is not rocket science. As in the past, the end user is who is going to be hurt. At least we have different codes for scooters. This whole process has been very frustrating," says Riecks.
Scott Meuser, CEO of Pride Mobility Products, Exeter, Pa., says, "What we have is a regulatory body that has been focused on restricting access to the benefit. Now they have gone too far."
Leita summed up his thoughts on the fight to repeal these drastic cuts, "Utilization has been very steady for the last three years. However, seniors are more aware of power mobility as a viable alternative to a nursing home. Everywhere you go, people are seen using these products, not for fun, but out of medical necessity. They are active within their communities. And because of it, Medicare saved billions due to less ER visits and hospitalization due to falls and fall-related injuries," Leita says.
Clinicians, physicians and other industry advocates will be fighting to repeal the cuts to allowables.
A Side Road: Down-Coding
While the revised LCD eliminated the wording regarding a least costly alternative, (down-coding from a Group II to a Group I chair) but some of the wording in the revised LCD regarding down-coding remains unclear.
"The original version created significant concerns from physicians, disability groups and the power mobility device (PMD) industry, particularly due to the least costly alternative language," says Leita. "Through a collective effort, we were able to raise significant awareness through our respective members of Congress and force CMS to clarify their position. However, even though CMS issued a revised LCD along with a press release/fact sheet, the two documents conflict with each other and we continue to have concerns about downcoding."
CMS will not blanket down-code between Group 2 and Group 1 mobility equipment, a move that will help prevent Medicare beneficiaries from receiving substandard products and services.
"Our position is that with a clear, objective documentation standard, there really wouldn't be a need to down-code. CMS clearly needs to create an objective tool that physicians can consistently use as a guide that helps capture the necessary information CMS is looking for to justify medical necessity. Right now, the standard is totally subjective and allows CMS to hold all the cards to fairness in the process," Leita says.
Physicians medical judgment should not be compromised by a supplier second-guessing his or her prescription and that applies to CMS' Regional Carrier's Medical Review staff as well, according to Leita. "The physician, by law, must conduct a face-to-face examination. He or she is the only one who knows that PMD is best suited for the patient."
While the POV market may have its share of challenges ahead, seniors and other people with mobility limitations are becoming increasingly aware of POVs as a product of freedom and independence. And with all of the new technology and element of choice to the savvy consumer, the POV market is positioned for growth.
Road to Scooter Safety
Road to Scooter Safety
- Braking while driving is mechanical and often requires the user to squeeze one or two braking handles, using one or both hands.
- Using the parking brake requires the use of at least one hand.
- Users should understand if they are selecting a model where use of one or both hands is needed.
- Tillers can typically be operated with the use of one hand.
- Scooter users should be able to operate the vehicle alone and unaided.
- Clients who have difficulty transferring into scooters risk serious falls.
- Clients should have enough body mobility and flexibility to maintain balance as the scooter tilts or bounces on sidewalks and pavement.
- Flat and level surfaces are the safest for indoor scooter usage.
- Deep-pile carpets can present a problem for safe scooter usage.
- Find out how deep of a grade your scooter can safely traverse.
- Avoid wet grass and soil as it can be dangerous.
- Never ride a scooter across a hill.
- Have a medical screening for eyesight.
- Use vision aids such as rear-view mirrors, sunglasses.
- Do not share your scooter with other users, especially when adjustments are made for a specific user.
This article originally appeared in the November 2006 issue of HME Business.