 and the elimination of the requirement that a specialist prescribe a scooter. </p>
<p>The NCD, announced in May of this year, uses functional criteria to determine reimbursement, rather than the former “bed or chair confined” criteria that many manufacturers and providers claimed was too rigid and limited accessibility to some beneficiaries. The changes in criteria are viewed as more flexible as beneficiaries will be assessed on whether they have a mobility limitation that prevents them from performing one or more mobility-related activities of daily living in the home. According to CMS, the evaluation “includes consideration of whether or not an assistive device — whether a simple cane or a sophisticated power wheelchair, or anything in between — would improve the beneficiary’s ability to function within the home.” The new functional criteria will focus on whether a consumer can move from room to room to perform activities of daily living such as bathing, dressing and feeding. </p>
<p>At the time of the NCD, it appeared that CMS was broadening its interpretation of qualifying criteria — good news for the POV industry. But it is unclear if the CMS Interim Final Rule will translate into more good news for the POV industry when manufacturers and providers alike are questioning who will be responsible for educating prescribing physicians, and if the removal of the Certificate of Medical Necessity (CMN) will result in prescriptions and physician notes that will be too ambiguous and subjective in their interpretation. </p>
<p>Overall the CMS proposed Interim Final Rule will:
</p>
<ul>
<li>Implement the face-to-face requirement of the Medicare Modernization Act — where a face-to-face meeting between the prescribing professional and the beneficiary will have to occur before a scooter can be ordered and delivered. </li>
<li>Eliminate the requirement for a specialist to prescribe a power-operated vehicle — any general practitioner will be able to prescribe a POV. </li>
<li>Eliminate the use of the Certificate of Medical Necessity (CMN) for power wheelchairs and scooters — in its place, a prescription is required. </li>
<li>Create new documentation requirements for physicians and suppliers — including specified physician notes and record-keeping information. </li>
</ul>
<p />
<p>Industry reaction on the specifics of the Interim Final Rule is mixed. While many believe eliminating the requirement for a specialist has opened up the playing field, others are advocating more clarity on CMS’s part on the details of the documentation required of a physician. Yet having more time to educate physicians before implementation appears to have an industry-wide consensus. </p>
<h3>Eliminating the Need for a Specialist</h3>
<p>Eliminating the restriction that allowed only a specialist in physical medicine, orthopedic surgery, neurology or rheumatology to prescribe a power-operated vehicle now opens up the playing field for all general practitioners to prescribe a scooter. </p>
<p>“I feel it will be a positive boost in the scooter business for Ranger All Season Corp. as well as the scooter industry as a whole. I think it is going to change tremendously where there are going to be more scooters funded now,” said Randy Riecks, national sales manager of Ranger All Season Corp. “It will put all scooter manufacturers on the same level. We are very excited,” Riecks said. </p>
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The change in the way scooters are prescribed has the potential to significantly impact the POV/scooter business. — Janet Hausbeck, director of marketing for Amigo Mobility
Janet Hausbeck, director of marketing for Amigo Mobility said, “The change in the way scooters are prescribed has the potential to significantly impact the POV/scooter business.”
Dan Gibbens, executive vice president of The Scooter Store, said, “We are glad that CMS is taking action to underscore the principle that the beneficiary’s physician or treating practitioner is in the best position to evaluate and document the beneficiary’s clinical condition and medical needs for mobility assistive equipment. We applaud the fact that CMS has recognized the burden that this places on the physician or treating practitioner and is providing the means for compensation. We have always agreed with CMS that the durable medical equipment supplier should not and cannot determine the existence of medical necessity for this equipment.”
With all physicians being able to write a scrip for beneficiaries instead of prescriptions being determined by a smaller pool of specialists, it makes logical sense that this change could potentially increase the sales volume of POVs by increasing accessibility for more beneficiaries.
“We believe that the elimination of the physician specialist requirement for scooters broadens the policy,” said Kevin Quaglia, reimbursement services manager for Pride Mobility Products. “Now because there is one main policy — Mobility Assistive Equipment — and scooters are a part of that national coverage policy — this allows more or additional access to scooters for Medicare whereas it didn’t in the past.”
According to Quaglia, for the market of individuals and patients who have the medical need for a scooter, have the ability to operate one safely, operate the tiller, have the cognitive ability and dexterity, and also have a home which is accessible for a scooter, “We feel now that this broadens the policy that these people can obtain one and be reimbursed by Medicare for one.”
Time to Educate
Despite this potential good news, there is a lingering question: Are physicians well-versed enough on the appropriateness of when a client needs a prescription for a scooter versus a power wheelchair and do physicians know when to accurately prescribe either for a variety of disease states or mobility limitations?
Hausback said the true determination of the amount of change will be based on two key factors. “First, the degree to which the clinical criteria algorithm for wheelchair prescribing is followed. Second, the degree of understanding and awareness on behalf of physicians and consumers on the differences between POVs and power wheelchairs,” Hausback said.
Manufacturers and providers are concerned that general practitioners or physicians might not have detailed product knowledge and won’t provide adequate information in their medical records that will ensure reimbursement on the providers’ end. Quaglia said that physicians need to understand the differences in coverage for products, when and why Medicare will reimburse for the different power mobility devices, what coverage criteria is for scooters vs. power wheelchairs and who they are most appropriate for. But he said they also need to know what is expected of them from a documentation perspective.
“What do they need to document in their charts, what type of information do they need about the patient’s condition, and what should be provided to suppliers in case Mediare ever asks for it so they can come to the determination that the patient qualifies for the equipment. We want to make sure physicians know the rules of the road — what the documentation requirements are and what they need to specifically outline and explain in their chart about the patient’s condition that will support medical necessity,” Quaglia said. “With Oct. 25 being the proposed implementation date, many dealers claim that it doesn’t give them enough time to ensure that physicians are adequately trained.”
“We believe this to be a new burden on physicians and other practitioners and we are deeply concerned that there won’t be sufficient time or training before implementation to prevent limitation of access to mobility assistive devices for beneficiaries,” Gibbens said.
Who is responsible?
But who is responsible for educating physicians?
“It is a combination,” Quaglia said. “CMS has a responsibility to educate physicians absolutely. I think there needs to be a stronger, more effective educational outreach plan for physicians from CMS. I think not only does CMS have a responsibility, but we as an industry have a responsibility to do our part as well. I think providers need to assist with that and I think manufacturers need to help providers in developing educational materials.”
Riecks said he doesn’t know whose responsibility it is to educate the physician but he thinks the government, CMS, should get involved. “A lot of people would prefer to be in a scooter if they have the dexterity and strength to operate it, power chairs really look nice, there’s no question about it, but people still have the persona that they are in a wheelchair.”
Riecks said, “My biggest concern is, do physicians have the time or are they going to take the time to evaluate a client?”
CMS officials contend that physicians know what needs to be included in their medical records.
But many manufacturers and HME dealers are launching programs to proactively educate prescribing physicians because dealers aren’t assured that physicians are aware of all the changes in regulations and what information is required in their medical records to support a prescription of a POV/scooter under the new Interim Final Rule.
“Scooter/POV manufacturers will have a greater responsibility to provide educational materials to both physicians and ultimately consumers on the differences between POVs and power wheelchairs,” Hausbeck said. “Both types of mobility devices are instrumental in providing mobility solutions to those with walking disabilities. The challenge is ensuring that all parties involved in the decision process are aware of all the options so the best mobility solution for each individual can be prescribed. In an ideal world, this would create a win-win solution. The individual’s mobility needs would be best served and Medicare’s dollars would be best utilized.”
What are manufacturers doing to facilitate the educational process for physicians and dealers? Amigo is in the process or updating its Web site and printed material to explain the differences between POVs and power wheelchairs. “Additionally, through the use of testimonials, we will encourage our customers to offer an objective explanation on their experiences,” Hausbeck said.
Riecks said that Ranger All Season Corp. will help educate physicians by attending a number of conventions next year, such as occupational and physical therapy shows; by facilitating information to the contacts of its reps and dealers; as well as providing funding education on allowables through advertising in magazines targeted to OTs and PTs.
Ranger All Season Corp. also is including information in its literature with specifications to help the dealer and customer. “We also have a Ranger Product Comparison Chart we send to every customer with literature, and our dealers have it in their Ranger Dealer Catalog. Our customer service department is trained to ask questions regarding the weight of a rider, the height of a rider, and where the product will be used more, indoor or outdoor. In the end, the dealer has to make sure they do the pre-evaluation so the customer gets the right product.”
Cy Corgan, Pride’s national sales manager for retail mobility, said, “We provide information through our Pride Web site and through our government affairs department to our representatives, then to the providers in what we call a referral-based marketing program where the provider is working very closely with referral sources — physicians and clinicians — and they are going in with the materials and making the time to sit down with them. It is a multi-pronged approach in educating physicians and referral sources.”
Pride updates its government affairs portion of its Web site, sometimes daily, offering providers the latest information. Pride also has a reimbursement guide for providers and an understanding Medicare coverage criteria guide for physicians.
In educating physicians, Hausbeck recommends more than printed materials. “Printed materials play an important role in educating physicians on the important differences; however, the most effective tools are customer testimonials,” Hausbeck said. “Individuals who have used both types of mobility devices often have a strong opinion on their preferences and will often effectively explain what works for them and why.”
Gibbens said if he were to educate a physician: “I would want physician’s to understand the limitations that a scooter has when it comes to maneuverability inside a residential home.”
“Pride has always worked very closely with out providers on consumer education programs. We help the provider in creating those and customizing those programs to their organization so they can get out that consistent daily message that they are the mobility specialists in their area and let the community know, through that consistent message — whether through print media, advertising or direct mail — to educate the consumer about the new policy,” Corgan said.
Eliminating the CMN
While physicians will be writing the prescriptions, it’s up to dealers to have supporting documentation for the product selection for reimbursement. Many providers have said that the documentation requirements are not clear because physician chart notes can vary dramatically depending on the physician and the DMERCs’ interpretation of the chart or progress notes is fairly subjective.
Riecks said it most definitely puts more pressure on the dealer to ensure that the consumer has been adequately assessed.
A statement released by Restore Access to Mobility Partnership (RAMP) Coalition, states, “Physician chart notes are inconsistent. Some doctors provide details of their patients’ mobility deficits, but many don’t because they are more concerned about the patient’s primary health concerns and that may be something unrelated to mobility needs. When the details in the chart notes weren’t to their liking, the DMERCs rejected the claims.”
While CMS officials claim that the dealer is only asked to make a product or supplier decision, and the physician is responsible for the medical decision, the distinction is not as clear for dealers who have to ensure that they have the correct medical documentation needed for reimbursement.
“We are hopeful that it is not CMS’s intent that the DME supplier would be expected to question the beneficiary’s physician or treating practitioner’s written order after having completed the face-to-face evaluation of a beneficiary,” Gibbens said.
Looking Ahead
Changes in regulations are likely to significantly impact POV business next year, but how effectively each segment of the market works together — from physician to end user — is yet to be determined.
The Ramp Coalition’s RAMP Report stated, “An objective system is needed, one that is fair to beneficiaries and suppliers. Rather than clarify the documentation requirements, CMS has taken a giant step backward. With an Interim Rule and other regulations, CMS has eliminated the CMN — opening up the system to even more subjective interpretation of claims.”
Quaglia said, “It is a workable rule. It is just a matter of providing some additional clarity to it, and I think time is needed to educate physicians, and for providers to be educated, and for the providers’ billing system to be updated or the DMERCs’ processing system to be updated to incorporate all of these changes. That is what is important, the time to get some additional clarity on the changes and allow for ample time to adapt to these changes,” he said.
The RAMP Coalition recommends an extensive physician outreach plan and a guide to help physicians learn the new process to ensure that adequate equipment is prescribed to the patient and to ensure that physicians adequately document the prescription.
At press time, many industry members are urging CMS for a delay in implementation from Oct. 25 to April, to give the industry time to address these significant issues.
“Ultimately, this is all about the patient who we serve. So whatever we can do to make sure access isn’t denied for our patients, and they get the most appropriate product, and providers and physicians have tools for that to happen — we are all in it together,” Quaglia said.
