How to have a vital dialogue about funding

By Seth Johnson and Mark Smith
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Wednesday, November 30, 2016

After years of challenges, are there any signs that funding medically-necessary, quality-of-life complex rehab technology (CRT) can advance coverage and payment policies to reflect advancements in technology?

Just over a year ago, Pride Mobility Products and Quantum Rehab launched an ambitious product that challenged funding entities based on the increased functionality it brought to complex rehab power wheelchairs. Consumer inspired, it was a power adjustable seat height system. Specifically, it allowed 10 inches of seat elevation, while mechanically stabilizing the power base, allowing walking-height function at up to 3.5 mph. For the consumers needing this technology, they were elated, expressing that it doubled the functionality of their chair and increased their independence significantly. However, many in the industry wondered, would it be a moot point, falling into a long-thought “no one pays for seat elevation” funding void?

Time has proved a resounding answer. In fact, not only have payers been funding the power elevating seat height technology at a remarkable rate, they’ve been doing so for an inspired reason: the best medical interests of complex rehab users.

To understand how we’ve gone from assumed funding roadblocks to proven paths of optimal client outcomes, let’s go back to the beginning of this journey.

This all began with the expressed needs of complex rehab users themselves and clinicians, a dialogue where all said that a higher-functioning, safer, more inclusive power elevating seating system could change lives. Both pointed out aspects like safer transfers, greater independence in the home, increased functionality in school and the workplace, and equalized inclusion in all aspects of life. Being able to go from seated to standing height, as all power elevating seats did, was possible—but, in users’ experiences, not adequate. Users wanted true mobility and functionality.

For us, we knew the codes, and that Medicare wouldn’t pay for seat elevation. However, we also understood from clients’ and clinicians’ passionate dialogue that if we could create a safer, more mobile seat elevation system, it would dramatically improve lives. And, it occurred to us that if clients, clinicians and other stakeholders saw the potential of such a quality-of-life technology, why couldn’t payers be equally enlightened?

While beta testing the technology, user and clinician feedback was so compelling that we knew a funding case could be made for the technology. That is, we knew proper documentation and dialogue was the ultimate funding tool. We went to work to educate payers and clinicians as to the reasons why power adjustable seat height should be funded. With real-world outcomes shared by users and clinicians, we demonstrated the medical, functional, and cost-saving benefits. Put simply, we showed how funding power adjustable seat height resulted in great outcomes for all, including the payer. So, what was the key to this process?

Documentation and dialogue. It all went back to documenting and explaining the client’s function, independence, safety, and what they can do with the technology that they cannot do without it.  For example, in one poignant example, 25-year-old Josh lost his ability to transfer from his power chair to his bed due to progressing muscular dystrophy. In the process, he had several harmful falls, resulting in hospital bills and the need for a paid caregiver. What’s more, this loss of independence took its toll on Josh emotionally. However, through a clinical evaluation, it was proven that stabilized, power adjustable seat height allowed Josh to safely perform an independent standing-pivot transfer into bed. Safety was increased, healthcare costs were avoided, a paid caregiver was no longer needed—and Josh’s quality of life improved.

When ATPs have a dialogue with funding sources through formal documentation for individual clients, it changes everything. For a case manager to see reason after reason why power adjustable seat height is medically necessary to provide, we see a high success rate.  While traditional Medicare (Part B) still doesn’t cover seat elevation, most other payers—when comprehensively, medically documented—are funding power adjustable seat height, to the extent of third-party funding approval rates of up to 65% and climbing. In fact, providers negotiating their contracts with third-party payers for 2017 are requesting that the E2300 HCPCS code be added to the list of covered benefits and seeking a mutually agreeable fee schedule for the feature. While this will never guarantee coverage and reimbursement for this feature for consumers, it does further break down a barrier of access and provides a cost effective solution for payers and providers.

What we’ve learned in this process is that successful funding of CRT isn’t as “code-based, yes-or-no” as many thought. Rather, using formal, comprehensive medical documentation creates a process that dramatically increases the likelihood of funding the CRT that complex rehab users need and deserve. Let us listen to our clients and clinicians, comprehensively provide that medical documentation to payers, and ultimately create a dialogue that best serves all in the process.

Seth Johnson is senior vice president of government affairs for Pride Mobility and Quantum Rehab. Mark E. Smith is general manager, PR, for Pride Mobility and Quantum Rehab, and a CRT user of 40 years.