Seat elevation coverage and funding continues to expand. Where are we today?

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Tuesday, February 27, 2018

It’s a new year that is full of opportunity on many fronts, including coverage and payment for seat elevation. A few years ago, providers, clinicians and manufacturers began challenging the notion that a power adjustable seat height (PASH) system was not “covered” or paid for by most third-party payers. Significant progress has been made over the last couple years due to extensive outreach and education efforts with stakeholders—consumers, providers, clinicians and payers—highlighting the medical benefits provided through this enabling technology. So, where are we, and what are the obstacles and keys to success?

The good news is that extensive progress has been made on the Medicaid, Veterans Affairs and third-party payer front, including commercial payers and Medicare HMOs, PPOs and Advantage Plans, which will consider PASH technology for coverage and payment when reviewing the documentation submitted for prior authorization. When we started tracking coverage and payment for this technology a few years ago most of what we heard from providers in nearly every state was “they won’t pay for it.” Fast forward to 2018 where we now have received hundreds of examples of payment from nearly every state that the technology has been paid for.

A significant obstacle that was identified early on was that many providers were simply not submitting a claim for payment because previous attempts to get paid were not successful or they did not believe the payer would cover it. As this issue was analyzed in detail, it was determined that most payers will “consider” PASH technology for payment with a complex rehab power wheelchair when documentation is provided that specifically mentions what the beneficiary can do with the technology that they are unable to do independently without the technology. As we know, many end users can more fully participate in their mobility related activities of daily living with this technology, and independently “transfer” to a bed, chair, toilet, etc., and “reach” for dressing, grooming and meal preparation purposes.

The coverage and funding battle has really come full circle where payers (aside from traditional Medicare) will consider it if the therapist’s wheelchair evaluation includes documentation as to why the feature is needed and providers submit the information to the payer as a part of the prior authorization process. I think it goes without saying that PASH technology will not be considered for coverage and reimbursement for if the need is not documented and the request is not submitted.

The technology available today is much improved over the standard power elevating seat systems that were available five to 10 years ago. Today’s technology is highly functional as it allows the individual to elevate/descend while driving their chair, the time it takes to move through the full range of elevation has been reduced by more than half and the chair can safely operate in the elevated position at a pace equal to or faster than average walking speed. These developments were a result of consumer feedback.

While traditional Medicare (Part B) remains the biggest obstacle to overcome due to its position that power seat elevation (E2300) is not reasonable and necessary and does not serve a “medical purpose,” progress is being made in this area due to consumer led efforts to highlighting the benefits and cost saving provided through the use of this enabling technology. Many consumers have stated that this technology doubles the functionality of the chair and allows them to more fully and independently access the three-dimensional world that we live in. They have stated that this reduces overall costs to the health care system by minimizing the risk for injury from a fall, burns, cuts, bruises, fractures and repetitive strain injuries sustained by individuals with disabilities who do not have safe access to the vertical environment. Savings can also be realized through a reduction or elimination of the cost of a caregiver who was needed to provide services they can now complete on their own.

We have come a long way in the last few years in getting most third-party payers to consider and pay for this life changing technology. There is certainly more work to be done to get Medicare to cover or consider it for payment, but the consumer efforts coupled with clinical studies and other stakeholder efforts are making real progress in this area. I remain hopeful that it will not be long before Medicare will join nearly all the other payers in recognizing the significant medical benefits and cost savings of PASH technology and consider it for payment.

Seth Johnson is senior vice president of government affairs for Pride Mobility Products Corporation. He currently serves on the executive committee and board of the National Coalition for Assistive and Rehab Technology (NCART), and is a past chairman of the AAHomecare Complex Rehab and Mobility Council (CRMC). He is active within state associations and various other industry stakeholder organizations and coalitions. He can be reached at (800) 800-8586 or sjohnson@pridemobility.com.

Comments

BCBS, UH, Ambetter, Medicaid all have approved this function on a Group 3 Complex Rehab PWC for me in appeals.