Page 15 - HME Business, August 2017

Provider Strategy
Approving PASH
Power adjustable seat height for mobility users is not only ‘medical,’ but it is also predominantly ‘funded.’
Not long ago, providers clinicians and yes, even manufacturers challenged the notion that a power adjustable seat height (PASH) system was not “covered” and therefore not paid for by most third-party payers. This has significantly changed over the last year or so due largely to extensive education efforts with stakeholders — providers, clinicians and payers — showing the significant medical benefits provided through this enabling technology. So, what are the remaining obstacles and opportunities?
Submission for Approval
There has been a very high level of assumption that a power adjustable seat height system Is not covered and therefore not reimbursable by third party payers. What we have found at Quantum Rehab is that every single third party payer with a prior approval process will consider it on a case by case basis. As a result, many payers are responding with approvals when PASH is shown to be medically necessary versus simply a feature that would be “nice-to-have.” To date the approval rate is approaching 70 percent largely due to more com- prehensive medical documentation highlighting the need.
I think back to the late 1980s movie “Field of Dreams” in which the lead character hears a voice while walking through a corn field that says, “If you build it they will come.” Later he sees a baseball field. He builds the baseball field and Shoeless Joe Jackson, a long time dead professional baseball player, turns up and asks to play catch.
This quote has been adapted for many business purposes since that
time. The analogy here, based on what we are hearing from many providers throughout the country is “if you submit it, they will approve.” So, go ahead and submit it once the need is properly documented. If you don’t submit it there is no chance they will approve.
Medical Documentation
The key to coverage and payment for power adjustable seat height technology, like all other durable medical equipment, is medical documentation support- ing the need. The best way to show the medical need for this feature to a third- party payor is to document what the beneficiary can do with the seat height adjusted along the vertical continuum as opposed to what they cannot do,
at a low, static seat height. Given the fact that a power adjustable seat height system doubles the usefulness of a power wheelchair, there are many benefits provided by this technology.
Here are two key areas that should be addressed and documented as a part of the comprehensive evaluation of the consumer to increase the likelihood of approval and payment:
• Transfers. Transferring in and out of a wheelchair has been found to be one of the most strenuous activities wheelchair users encounter throughout their day. Studies have shown that transferring to/from the wheelchair puts higher stress on the arms than any other activity, especially when the transfer is in an uphill direction (bed, toilet, etc.).
However, for consumers to use the power wheelchair to perform or partici- pate in their activities of daily living they must be able to transfer into it at the start of their day and out of it at the end. Therefore, transfers are an essential part of the daily routine and considered medically necessary. During the evaluation, it is essential to assess the individual’s transfer technique, docu- ment the level of assistance necessary and determine whether a safer, more
Management Solutions | Technology | Products
Seth Johnson
efficient or greater level of independence can be achieved by use of a power adjustable seat height feature.
• Reach. Consider (and document) how many times an individual needs
to reach overhead in a wheelchair with a low, static seat height to perform
or participate in an activity of daily living. It is not hard to see how quickly overuse injuries and secondary medical complications can occur, especially
if the person has limitations in strength, range of motion and/or balance
that preclude them from using a manual wheelchair. Is the ability to reach
and carry at various surface heights limited such that the wheelchair user’s capabilities cannot be realized because they have a mobility device that does not allow them full access to the vertical environment? If so it is essential
to evaluate them in a power wheelchair with a power adjustable seat height system during all aspects of their activities of daily living and document them.
Clear documentation of what the person can do with the technology as compared to what they cannot do without it is exactly what every third-party payor needs to know to consider it for coverage and payment.
Medicare
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. The good news is that national consumer organizations and RESNA are engaged and leading the effort to get Medicare to reconsider its outdated position to allow for consideration of power adjustable seat height technology.
Consumer groups and other industry stakeholders have had meetings and exchanged more formal communications with Medicare that seem to indicate a real willingness by the agency to change its current position and allow for consideration of this technology when provided as an attachment or accessory on a medically necessary power wheelchair. They have acknowledged that the technology is “durable” and that it is appropriate for use “in the home.”
The one area where Medicare has indicated it would like to see more information is regarding how PASH serves a “medical purpose.” Information to address that has been provided by consumer groups indicating the since seat elevation can assist in the performance of MRADLs (e.g. toileting, grooming, etc.) it logically follows that seat elevation also primarily serves a medical purpose to the same extent as power wheelchairs, or other mobility assistive equipment (MAE).
One positive sign is that most Medicare Advantage plans do consider power adjustable seat height technology when submitted for prior authorization,
as do most state Medicaid programs, private insurance companies and the Veterans Administration. Progress is being made on the Medicare front and
I do not think it will be long before we will be hearing “if you submit it, they will approve.” n
Seth Johnson is senior vice president of government affairs for Pride Mobility Products Corp. 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.
hme-business.com | August 2016 | HMEBusiness 15