Page 16 - Mobility Management, October/November 2019

Funding Series
JUSTIFY IT: GROUP 2 VS. GROUP 3 POWER
Due to the higher prices associated with Group 3 chairs, substi- end-user, then they ‘assume’ that a Group 2 PWC would be suffi-
tuting a Group 2 chair can be a great temptation to payors. At times, CRT providers have provided more robust power chairs, then down-coded them to the funding source. Why isn’t that an optimal practice?
“The only payor where ‘down-coding’ would be required,” Piriano said, “in certain circumstances, is traditional Medicare, otherwise known as Part B or Medicare Fee for Service, as they are bound by law to the Social Security Act. Every other payor — including but not limited to Medicare Part C, Medicaid and commercial payors — has the ability to make coverage and reim- bursement decisions on a case-by-case basis, based on the iden- tified needs of the individual and technology solutions necessary to address them. In addition, each of these payors has a true prior authorization process. Even when they ‘follow Medicare guide- lines,’ they have the discretion to consider what recommendation best meets the overall needs of the person, regardless of diagnosis.
cient, and show cost savings to their bottom line.”
But Piriano said the CRT industry has a responsibility to advo-
cate for the technology that will provide the best outcome for the client, based on that client’s needs.
“When a Group 3 PWC is necessary,” she said, “we have an obli- gation to our patient to highlight why a Group 3 PWC is medically necessary, detail any safety concerns associated with the provi- sion of a lower-level chair, and submit what they need for prior authorization. If the payor denies the request, or down codes it, we have an opportunity to figure out what information we did not provide so that they could see why the recommended Group 3 base is needed.
“When we assume the payor will not consider our request for the Group 3 PWC with any payor, other than traditional Medicare, we are not fulfilling our obligation to the consumer, or from a provider perspective, to the business.” m
“The devil is in the details of the documentation, and it typically
comes down to when, where, why and how the individual will
use the chair. If the payor can ‘see’ that the person needs powered
mobility but does not understand the distances that will be trav-
eled, the terrains, obstacles and inclines that will be encountered,
or the significant importance drive-wheel suspension has for the https://tinyurl.com/permobilpowerlmn.
Editor’s Note: For more about comparing/contrasting Group 2 and Group 3 power chairs, and their documentation requirements, check out https://tinyurl.com/sunrisemedicalpowerwheelchair and
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