Thursday, May 31, 2007

Mobility and Medicare: A Practical Guide, Part 1.

Now, here’s a topic we spend a lot of time explaining to many of customers. We thought we’d start a conversation in this week’s blog, and invite you to join in by posting your own experiences and thoughts about it. We know passions run deeply on the subject, so don’t hesitate to put in your two cents.

Until recently most working people over the generations believed deeply that between Social Security and Medicare, most of our needs as we age would be taken care of. Talk to most 40 and 50 somethings today, however, and you will hear a lot of cynicism on the subject. And anyone younger than that will say plainly that they are working on alternative solutions to ensure ways to take care of themselves when they are older. There are, however, many folks over 65 who still believe in these programs. And for some, the programs will deliver as promised long ago. Let’s peel back a few layers of this complex situation of Medicare, starting with a focus on mobility. We will write periodically on the topic, reviewing different products and how to consider whether it is likely that Medicare will cover them or not.

Individuals must qualify for Medicare coverage for mobility equipment, or mobility assistive equipment as it’s officially called. The process starts with a prescription signed and dated by a physician that must contain:
• the name of the beneficiary of Medicare
• the date of what’s called the “face-to-face” examination (more on that later)
• a description of the product ordered, such as a “power wheelchair” or “scooter,” a pertinent diagnosis and explanation of the conditions that relate to the need for the power mobility device
• length of need

Very often the process stops right here for us at the store. A customer in need (or someone in his or her family) arrives with a prescription that simply has the words “wheelchair” on it. The customer explains that the doctor said Medicare would pay for a power chair, although the prescription does not indicate such. Now, we respect doctors very much. We also know that they are focused on care and treatment, not on maneuvering their way through the wiles of insurance systems, especially one with as many details as Medicare. So, it is perfectly understandable that in many cases physicians believe they have completed their part of the deal, or they know that we will continue the work with someone in their offices to complete the paperwork that Medicare requires. The disappointment of that customer in that moment, however, is hard to witness and we do the best we can to help with the situation.

You should know that in no circumstance could you actually drive the power operated vehicle (power wheelchair or scooter) out of the store even if the written order had every detail covered.

We need evidence that the face-to-face examination was conducted and that it yielded appropriate results. In fact, we must submit the physician’s chart notes as evidence that we, as the dealer of the power operated vehicle, have done due diligence, too.

Let’s take a closer look at what kinds of questions get uncovered during that examination.
The primary question that has to be answered is this:

Does the patient have a mobility limitation that impairs participation in what are called Mobility Required Activities of Daily Living (MRADLs) in the home? MRADLs are things like eating, dressing, toileting. Unfortunately, being able to go out shopping or to the library does not count as MRADLs. Note, it also says “in the home.” So, the fact that you have not been out to dinner in six months is not what Medicare will worry about when they consider coverage for your power chair.

If the doctor cannot answer this question affirmatively, the process stops there. You do not qualify for coverage. If the answer is yes, the next question is whether the limitation can be compensated by the addition of other “mobility assistive equipment” to improve the ability to participate in MRADLs in the home. This means, can the situation actually be helped by the addition of some type of mobility assistive device? If no, you do not qualify for Medicare coverage. If the answer is yes, then there are a series of questions about specific alternatives. I will simply list the next series of questions that must be answered.

• Is the patient or caregiver capable and willing to operate the mobility assistive equipment (MAE)? If no, then stop. No coverage. If yes, go on.
• Can the mobility deficit be safely resolved by a cane or walker? If yes, stop and order cane or walker. If not, why not. You can only go on with the next question when the doctor has documented why these simpler devices will not work.
• Does the patient’s home environment support the use of a wheelchair or power operated vehicle, such as a power wheelchair or scooter? If no, you are not qualified for coverage. If yes, the supplier (like us at Capabilities) has to do a home evaluation to ensure the type of equipment does in fact work in your home.

There are more questions, so buck up. Take a break, get a cup of tea and read on…

• Does the patient have the upper extremity function to safely propel a manual wheelchair in order to actively participate in MRADLs in the home? If yes, stop and order the manual wheelchair. If not, go on.
• Does the patient have sufficient strength and trunk stability to operate a power operated vehicle in the home? The doctor has to explain a bit more about this part of the assessment. For example, how does he or she know the patient has sufficient strength. If yes, go on to next question. If no, skip to the following question.

Are you still following me here? No easy feat, is it?

• If patient has sufficient strength and trunk stability, is the patient able to maneuver the power operated vehicle in the home? Explain. If yes, stop and order that power vehicle, most likely a scooter. If no, go on.
• Does the patient need additional features (e.g., customized seating, joystick, reclining back) of a power wheelchair to participate in the MRADLs in the home? Why? If no, stop. There is no rationale for Medicare to cover this vehicle. If yes, one more question.
• Is the patient safe and able to maneuver a power wheelchair in the home? If yes, stop and order it. If no, stop.

The physician has another page of information required before we can consider doing the home evaluation and completing the paperwork for your power wheelchair.

While onerous, the process is designed to weed out fraud or unnecessary purchases for those who truly do not need such high powered and expensive equipment. Unfortunately, like most processes that really do have a purpose, it can also be so difficult that people get discouraged or angry. They find it hard to believe that something they believe they were entitled to can be so impossible.

Medicare is insurance and as for every insurance policy, there are conditions that must be met. If you keep this perspective, you can maneuver more easily through the process without raising your blood pressure. We will help you do this as best we can.

I’ve learned a lot about Medicare in these two years. Not only can I help our customers understand the process more effectively, I know I will be a better consumer of Medicare when it’s time for me to qualify as a card carrying member.

Let us know if this type of informational blog is helpful to you by posting your comment below or email us. What else would be helpful? As I mentioned, we will continue with our series on understanding and using Medicare effectively in coming weeks.

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