Wednesday, June 27, 2007

Mobility and Medicare: A Practical Guide, Part III

Earlier this month we wrote about Medicare and eligibility requirements for coverage of power vehicles, walkers and canes. This week we tackle manual wheelchairs. It’s a bit complex, so pour yourself some lemonade and focus.

Manual wheelchairs fall under a category called “capped rental.” What this means is that Medicare sets up a “rent to buy” approach when covering manual wheelchairs. The assumption is that the need for a manual wheelchair may be temporary, or the need might not be clear after just a short period of time. Rather than covering the purchase outright, Medicare sets up this approach to ensure that only the need is covered. Here’s how it works.

You still need all the same essentials as previously mentioned:
  • A written and signed order from your physician with a clear diagnosis and length of need. This must be in the dealer/provider’s hand before you can get the wheelchair.
  • The physician must have a written evaluation in his/her medical charts of your condition that supports the need for a manual wheelchair. (You might recall from our earlier discussions that this need is primarily to address MRADLs, mobility-related activities of daily living in your home. The fact that you would like to get out and shop once in a while is not a covered reason!)
  • Signed forms and copies of your Medicare card to leave with us, the dealer/provider of the wheelchair, so we can do the complimentary billing for you. The paperwork also gives us permission to work directly with the physician to ensure all materials are provided. We help assess the likelihood of whether your claim will be covered or not.

So, let’s assume you have the written and signed order and show up at Capabilities. You also have your Medicare card. (If you have the Power of Attorney or are the spouse of the individual needing the wheelchair, you have the authority to sign. We still need the Medicare card to copy for our records.) The prescription (written order) makes it clear, for example, that you must have an 18” standard manual wheelchair for an indefinite period of time in order to perform MRADLs in your home.

You must fill out Medicare paperwork and a “capped rental” agreement that sets a monthly fee for the use of the wheelchair. You pay Capabilities directly for that monthly fee since our arrangement with Medicare is such that we collect payment up front. If Medicare accepts your claim, you will be reimbursed for the covered amount (generally about $57). You will not be reimbursed for any additional fees that the dealer/provider charges. If we believe your claim is not viable, or if paperwork is incomplete, we will explain to you up front that we have reservations about the claim. You can choose to continue by signing an authorization that allows us to continue, called an ABN (Advance Beneficiary Notification) that acknowledges that you know Medicare may deny the claim and not reimburse you. You can also decide not to proceed at this point. The choice is yours.

If Medicare covers your claim, you will continue renting the wheelchair on a month-by-month basis for up to 13 months (or sooner if the rental fees equal the covered cost of the wheelchair in less time). At the end of that period, you effectively own the wheelchair.
If, however, your need for the wheelchair ends sooner than that period, you must return it and Medicare will cease reimbursement.

We should briefly mention other types of manual wheelchairs. In some cases, a patient might not have the upper body strength to self-propel a standard wheelchair. This is one of the evaluation points that the physician must be clear about in his/her notes. If there is insufficient strength for a standard wheelchair, but the physician determines there is enough strength for a lightweight manual wheelchair, the order must clearly state this to be the case, along with the diagnosis and length of need. In some cases, upper body strength is so weak, a power wheelchair is the only solution. We have already discussed coverage of this item in previous blogs.

We are also asked about whether Medicare covers transport wheelchairs. These are the chairs with smaller wheels and must be pushed by someone else. As you might guess, there are very particular, and rare, circumstances when a transport chair will be covered. Coverage requires evidence of a caregiver in the home, for example. Reimbursement is minimal and many dealer/providers do not offer a billing option for this type of wheelchair. As always, it is best to discuss your needs fully with your physician.

Clear as mud, right? We can help you sort your way through the morass of paperwork. What we cannot do is hustle the process along. You should expect the process to take several months before you receive a clear response to the eligibility of the claim. We get calls all the time from customers who wonder where their reimbursement is. Sometimes we can easily track down the claim with Medicare, other times it takes an army. Claims often get rejected several times due to insufficient information from physicians, old codes, or details that are not completely clear to the administrators processing the claims. If there is a problem, we work on solving it as speedily as possible if it something we can troubleshoot. If, in fact, the physician has not provided the appropriate diagnosis or proof of evaluation of your situation, there is little we can do to remedy that situation. Believe me, when Medicare accepts the claim, you will know about the same time we know.

As we have mentioned previously, the way to appreciate Medicare is to view it through the same lens you would use for any insurance coverage. There are covered benefits and there are many situations not covered. To imagine Medicare as an entitlement or to rely solely on it for all your medical needs is to invite heartache and disappointment. When the circumstances match the eligibility requirements, Medicare is an important tool in managing your healthcare. Always feel free to ask us questions at Capabilities where we have experience working with Medicare.

Please post your questions and comments and we’ll get back to you right away.

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