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Thread: New Manual chair through Medicare/Medicaid understanding available options for 2018

  1. #31
    wow that means it is going to be just as hard to get a chair as i thought! this sucks!
    T6 Incomplete due to a Spinal cord infarction July 2009

  2. #32
    Senior Member NW-Will's Avatar
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    Totally sucks.. and sucks all the energy out of you.. that you could be using for something positive...

    Quote Originally Posted by Smashms View Post
    wow that means it is going to be just as hard to get a chair as i thought! this sucks!

  3. #33
    Senior Member NW-Will's Avatar
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    Question hoping some one knows.

    Does a wheelchair count as something different to Medicare and Medicaid than other DME equipment?
    Just as far as procedure for buying obtaining etc. ?

    With some DME equipment the DME supplier tries to get pre-authorization for it.. and medicare denies it..and then you get a bunch of paperwork where you can appeal the medicare decision.
    Because I have Medicare/medicaid.. once medicare denies an item the DME supplier then submits the paper work to medicaid with the Medicare denial, again it may be denied and you may appeal to medicaid.
    Just from my experience, it seems like we just try to appeal medicaid, and so far in my experience after appeal with what ever paper work they require the item has been approved.. I admit this process can go on for 12 months but so far every item I've appealed mediaid has paid for.

    Getting a DME supplier to follow through on this process is a royal pain in the ass I admit, and I'm constantly phoning my doctor, medicaid and the DME supplier to see where the paperwork is held up.... 100% of the time it is the DME supplier. From faxing to the wrong place, to incorrectly filling out paperwork to not following procedure, to not filling documentation in a timely manner, super frustrating.

    Just wondering why the DME supplier won't go through this same procedure with a wheelchair ?

    I'm using different DME supplies for all different things.. and I'm only talking to this DME supplier about wheelchairs.

    Are wheelchairs automatically assigned as some kind of different equipment. ?

  4. #34
    Quote Originally Posted by NW-Will View Post
    Question hoping some one knows.

    Does a wheelchair count as something different to Medicare and Medicaid than other DME equipment?
    Just as far as procedure for buying obtaining etc. ?

    With some DME equipment the DME supplier tries to get pre-authorization for it.. and medicare denies it..and then you get a bunch of paperwork where you can appeal the medicare decision.
    Because I have Medicare/medicaid.. once medicare denies an item the DME supplier then submits the paper work to medicaid with the Medicare denial, again it may be denied and you may appeal to medicaid.
    Just from my experience, it seems like we just try to appeal medicaid, and so far in my experience after appeal with what ever paper work they require the item has been approved.. I admit this process can go on for 12 months but so far every item I've appealed mediaid has paid for.

    Getting a DME supplier to follow through on this process is a royal pain in the ass I admit, and I'm constantly phoning my doctor, medicaid and the DME supplier to see where the paperwork is held up.... 100% of the time it is the DME supplier. From faxing to the wrong place, to incorrectly filling out paperwork to not following procedure, to not filling documentation in a timely manner, super frustrating.

    Just wondering why the DME supplier won't go through this same procedure with a wheelchair ?

    I'm using different DME supplies for all different things.. and I'm only talking to this DME supplier about wheelchairs.

    Are wheelchairs automatically assigned as some kind of different equipment. ?
    I had medicaid/medicare with my last chair, and I think it works the way you describe.

    I currently have pointless secondary medicare right now, and my DME provider made me sign a form listing the items that medicare denies and I have to select whether to appeal their decision, or agree to pay and then appeal or just agree to pay for those items. I'm sure it depends on how good medicaid is in your state, but in mine they pretty much covered everything that medicare denied as long as I had the doc list a reason why I needed it.

  5. #35
    Senior Member NW-Will's Avatar
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    How long ago did you go through this?
    And which DME supplier did you use ?
    Seems like it's super hard to find a motivated DME supplier.


    Quote Originally Posted by funklab View Post
    I had medicaid/medicare with my last chair, and I think it works the way you describe.

    I currently have pointless secondary medicare right now, and my DME provider made me sign a form listing the items that medicare denies and I have to select whether to appeal their decision, or agree to pay and then appeal or just agree to pay for those items. I'm sure it depends on how good medicaid is in your state, but in mine they pretty much covered everything that medicare denied as long as I had the doc list a reason why I needed it.

  6. #36
    Senior Member NW-Will's Avatar
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    I'm just sticking this here, as I am still learning about Medicare.. and Medicaid and the interaction.

    According my DME... Medicare only cares about inside the Dwelling, Medicaid care about your life outside the dwelling.
    So for a Hypothetical I put it to him. I don't need a smartdrive attachment inside the house, I can maneuver just fine in my manual chair inside the house, so Medicare would deny this.
    But my PT will justify a Smart drive outside the house, so Medicaid should cover it once Medicare denies it.

    The supplier says they have never tried this, but that should be the case! Thoughts ?

    If you have Medicare. you can pay the supplier up front for the chair, the supplier will then submit the claim to medicare and whatever they don't pay for you pay for.. (can't imagine a supplier I would trust with this option to be honest)
    If you have medicaid only, they will pay for the chair! determined by doctor justification

    This is the part I find hard to believe. or any real substantiation of.
    If you have Medicare and Medicaid, What ever Medicare denies, Medicaid automatically denies, but they don't submit directly to medicaid!! So you as the client never get a medicaid denial letter, which comes with the appeal form.
    Also no option to Pre-Pay or Use an ABN, because Medicaid is means tested.

    This is a pre-authorization, so no equipment is supplied.
    In my experience with various other equipment(not wheelchairs), you have to get your supplier to submit to medicare, medicare denies it, then they submit to medicaid, and when medicaid denies it, medicaid sends the client documentation, documenting the denial with the option to appeal the denial decision. At this point, you as the client can appeal it directly to medicaid and take it to some pseudo judge to revaluate the decision, and you can argue why you require it etc.

    For some reason.. the supplier seems to say that wheelchairs don't work like this!!!

    How is it the supplier doesn't submit the basic ultralight frame as a K0005 to medicare pick up the $1700 (80%) from medicare and $425(20%) from medicaid.
    Then use all the other K codes for the add ons...
    The codes that Medicare picks up the 80% for , great Medicaid will kick in the 20%
    The codes that Medicare doesn't cover, then apply 100% to medicaid, when they deny it.. the client has the option to appeal!

    The supplier then gets documented exactly what is pre approved?

    Is there a Miscellaneous K code ? in my conversations, they keep mentioning K0008 or it may be K0018 but looking up these codes they are defined.


    • K0008

      Custom manual wheelchair/base



    • K0018

      Detachable, adjustable height armrest, upper portion, replacement only, each


    I am only asking the suppliers to submit paperwork for pre-authorization of payment,
    All the supplies love to throw out.. we can't do that .. because that is medicare fraud! I am lost how submitting any paperwork trying to get pre authorization would ever be fraud. Obviously not trying to do anything nefarious, just trying to get a damn chair paid for or at least pre-authorized payment so the supplier should be happy enough to put the damn order in etc. .. blah blah.

    Have to admit it would be interesting to do an internship for a supplier to just work on submitting paper work to see how the process really does work. and maybe blog my experience..

  7. #37
    i don't know why you are having such issues my chair was finally ordered on may 8th so i should have mine in approx 3 weeks they say. have you been to a seating clinic? they can then justify for the chair it really shouldn't be that hard to get one. my aero z was no problem getting it approved thru medicare
    T6 Incomplete due to a Spinal cord infarction July 2009

  8. #38
    Senior Member NW-Will's Avatar
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    That is pretty sweet. congrats

    Yeah I thought it was going to be simple.. I pretty much wanted my previous chair but with an Ergo seat pan and a few other slight dimension tweaks... but the TR is no longer covered by medicare and can't be up-charged if you have medicare/medicaid.
    Yes going through a seating clinic.
    Curious what supplier are you using ?

    Are you using Medicare only ?
    or Medicare/medicaid?

    Quote Originally Posted by Smashms View Post
    i don't know why you are having such issues my chair was finally ordered on may 8th so i should have mine in approx 3 weeks they say. have you been to a seating clinic? they can then justify for the chair it really shouldn't be that hard to get one. my aero z was no problem getting it approved thru medicare

  9. #39
    both i used monroe wheelchair.
    T6 Incomplete due to a Spinal cord infarction July 2009

  10. #40
    Titanium upgrades are not allowed by original Meidcare out of retaliation of DME abuse. Now Meidcare says it's part of the base charge. What that means to us is that the DME can't deliver... because they can't make money on a base charge alone.

    If you want a titanium upgrade then you need to go with Medicare Advantage. They still offer the upgrade.

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