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

  1. #1
    Senior Member NW-Will's Avatar
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    New Manual chair through Medicare/Medicaid understanding available options for 2018

    2018.

    Any insight, thoughts, ideas, perspective gratefully accepted.

    I'm just talking Medicare/Medicaid here.

    New Manual chair through Medicare/Medicaid understanding the system, what is available, what are the options, what is a good strategy for obtaining the best chair for the individual.

    Not meaning to be too long winded, but basically how do we make the system work for us ?

    I really don't want to go through the new chair nightmare, but my butt pain is so bad, my doctor and PT think it would really help me.

    Back in 2011 when I got my current chair, I went to the PT, the DME came to the measuring session and then I just waited and waited felt like it took 12 months and then the chair arrived just as the PT prescribed. Tilite titaninium TR etc. life seemed good.

    Fast forward to now and 2018 and everyone seems to be throwing their arms in the air, "there have been so many changes we could never get you that chair for you now." Different PT same DME.

    So what are other folks experiencing and what really are the options.

    Has anyone managed to get a titanium chair recently? ( last 6 months)

    My DME is also telling me that I can't pay for the upgrade myself, medicare/medicaid won't allow it.
    Also I can't pre-pay (bill unassigned) either.

    Are my options really going to be I'm stuck with what whatever Medicare/Medicaid pay for
    or
    Pay for the whole thing out of pocket?

    From my DME :
    Our hands truly are tied by ill-designed policies for patient care by Medicare/Medicaid. Medicare doesn't allow us to provide an upgraded feature (like Titanium) based on their policy. Furthermore, even if they did, Medicaid would not recognize it and per Medicaid's policy we are not able, by law, to charge you the difference. Furthermore, you pre-paying doesn't work for similar purposes:

    1. If you only had Medicare, this would be a possibility and we could bill unassigned (in which Medicare would pay what they pay and you've already accepted that it may be less than you had pre-paid)

    2. Because you have Medicaid, we are unable to collect any payment from you (as Medicaid does cover a wheelchair, of some type, under your benefits). Legally, we are not able to collect any difference from you between what Medicaid deems "medically necessary" and what you actually received

    We share the same frustrations as you, as we see this situation on a nearly daily basis. If there was a loop-hole to any of this, we would have found it by now. Unfortunately, we have consulted professionals at all levels and have yet to find it.

    I wish I could be the bearer of more positive news, but the rules are stacked against it unfortunately.

    From a Tilite Representative:
    The current problem with Titanium chairs for clients with Medicare is related to the reimbursement amount. Just about five years ago CMS administration told us that the titanium option for MWC building material was not included in the K0005 code and could therefore be billed separately as an upgrade. It is my understanding that other manufacturer(s), that had given up on titanium frames because they did not believe that they were fundable under the current Medicare billing guidelines, were upset about this decision and asked CMS to review the definition of the K0005 code. At the beginning of 2017 CMS reversed their decision and stated that the wheelchair frame is included in the K0005 code regardless of the building material. This means that a dealer is unable to bill Medicare or a client separately for any upgrade to the building material. CMS is preventing clients from paying extra for this option even though it would not cost CMS any money. They are simply preventing access.


    This means that titanium chairs are just not profitable for dealers when providing them to Medicare clients. We are actively pressuring CMS to change this rule but the current administration is not very receptive to rational ideas and we are not getting support from other MWC manufacturers that do not want us to have a competitive advantage because we can make chairs out of titanium. One more reason to be disgusted with politics these days.

  2. #2
    i am in the same boat currently i will be watching this post as i have both medicare and medicaid, and am just starting the process to get another chair.
    T6 Incomplete due to a Spinal cord infarction July 2009

  3. #3
    Senior Member NW-Will's Avatar
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    Looking forward to hearing about your experience and what you learn.

    Would love to talk to someone who really understands this. Always feels like the DME just doesn't want to do any extra work.

    Quote Originally Posted by Smashms View Post
    i am in the same boat currently i will be watching this post as i have both medicare and medicaid, and am just starting the process to get another chair.

  4. #4
    Senior Member NW-Will's Avatar
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    If "Medicare is technically not denying the Titanium" .... why is it the DME can't submit for pre-approval? anyone know ?


    From my PT to Tilite representative :
    To clarify, patient has Medicare with WA Medicaid back up, if he gets the Medicare denial of the requested titanium wheelchair frame, couldn't we then go to Medicaid for approval of features Medicare denies?

    Then when Medicaid denies, couldn't we then go through our normal appeal process?


    Would Medicaid be following Medicare rules if Medicare is his primary? Or would they use their administrative rules?
    Response from Tilite representative :
    Unfortunately that would not work because Medicare is technically not denying the Titanium. They are saying that it is included in the allowable for the K0005. This new policy essentially blocks any Medicare recipients from getting Titanium chairs.

  5. #5
    Quote Originally Posted by NW-Will View Post
    2018.

    Any insight, thoughts, ideas, perspective gratefully accepted.

    I'm just talking Medicare/Medicaid here.

    New Manual chair through Medicare/Medicaid understanding the system, what is available, what are the options, what is a good strategy for obtaining the best chair for the individual.

    Not meaning to be too long winded, but basically how do we make the system work for us ?

    I really don't want to go through the new chair nightmare, but my butt pain is so bad, my doctor and PT think it would really help me.

    Back in 2011 when I got my current chair, I went to the PT, the DME came to the measuring session and then I just waited and waited felt like it took 12 months and then the chair arrived just as the PT prescribed. Tilite titaninium TR etc. life seemed good.

    Fast forward to now and 2018 and everyone seems to be throwing their arms in the air, "there have been so many changes we could never get you that chair for you now." Different PT same DME.

    So what are other folks experiencing and what really are the options.

    Has anyone managed to get a titanium chair recently? ( last 6 months)

    My DME is also telling me that I can't pay for the upgrade myself, medicare/medicaid won't allow it.
    Also I can't pre-pay (bill unassigned) either.

    Are my options really going to be I'm stuck with what whatever Medicare/Medicaid pay for
    or
    Pay for the whole thing out of pocket?

    From my DME :



    From a Tilite Representative:
    I got measured for my chair November of 2016, so a little more than 13 months ago. BCBS approved it two days after the DME submitted it, but despite the fact that Medicare is secondary (and therefore not going to pay anything), DME has been insisting that they have to get approval or denial from Medicare before they can actually place the order. Therefore I haven't had a yes or no for 13 months (part of this is surely the DME's fault, but most of the waiting is on Medicare). Luckily my Medicare will be canceled at the end of the month so then I imagine we can proceed with the order.

    It took me six months of back and forth to get my last chair in 2011, but my experience has been much, much longer this time around, just as you are experiencing.

  6. #6
    Senior Member Oddity's Avatar
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    Quote Originally Posted by NW-Will View Post
    If "Medicare is technically not denying the Titanium" .... why is it the DME can't submit for pre-approval? anyone know ?


    From my PT to Tilite representative :


    Response from Tilite representative :


    I say this a lot on this board, but ask them about signing an ABN (Advanced Beneficiary Notice of non-coverage). Having this form signed allows your provider to essentially balance bill you for what Medicare denies. There may be some restrictions with being dual enrolled in both Medicare and Medicaid.

    Ive used this form a number of times after being told I can’t pay for something denied out of pocket, or if the Doc doesn’t accept assignment but I really want to use them.
    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

    "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

  7. #7
    Senior Member NW-Will's Avatar
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    Thanks for the input.

    wonder what is the difference between "bill unassigned" and an ABN.
    Shall ask my DME about the ABN.

    Wondering how the ABN interacts with Medicaid ... wishing there was some kind of idiot flowchart, on how all these parts of the jigsaw interact.


    Quote Originally Posted by Oddity View Post
    I say this a lot on this board, but ask them about signing an ABN (Advanced Beneficiary Notice of non-coverage). Having this form signed allows your provider to essentially balance bill you for what Medicare denies. There may be some restrictions with being dual enrolled in both Medicare and Medicaid.

    Ive used this form a number of times after being told I can’t pay for something denied out of pocket, or if the Doc doesn’t accept assignment but I really want to use them.

  8. #8
    Senior Member pfcs49's Avatar
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    A year ago I got on Kessler's wheelchair clinic waiting list.
    Then I had three appointments there, June & July.
    I thought that started the "ordered" clock, but now, they got back to me and told me I need another appointment for a Dr's visit and a "letter of medical necessity"! which I had 12/22.
    So, a year wait BEFORE even ordering the fucking thing which has several compromises in addition to being aluminum. (My last new chair was Ti, 2006)
    If you're going to fuck me, could you please make it quick??!
    Maybe by spring?
    69yo male T12 complete since 1995
    NW NJ

  9. #9
    that sucks! still waiting for my wheelchair eval hopefully i will hear in the new year. if not i will call them again! i WILL HAVE A NEW CHAIR SOMETIME NEXT YEAR i am determined at that!!!
    T6 Incomplete due to a Spinal cord infarction July 2009

  10. #10
    Senior Member NW-Will's Avatar
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    Look forward to any feed back whether good or bad on your experiences this coming year... I'm just trying to stay motivated.

    Wanted to share this from another thread I started as it's pertinent and maybe helpful to others.

    Quote Originally Posted by NW-Will View Post
    "bill unassigned" vs "ABN" - Advance Beneficiary Notice or are they the same thing?

    Figure somebody here would know definitively what the difference is or are they the same thing?
    Quote Originally Posted by Oddity View Post
    Different things.

    Bill unassigned essentially means the provider does not accept assignment from Medicare for the particular service or DME, and they are going to charge their own price, unrestrained by Medicare assignment (Assignment is the term for the Medicare $ reimbursement amount). They also typically collect upfront. You pay out of pocket, upfront, they bill Medicare, and the assignment $ is sent to YOU. An ABN is STILL used if anything is known or suspected of being denied!

    (Note: If they accept assignment on the product or service from one Medicare patient, they must accept it from all. It is product, and Medicare participation based, not patient based.)

    An ABN is simply a way for us to get upgrades, and for the provider to have financial liability protection. It is only used when the provider expects Medicare to deny something (usually an upgrade). If you sign it, you?re on the hook for whatever Medicare denies (which is why it is also a good idea to have an Advanced Determination of Coverage submitted first)

    An ABN is used when billing assigned or unassigned claims if there is a denial expected. No expected denial, no need for an ABN. If a DME provider is a Medicare participant they have to accept assignment, meaning they can?t bill YOU unassigned if they don?t bill EVERyONe unassigned for the same product.




    TL;DR: Assigned vs Unassigned boils down to this: The DME is either a Medicare participant, or not. If not, they bill unassigned. If so, they bill assigned. In EITHER scenario, if the claim, or any part thereof, is anticipated to be denied, an ABN form is used to inform the patient of this fact, show them by how much $, and acquire their sign off and guarantee to pay what Medicare denies. Big differences: Unassigned means paying upfront and YOU get the Medicare reimbursement. Assigned means you pay your 20% when you get the chair and the DME gets the reimbursement. Bill Unassigned is essentially the way we Medicare patients gain access to non-participating providers, but can still get reimbursement for ourselves, and the provider can still make his vacation home and boat payments.




    Here is guidance from when the ABN process was introduced, from Invacare, to its suppliers:

    http://www.invacare.com/images/pdfs/ABNbooklet.pdf

    Page 7, section b, is specifically about the K0004 to K0005 wheelchair upgrade.


    (NOTE: This is all very tricky and I?m not an expert. Things could be different now then when i was involved, 10+ years ago, so do your own research and read read read! Lots of info online about this process at CMS.)

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