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Thread: Finally gonna try to use Medicare to get a chair

  1. #41
    Senior Member Oddity's Avatar
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    There was a window between when they deactivated the K0009 HCPCS code (forcing manufacturers to code all their "ultra-light" wheelchairs K0005) and when the "unbundling" policy letter referenced in my EoB was issued (Dec 2017), during which the titanium upgrade option (with separate billing code and additional reimbursement) worked fine. I know a number of folks who used this method between ~2014 and late 2017 to acquire TiLite TR and ZR titanium frames. Sadly, no longer, it seems.

    On a complete side note, I've gotten a handful of PMs about HoC chairs, and my "$1,500" statement. To be clear: I don't know first hand how much a completed chair costs. They've posted prices in comments on their Instagram feed of starting at $1,500 for simplest raw frame, and between $3,000-$5,000 for complete chairs. I could imagine spending $5k on one and being very happy, relative to my experience these past 10 years pushing the Lasher.
    Last edited by Oddity; 03-16-2019 at 05:59 PM.
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "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

  2. #42
    Well I have the HoC order form but, I can't figure out how to post a picture. $1,500.00 is just a bare frame.

    on a side note if it were easier to post pictures I think more people would use this site.

  3. #43
    If everything was approved can't you just pay for the titanium upgrade and color anodizing?

  4. #44
    Senior Member Oddity's Avatar
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    Partly true. By signing an ABN form (advanced notification of uncovered costs form from Medicare) Medicare patients CAN pay out of pocket for uncovered options. CMS just requires we know ahead of time what those costs will be, before we decide. I explained the "unbundling" issue, in an earlier post, as to why this doesn't apply to frame material upgrades (like titanium). I could indeed use this ABN form process to pay for the color anodizing myself, but not the titanium upgrade.
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "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

  5. #45
    Quote Originally Posted by Oddity View Post
    Partly true. By signing an ABN form (advanced notification of uncovered costs form from Medicare) Medicare patients CAN pay out of pocket for uncovered options. CMS just requires we know ahead of time what those costs will be, before we decide. I explained the "unbundling" issue, in an earlier post, as to why this doesn't apply to frame material upgrades (like titanium). I could indeed use this ABN form process to pay for the color anodizing myself, but not the titanium upgrade.
    This is so absurd. I mean I totally get that insurance companies (Medicare especially) doesn’t want to pay for medically unnecessary stuff. But a frame that is 2# lighter offers at least the potential of benefit, at least let us pay for the upgrade. I double the bright pink anodizing you’re planning on getting is going to put any less strain on your shoulders.

  6. #46
    Quote Originally Posted by funklab View Post
    This is so absurd. I mean I totally get that insurance companies (Medicare especially) doesn’t want to pay for medically unnecessary stuff. But a frame that is 2# lighter offers at least the potential of benefit, at least let us pay for the upgrade. I double the bright pink anodizing you’re planning on getting is going to put any less strain on your shoulders.
    OK, I'm sure I'm missing a few bricks cause I ain't never been real bright guy!
    But, a chair frame, any material built out of is still a chair frame! If it's coded by CMS as passing their testing it makes no sense it ain't covered!
    Profit! DME's cover their rears with piece by piece billing for everything on a chair.
    They have outside company, in most cases, do their billing to Medicare and insurance companies, right?
    Someone other than end user is one decides what is ordered or billed in their good old time while end user just waits and waits!
    Then here comes the ABN form so DME makes sure they don't lose out a extra penny and that penny turns into any amount.
    I think we the end user should have a form for DME to sign that every day past 90 day Face to Face with getting order for chair ought have pay us! Would that not give them incentive to get on the ball?

  7. #47
    Senior Member Oddity's Avatar
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    There are many layers to this subject, and it's not entirely CMS's "fault". CMS doesn't care about frame material, as far as I can find. I've found a number of DME policy statements from private insurers (I.e. Blue Cross of NC) who have explicitly decided titanium frames are not medically necessary; citing a lack of credible research and the fact a titanium chair can weigh more than a cheaper aluminum chair. There is no guarantee a titanium chair will be lighter, but there is a guarantee it'll be ~30% more expensive. Medicare has no such policy that I can find. They have a list of codes, with reimbursement amounts for each, and manufacturers apply to have their products "registered" to that code so dealers can use the code to get the reimbursement amount. That's about it.

    The current state of affairs began when CMS discontinued the K0009 code in ~2013. That code had the highest possible reimbursement amount, and worked well for more costly titanium frames, like the ZR and TR. When the 'K9' code went away, the remaining "ultra-light wheelchair" code was K0005, which had ~30% less potential reimbursement than K9. Reimbursement for K9 codes chairs was very difficult to get via Medicare but wasn't explicitly impossible. It happened, but not often, and not without effort and appeals, etc, but it did happen when the need was genuine and advocacy strong.

    Since K9 went away, manufacturers (like TiLite) changed their product-code associations for their ultra-light chairs from K9 to K5. At the same time TiLite also changed their order form to make 'titanium frame' an "option" on the ZR, with a separate billing code (K0108 I think). This allowed dealers to make back the additional reimbursement they used to get from the old K9 coded chairs, now coded K5, plus additional reimbursement for the cost of the titanium upgrade code.

    They had to do this because the base reimbursement value of K5 is only ~$2,000, which probably doesn't even cover dealer cost on a complete TiLite ZR chair. Bottom line is this: titanium chairs are expensive and without proven medical benefits inside the home. K5 doesn't cover the cost of these chairs so "the industry" got creative with the coding (adding K0108 to K0005) so they could cover their costs and still have a profit.

    Fast forward 3-4 years and CMS discovered, after discontinuing K9 code (ostensibly to save money and standardize benefits) this use of an additional code (K0108) to cover costs they considered already paid by the K5 code. This is the "unbundling" of a single code into multiple codes in order to get more money, when a single code covers the item. That is Medicare fraud since the time the "unbundling" policy statement was issued (late 2016 or 2017, I forget which).

    So, this tale isn't about how the govt/CMS doesn't want us to have titanium wheelchairs. They don't care. They just don't want to pay for frame material twice. They also don't seem to want to pay more than ~$2,000 + medically necessary options and accessories, which, to all of us, seems WAY too low. Although, since one of my "medically necessary" accessories is a $7,000 SmartDrive...it would seem spending money isn't the problem, it's "medical necessity within the home" and "unbundling" that are the obstacles.

    We need credible research, IMO. With some private insurers now explicitly denying titanium, like BCBS of NC, I don't think it'll be too long before that becomes wide spread, without credible research showing titanium being a genuine difference maker.

    But, for clarity, I've found NO CMS publication that says titanium is not covered, just not covered as a separately billable option, and covered only within the reimbursement value of K0005, which effectively means no DME can sell one without losing money. It's a cluster.
    Last edited by Oddity; 03-19-2019 at 11:48 AM.
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "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

  8. #48
    Senior Member Oddity's Avatar
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    Cut to...some more time has passed...

    I've decided not to proceed with the titanium frame option. The DME (Tycon Medical, recommended) has worked me a terrific deal on the chair, in aluminum, Roho CF backrest, SmartDrive, and cushion, so I've decided to take it. This was mostly an exercise in the process than anything. I always new I'd end up in an aluminum chair, and told them so during the very first seating eval, so I'm content. (See my post history for my opinions on the benefits/value of titanium for wheelchair frames; TL;DR: I'm not a huge fanboy. It has its uses.)

    Just waiting to see a copy of the order form submitted, and the CAD after my mark-ups, to seal the deal.
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "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

  9. #49
    Senior Member NW-Will's Avatar
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    Oddity, thank you for taking the time to write all this out... these are some of the best explanations, much appreciated.

    Also going through this process.. but have medicare and medicaid... so not allowed to use an ABN as medicaid is means tested etc.. but still trying to figure it out.

    Quote Originally Posted by Oddity View Post
    Cut to...some more time has passed...

    I've decided not to proceed with the titanium frame option. The DME (Tycon Medical, recommended) has worked me a terrific deal on the chair, in aluminum, Roho CF backrest, SmartDrive, and cushion, so I've decided to take it. This was mostly an exercise in the process than anything. I always new I'd end up in an aluminum chair, and told them so during the very first seating eval, so I'm content. (See my post history for my opinions on the benefits/value of titanium for wheelchair frames; TL;DR: I'm not a huge fanboy. It has its uses.)

    Just waiting to see a copy of the order form submitted, and the CAD after my mark-ups, to seal the deal.

  10. #50
    Quote Originally Posted by Oddity View Post
    Cut to...some more time has passed...

    I've decided not to proceed with the titanium frame option. The DME (Tycon Medical, recommended) has worked me a terrific deal on the chair, in aluminum, Roho CF backrest, SmartDrive, and cushion, so I've decided to take it. This was mostly an exercise in the process than anything. I always new I'd end up in an aluminum chair, and told them so during the very first seating eval, so I'm content. (See my post history for my opinions on the benefits/value of titanium for wheelchair frames; TL;DR: I'm not a huge fanboy. It has its uses.)

    Just waiting to see a copy of the order form submitted, and the CAD after my mark-ups, to seal the deal.
    Two big advantages with titanium are weight and no maintenance. I want to resurrect my Quickie Titanium because it is significantly lighter than anything else I ever used. Doesn't make any difference except for one thing. My shoulders feel the difference when transferring the chair in and out of the car. That's just one thing. But it's a biggie.

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