Achieving real success as a provider of pediatric wheelchair seating-and-positioning services seems on the one hand a more elusive goal than ever, what with funding-source hassles mounting and per-client demands on technician time steadily increasing.

Yet, on the other hand, finding genuine success in this niche has never been more possible, say some pediatric rehabilitation equipment providers. The starting point, these providers say, is learning to view seating-and-positioning as a highly individualized process.

“You cannot approach seating-and-positioning on a cookie-cutter basis,” instructs Paul D. Rice, CRTS, ATP, president of The Wheelchair Shop in Houston. “You have to always remember that you are creating something that is never exactly the same from one client to the next, because every child’s situation and needs are different.”

For HME companies who hope to be successful providers of pediatric seating and positioning systems, this means being much more than simple order takers who blindly follow the instructions of therapists and physicians and the dictates of payors.

“You have to be fully involved in the evaluation process,” Rice says. “And you must make sure that families, caregivers, educators, therapists, and anyone else with significant involvement with the child is also involved and offering input.”

This is not to suggest that there is no market pressure on providers to embrace a one-size-fits-all mentality, Rice concedes.

“We have some payors who, in my opinion, are doing nothing less than rewriting prescriptions in order to compel use of less expensive products and, by extension, lower the amount they must pay out,” he says. “Unfortunately, the effect of that is the product is also less effective for the end user.”

To combat such payor tactics, Rice believes an all-out effort should be made to persuade the funding source of the necessity of the prescribed items.

“The best way to deal with this is documentation—lots of documentation,” he says. “That’s why I make it a practice to take many photos of clients engaged in their daily living activities. I’m a firm believer in the saying that one picture is worth a thousand words.”

Provide the Best
Another key to success in seating-and-positioning involves providing top-quality equipment to clients with the help of the therapists and nurses who are part of the evaluation team.

“We support manufacturers that provide high-quality products and technical support, back up their warranty, and have good and knowledgeable representatives,” says Rick Echemendia, rehab division director for Pedi Stat in Miami. “We also provide in-services and training for therapists, showing them the latest equipment and sometimes a different application of a technology they already know.”

Echemendia points to manufacturer improvements in pelvic belts, chest harnesses, molding systems, and pressure mapping technology as among the most valuable recent advances in equipment design and engineering. In particular, he praises product makers for coming up with folding tilt-in-space frames.

“Folding tilt-in-space was a great thing because it allowed the caregivers to fold and put these big frames in their cars,” he says. “My clients were able to get out and about more frequently and go to more places because of this new frame.”

Paul D. Rice, CRTS, ATP, president, The Wheelchair Shop, Houston

Rice, who also makes extensive use of folding tilt-in-space frames, agrees with that assessment.

“Folding tilts allow families to sidestep having to buy a $40,000 van just to be able to transport their child,” he says. “Not many of them can afford the price of a van. They are often on Medicaid or having to pay off co-pays in installments. So being able to fold up a tilt-frame chair is a huge plus for them.”

However, because the frame folds, extra pains must be taken to correctly configure the seating-and-positioning components, Rice adds.

“Seating systems typically use seat-to-back brackets,” he says. “As their name implies, these hold together the seat and the back. Some are rigid, others are hinged. Both are fine for a rigid-frame chair. But for a folding-frame tilt chair, you need to be able to separate the seat and the back or else it is not going to work as well. So, what we do is use special hardware that permits us to mount the seat separate from the back. No extra measuring is involved. The only downside is that the hardware is more expensive than standard seat-to-back bracketing.”

Maximize Your Time
Work smarter, not harder is an old management adage that is particularly true in the pediatric seating-and-positioning niche, Rice says. Because creating individualized seating solutions that can grow and develop with children is labor-intensive, successful providers know how to make the most of the time they have.

“While many providers are halting the practice of doing field evaluations because of the costs involved, I still perform them; I feel they’re too important to not do,” Rice says. “To help me hold down the cost, I’ve tried wherever possible to make use of productivity-enhancing tools.”

For example, a laptop computer in Rice’s truck gives him the means to complete forms and other documentation away from the office. Making that task more efficient is his use of voice-recognition transcribing software.

“I dictate my notes while I’m on the way to my next appointment,” he says. “That allows me to utilize the commute time—time that [otherwise] is largely wasted.”

Rice also can send and receive emails on the road through a wireless Internet connection.

“The notes and various pieces of documentation I prepare off-site can be transmitted back to my office for others to then act upon,” he says. “It really helps to speed up the process, especially if I’ve got a lot of appointments, and I am not expected to get back to the office for 1 or 2 days. The faster we are able to complete tasks, the happier the clients and the sooner we get paid.”

Legislative Challenges
However, some hurdles in the seating-and-positioning arena are not so easily surmounted, as Echemendia knows only too well. Last year his state, Florida, nearly succeeded in passing a competitive bidding provision for HME companies that serve its Medicaid patients.

“The introduction of competitive bidding created a situation in which providers were bidding without thinking about the end user,” he says. “Low bids can only translate into low quality equipment and poor service because the client has no choice in the matter and companies will look for less expensive products to maximize their profits.... The final cost will be paid by the client, the same people that we are supposed to help. That is why I think it’s a bad, bad idea.”

Perhaps the most daunting obstacle to achieving success is the relatively recent requirement that providers use published Healthcare Common Procedure Coding System (HCPCS) codes when billing for even highly customized work.

“Texas is one of a number of states where Medicaid providers had been allowed to use home-grown codes on products that didn’t have published codes associated with them,” says Nancy Rice, CRTS, ATP, vice president of The Wheelchair Shop. “Now it’s a federal law that we must use published codes only. The problem is that the published codes are so vaguely defined as to be almost useless. We have so many specific products involved in what we do and yet there are just a handful of published codes, so we end up having to assign a large amount of our work to the K-0108 miscellaneous code.

“The problem there is that using the K-0108 code really slows down the processing of our billings,” she adds. “When we submit a bill with K-0108 for one thing and another K-0108 for something else on the same claim, the payor’s computer system may kick it out, thinking these are duplicate services, when in fact they are not.”

Read the Fine Print
Nancy Rice recommends providers angling to attain success in the pediatric seating-and-positioning niche avoid becoming enmeshed in contracts that demand big discounts or offer empty promises.

“Be very careful about your contracting,” she warns. “We turn down contracts that don’t have room in them to bill and get paid for what we do. We turn down contracts that have unreasonable ‘max-pay’ amounts on codes or absurd discount requirements. You have to watch out for contracts that promise to pay 80% of what the payor considers to be reasonable and customary charges as defined strictly by the payor, which can be anything the payor wants it to be and which will almost certainly be a lot less than what we think is reasonable and customary.”

On contracts she does accept, Nancy Rice acts prudently with regard to preauthorizations.

“Before submitting requests to obtain preauthorization of services, you should take the time to analyze how the services are actually to be billed,” she says. “And you should also look at how you’re going to get paid for them. Because, if you gain preauthorization on the basis of a wrong code, then you may be facing delays in getting paid or end up not getting paid at all.”

Keeping track of contracting details, managing your time, worrying about legislative changes, and gathering input from all parties involved in selecting the right seating-and-positioning system for a child are not easy, but as long as you do not lose sight of the interests of the child, things tend to work out, Echemendia says.

“You have to make a 100% commitment to total customer satisfaction on everything from the initial order to the after-delivery follow-up,” he says.

Yes, his company is good at managing the challenges of the pediatric seating-and-positioning niche, but when it comes down to achieving the company goal of becoming the best rehabilitation equipment company in its area, it all boils down to one simple thing. “We love our clients and they come first,” he says.

Rich Smith is a contributing writer for Dealer/Provider.