Winning payor permission to supply an ultralight manual wheelchair—often referred to by its Healthcare Common Procedure Coding System code K0005—has, in many instances, grown easier over the last few years. Harder than ever, though, is the part where you convince the insurance company to reimburse appropriately for the product you have delivered.

“Rates of reimbursement are still often very limiting,” says Dan D. Lipka, MEd, OTR/L, CRTS, sales evaluator for Miller’s Sales, Rental and Service in Akron, Ohio, and current president of the National Registry of Rehabilitation Technology Suppliers (NRRTS). “For example, it might be determined following a complete evaluation that a person’s needs would best be met by putting him or her in a $2,800 K0005 rigid wheelchair, then it turns out that the insurance company will allow only $1,400 as your reimbursement and that’s the amount you’ve contractually agreed to accept as payment in full. It’s a losing proposition that leaves you stuck in the middle.”

Until the advance determination system was instituted, you could really end up burned by Medicare any time you supplied a K0005 to the elderly, say providers interviewed for this article.

“Advance determination isn’t a perfect remedy, and it’s not available for all chairs—but it’s a good method for providers, beneficiaries, and referrals to get an understanding of how Medicare will accept or not accept the K0005 claim,” says Paul Bergantino, president of Connecticut Rehab & Medical Products in Newington, Conn. “Prior to this, it was a roll of the dice as to what Medicare would or wouldn’t do, so you had little basis for making a sound decision as to accepting the transaction or assignment. In those days, if you had already supplied the chair and Medicare then downcoded it, you were out of luck.”

More Compelling Documentation
Still, it is possible to get paid appropriately for the K0005s you supply. First and foremost, you must demonstrate plenty of grit in the face of seeming payor intransigence.

“Among private payors, many try to avoid paying appropriately by first denying claims for ultralight chairs and then wearing you down by dragging out the appeals process on that denial,” says Gary J. Gilberti, CRTS, president of Chesapeake Rehab Equipment in Baltimore. “They set up obstacles to discourage us from fighting for appropriate reimbursement. They count on us throwing in the towel rather than sticking it out and battling them for a year, year and a half, before there is any resolution. They want us to make the calculation that it is not worth it in lost time and effort to fight them to that extent over a few hundred dollars.

“Unfortunately, a lot of suppliers come to exactly that conclusion and decide to give up. The result is unfairness to the consumer. A lot of people aren’t getting product they need that could be helping better their lives. They’re ending up in lower-end wheelchairs when they would be better served by a K0005 or, at minimum, a K0004.”

Other HME and rehab equipment providers—Gilberti among them—are not willing to let payors run roughshod over them. So they have developed various techniques to increase the potential for securing appropriate reimbursement.

One such technique entails getting off to a stronger start by submitting more compelling documentation—the kind that can make a tight-fisted insurance company realize it will be financially better off in the long run paying full fare now.

“Among the statements you should include in your documentation is a discussion about the nonambulatory status of the person you hope to put into that K0005 chair,” Gilberti says. “A second discussion point is upper extremity range of motion. You need to be able to demonstrate upper extremity weakness sufficient to prevent the person from self-propelling anything less than a K0005.”

Adds Toby Bergantino, CRTS, Paul Bergantino’s brother and coworker at Connecticut Rehab & Medical Products, “You should also explain the harm done by other related medical issues—such as carpel tunnel syndrome, arthritis, and shoulder rotator cuff injury—in preventing the user from self-propelling and achieving functional independence apart from the K0005 chair.”

Helpful, too, is evidence that only a chair with superior adjustability in terms of seating, axle-caster position, and various accessories will meet this wheelchair user’s unique needs, Gilberti says. In addition, a summary of the wheelchair user’s activities of daily living may be useful if it demonstrates that only the outstanding maneuverability and frame-strength characteristics of a K0005 are up to the challenge of enabling the user to be a more productive member of society.

Pushing Payor’s Buttons
Toby Bergantino notes that describing a particular chair as necessary for achieving functional independence is a hot button for various payors. “They typically like products that promote functional independence because it allows them to avoid paying for caregivers, which can be a major cost to them,” he says.

Along similar lines, you might also project what will happen in the future were the wheelchair user to be denied that desired K0005. For example, as Toby Bergantino sets forth, the equipment provider can offer clinical evidence that without a lightweight wheelchair the user will likely suffer additional physical maladies, such as repetitive motion injuries of the arms, from self-propelling a heavier and less maneuverable wheelchair. With such evidence, you can build a case that putting the user in the right chair from the start may save the payor thousands of dollars treating those avoidable repetitive motion injuries in the future.

Meanwhile, photographs and video often represent an effective way to buttress your argument.

“It’s true that a picture is worth a thousand words,” says Paul Bergantino, who advises snapping comparison shots showing a standard wheelchair setup and then the higher-end wheelchair in the particular configuration you have in mind. “These photos should make it readily apparent how awkward propelling will be for the user if he or she is forced to accept the lower-end chair,” he says.

A reminder: When taking pictures or video, be sure to obtain a signed release form from the consumer allowing you to share those images with the insurance company, Toby Bergantino adds.

Consumer as Advocate

You can further fortify your documentation by working more cohesively with referring clinicians. Ask your clinician partners to spell out in their paperwork precisely why they have specified each particular wheelchair and option, advises Paul Bergantino.

“The justifications that you will receive from clinicians often either are short on information or go off on the tangent of explaining what a particular piece of equipment is and how it works rather than explaining why the specific client medically needs it,” he says.

Lipka, however, thinks the team member possessing the ability to make the most forceful contribution to these efforts is the consumer—or, alternatively, the consumer’s employer.

“They are the ones paying the insurance premium,” he says. “And, often, they don’t realize that what they are paying for and what they get are quite different. The consumer and/or the employer should be encouraged to contact the payor and demand funding sufficient to cover the full cost of the equipment needed.”

If the payor refuses to fund a lightweight wheelchair, then the person writing the premium checks can threaten to shop for a payor that will, Lipka hints. Alas, consumers too often are reluctant to lock horns with insurance companies over such matters.

“No one who seeks any kind of health care services expects to have to negotiate with their insurance company,” Lipka says.

In the event the payor absolutely will not budge, do not automatically assume all is lost. “We might still be able to provide that K0005, but what we usually have to do is choose economical options within the K0005 category,” Lipka says.

Then, of course, there are always alternative funding sources. Some consumers opt to bypass their insurance by paying for the product entirely out of pocket. However, those who can afford to go this route are relatively few in number since most people with disabilities already struggle with extensive financial burdens arising from their health conditions.

“Another possible alternative funding option,” Lipka says, “is the consumer’s state-sponsored vocational-rehab system, if it can be demonstrated that having this wheelchair will have a significant favorable impact on his or her ability to maintain employment.”

The point, he says, is that if at first you don’t succeed with your bid to be appropriately paid, try, try again. Only after exhausting all conceivable angles and avenues should you wave the white flag of surrender. However, you may be pleasantly surprised at what you can achieve with payors simply by making the effort to convince them to fully fund the consumer’s ultralight manual wheelchair needs.

Rich Smith is a contributing writer for Dealer/ Provider.