Things that are going on that you might want to know. 

5

Just in case, you didn’t get it!

It is important to all of us!

Last fall, the Medicaid office, here in NYC, which had approved DME (durable medical equipment, which includes things like wheelchairs & repairs, rollators, ramps, etc.) closed and was moved Albany. Of course, Medicaid & the Dept. of Health, says there is no problem. In reality, it is a big problem! Most of us know it!

If you have had or are having trouble with getting durable medical equipment since the New York City Medicaid office which processed such claims closed please email or call them at

Edith Prentiss emprentiss@juno.com or call at 212-781-8309

Paula Wolff pwolff@cidny.org, home at 212-255-2586, work at 212-674-2300, ext. 118 ASAP!



Edith Prentiss and Paula Wolff will be testifying and desperately need information on the clients' experiences of any DME problems in 2005, after the NYC office closed.
 

6

They need it now Medicaid approval for special equipment for disabled has slowed to a trickle, say docs and patients

BY RIDGELY OCHS
STAFF WRITER

May 25, 2005

At 95 pounds, Linda Brewi of Levittown has a hard time getting her 12-year-old daughter Lauren, who is severely disabled, in and out of the bathtub. That's why an automatic bath chair has been a godsend.

But for the past four months, she hasn't been able to use the chair because Medicaid has not approved a battery that costs less than $200.

Brewi's case is not unusual, said doctors who treat the disabled. In November, a Manhattan Medicaid office that handled thousands of equipment orders for the downstate region, which includes Long Island, was shut and the function centralized in Albany. Since then, the physicians said, many more requests for specialized equipment have been delayed or denied, leaving thousands of disabled people in the area without equipment that means independence for many.

"My daughter can't do anything for herself," Brewi said. "They're not luxury items. These are absolute necessities. Come to my house. Come to her school. This is my life."

Assembs. Richard Gottfried (D-New York), James Brennan (D-Brooklyn) and Amy Paulin (D-Westchester) have called for hearings this summer to investigate the delays. Brennan said they also are considering legislation to clarify equipment approval guidelines.

"We're trying to get DOH [the Department of Health] to clarify with all providers what the guidelines are, make sure there is adequate response time and that peoples' problems can be resolved fairly and expeditiously," Brennan said. "I have to say after reviewing everything, DOH has mishandled this matter. If you're planning to close an office, there should have been a whole plan in place beforehand rather than this willy-nilly closure, followed by months and months of confusion ..."

Health department spokesman William Van Slyke said Medicaid has not reduced its approvals of equipment requests. "The data suggest just the opposite. We have just 1 percent rejected," he said. As for clarifying what information vendors and doctors need to expedite approvals, Van Slyke said: "We understand that this has had an impact and we have had several training sessions." He said the office has invited doctors and vendors to a June 15 meeting to discuss the procedures.

Van Slyke said the processing of equipment orders was moved to Albany because "we were seeing different interpretations of the [Medicaid] rules and we wanted parity. ... We basically tightened up our ship."

Doctors said approvals for standard equipment, such as a walker, now take less time, but approvals for specialized equipment, such as Brewi's bath lift, have slowed down significantly.

"I have had delays upon delays upon delays," said Dr. Meg Allyn Krilov, who treats disabled patients in clinics in all boroughs except Staten Island. Krilov said she has submitted more than 400 requests for equipment or repairs since November; only three have been approved.

And that is after they provide detailed, often excessive, information, Krilov and other doctors said. "They had us measure the bathtub and asked how many baths a day the patient took," Krilov said of a request for a special bath chair. "This is ridiculous."

Susan Eckert, public relations manager for United Cerebral Palsy of Suffolk in Hauppauge, said before, her group could send pictures showing patients and equipment, but "now we're asked to take videos." The group, she said, has made 100 requests; so far none have been approved.

This has meant more work for doctors and clinics. Dr. Rani Kathirithamby, who treats severely disabled children at the Bronx's Albert Einstein College of Medicine, said she now spends two afternoons a week providing Medicaid officials with more information - down to the original bill of sale on an item requiring a repair.

"This is time taken away from patients," she said. "My therapists are taking time to do this. My secretary does nothing else but this."

But, she said, the patients suffer the most. She spoke of a Bronx mother who is reconsidering adopting a foster child with cerebral palsy because of the difficulty in obtaining Medicaid approval for equipment.

Dr. Patricia Tan, who treats the disabled at United Cerebral Palsy in Nassau in Roosevelt and at South Nassau Communities Hospital in Oceanside, said some pay out of their own pockets to rent the equipment they need pending Medicaid approval. "But not everybody can afford that," she said. "They are the ones who are really suffering. ... Some of them are becoming more disabled and it gets them depressed."

Katherine Lewis, 58, of Oceanside, said she has waited for almost a year for Medicaid to approve a motorized wheelchair.

"I use the walker and fall all the time," said Lewis, who added that her cerebral palsy is worsening. "I want to continue to be independent and do my own housework."

Plainview resident Lisa Borgen said her 8-year-old daughter Brittany, who has multiple disabilities, has outgrown a special stroller she has had for five years. Brittany has athetoid, or excessive, movement, and needs to be strapped in for her own safety, Borgen said. She applied for a new stroller in June and was turned down, resubmitted forms, was turned down again and resubmitted another set of forms. In January, the office told her it no longer approved strollers. Now she's "starting from scratch," she said, filling out forms and getting measurements to apply for a special wheelchair. In the meantime, Brittany is using a stroller on loan from a vendor.

"This is inhumane. ... Thank God for the loaner. Otherwise, I don't know what we would do," she said. "She had bruises because nothing fit properly and it was almost choking her. They're putting safety at risk."

Waiting for:

A special wheelchair

Lisa Borgen, of Plainview, waited months for a specialized stroller for her 8-year-old disabled daughter, Brittany. The request was finally denied and she is now applying for a specialized wheelchair.



Waiting for: A motorized wheelchair

Katherine Lewis, of Oceanside, who has cerebral palsy, has waited almost a year for a motorized wheelchair. In the meantime, she has had to use a walker.

Waiting for: A battery

Linda Brewi, of Levittown, has waited four months for a battery for an automatic bath chair for her 12-year-old disabled daughter.

Some ways to get help

For questions involving Medicaid coverage of medical equipment, call the Medicaid help line at 518-486-9057 or 800-541-2831.

You also can contact the state Commission on Quality of Care and Advocacy for Persons with Disabilities at 800-522-4369 or go to www.oapwd.org.

United Cerebral Palsy offers information and clinical services for people with any disability:

In New York City: 212-979-9700, ext. 237, or 877-UCP-CONNECT, ext. 237

In Nassau: 516-378-2000, ext. 285

In Suffolk: 631-232-0011

 

7

MEDICARE IMPROVES ACCESS TO POWER WHEELCHAIRS AND SCOOTERS
May 6, 2005
Medicare has implemented new national coverage criteria for power wheelchairs, scooters and other mobility equipment. The new criteria, which are effective immediately, adopt a function-based determination of medical necessity, the Centers for Medicare & Medicaid Services (CMS) said.



The new determination looks at the ability of the beneficiary to safely accomplish mobility-related activities of daily living, such as toileting, grooming, and eating, with and without the use of mobility equipment such as a wheelchair. The new standard addresses the full range of equipment from simple canes and walkers to sophisticated power wheelchairs.

"The steps we are taking today are part of our efforts to ensure that seniors who need mobility help will get it promptly, and that we are paying appropriately for mobility assistive equipment," said CMS Administrator Mark B. McClellan, M.D., PhD.

"The new functional criteria reflect current medical practice and mean that beneficiaries will have the freedom to live better, more mobile lives, without needing to fit into a rigid ‘bed or chair-confined’ standard."

Critics disagreed. Robert M. Hayes, president of the Medicare Rights Center said the new policy "maintains an antiquated and illegal policy that will keep tens of thousands of Americans in cruel and unnecessary isolation."

“Today’s national coverage decision maintains a long obsolete Administration policy that pays 80 percent of the cost of a power wheelchair for a person with Medicare who needs it to move from a bedroom to a kitchen, but not for a person who requires the wheelchair to leave home for medical care, shopping or even employment," Butler said. "The policy imprisons people in their homes and is based on an outdated reading of the Medicare law."

The new coverage criteria are part of a larger three-pronged Modern Mobility Initiative announced in April 2004 focused on improving coverage, payment and quality of suppliers of power wheelchairs and other mobility aids. In addition to developing new coverage criteria, CMS has developed new billing codes that will take effect January 1, 2006, to reflect the variety of wheelchairs now on the market. CMS expects to issue new quality standards for suppliers in 2006.

"This coverage policy ensures that a beneficiary’s functional status and individual circumstances are considered so that the most appropriate technology for each beneficiary’s personal needs is covered," said Barry Straube, M.D., CMS’s Acting Chief Medical Officer and Acting Director of the Office of Clinical Standards and Quality.

CMS plans to issue additional guidance in the near future to help physicians and treating practitioners better understand the new coverage criteria and CMS’s expectations about proper documentation in the medical record.

The new standards are expected to help root out fraud and abuse, the department said.

Butler said the CMS decision shows it is time for the White House to intervene.

“It is now the 21st century: changes in technology, medicine and law require coverage of equipment that allows people with disabilities to have a productive life outside the four walls of their homes," Butler said in a statement.

“It is time for the White House to intervene. President George H.W. Bush championed the Americans with Disabilities Act (ADA). President George W. Bush has repeatedly said he too supports allowing maximum independence for people with disabilities."



The Centers for Medicare & Medicaid Services (CMS) today announced new national coverage criteria for mobility assistive equipment (MAE) including power wheelchairs and scooters. The new criteria, which are effective immediately, adopt a function-based determination of medical necessity. This determination looks at the ability of the beneficiary to safely accomplish mobility-related activities of daily living, such as toileting, grooming, and eating, with and without the use of mobility equipment such as a wheelchair. The national coverage determination (NCD) addresses the full range of MAE from simple canes and walkers to sophisticated power wheelchairs.

“The steps we are taking today are part of our efforts to ensure that seniors who need mobility help will get it promptly, and that we are paying appropriately for mobility assistive equipment,” said CMS Administrator Mark B. McClellan, M.D., PhD. “The new functional criteria reflect current medical practice and mean that beneficiaries will have the freedom to live better, more mobile lives, without needing to fit into a rigid ‘bed or chair-confined’ standard.”

The new coverage criteria are part of a larger three-pronged Modern Mobility Initiative announced in April 2004 focused on improving coverage, payment and quality of suppliers of power wheelchairs and other mobility aids. In addition to developing new coverage criteria, CMS has developed new billing codes that will take effect January 1, 2006, to reflect the variety of wheelchairs now on the market. CMS expects to issue new quality standards for suppliers in 2006.

“This coverage policy ensures that a beneficiary’s functional status and individual circumstances are considered so that the most appropriate technology for each beneficiary’s personal needs is covered,” said Barry Straube, M.D., CMS’s Acting Chief Medical Officer and Acting Director of the Office of Clinical Standards and Quality. "It is also consistent with the documentation of the functional needs of the patient that should be in medical records for our beneficiaries."

CMS plans to issue additional guidance in the near future to help physicians and treating practitioners better understand the new coverage criteria and CMS’s expectations about proper documentation in the medical record. Because the new functional criteria more explicitly refer to standard clinical evaluative methods, CMS expects that the medical documentation generated during the patient evaluation will more accurately be reflected in the beneficiary’s medical record. It is CMS’s intent that this will make the power mobility device coverage process more straightforward.

“During the course of reviewing Medicare’s policies for power mobility devices, CMS came to the conclusion that there are more accurate tools to root out fraud and abuse,” said Kimberly Brandt, Director of CMS’s Program Integrity Group. “The combination of the new NCD and the planned enhanced educational outreach by Medicare to physicians and treating practitioners, as well as to suppliers, will eliminate most honest billing errors. More accurate claim submission will allow CMS to better analyze claims data and focus claims review to target abusive billers.”

For questions about Medicare please call 1-800-MEDICARE or visit www.medicare.gov


 

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