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Public and Private Insurance Show Increase in Denials for New Wheelchairs

People who evaluate and fit patients for wheelchairs say many requests for more expensive, motorized chairs with multiple custom features are being denied because insurers and Medicare officials are worried about high costs and fraud. Doctors, physical therapists, and patients must appeal the decision, or else the patients give up and accept lesser chairs.

“It’s gotten to the point where words are not enough to convince the medical directors” of insurers, said assistive technology professional Robert Townsend of Jeff Quip, a Boothwyn company that supplies complex chairs.

Experts said patients who fight – especially those who appeal in person – often can get the chair they need, but during the bureaucratic battle, they must make do with loaner chairs or lie in bed.

People who have battled for chairs say both public programs such as Medicare and private insurers are balking. The delays likely flow from Medicare’s attempts to curtail fraud in the motorized wheelchair market; other insurers follow its lead. Medicare’s response to companies that advertised widely on TV and amped up demand for scooters is a set of rules that Donald Clayback, executive director of the industry group the National Coalition for Assistive Technology and Rehab Technology, calls “onerous” and “overly aggressive.”

Insurers deny that they are stalling or have increased denials for high-end chairs recently, but say they must help prevent fraud and spend money wisely. “It is often a challenge,” said Don Liss, medical director for Independence Blue Cross. He said IBC processes 22.2 million claims a year and had denied 38 claims for complex wheelchairs last year. He called the “flat-out” denial rate “fleetingly small.”

Medicare, which requires patients to have a face-to-face visit with a doctor before submitting a wheelchair claim, will pay only for chairs that patients need to function in their home, and private insurers have followed suit. They won’t pay for more powerful chairs, for example, if someone needs one to go to work or get around a college campus.

Liss said insurance typically does not cover accessories that are not primarily medical in nature, such as interfaces for turning lights on or tray tables. Patients can pay out of pocket for accessories that aren’t covered.

People who fit patients for chairs at area rehabilitation hospitals say they have a particularly hard time getting approvals for seats that go up and down so that patients can access work surfaces of different heights. Seats that tilt to prevent pressure ulcers can also be hard to get. Estimates of denial rates varied widely, but people involved in sending claims said they were up markedly in the last two years.

For the entire article: Insurers Put Brakes on Wheelchair Approvals


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