Winning Strategies for Group 2 Consumer Power David Moon

Winning Strategies for Group 2 Consumer Power

David Moon

challenges you face

Times are tough for Power Mobility Providers.

• Audits have increased and reimbursement rates are nowhere near what they used to be.

•

These changes and demands are making it harder and harder for you to run your business.

Winning Strategies for Group 2 Consumer Power in Competitive Bidding

challenges you faceIn addition, administrative regulations from Medicare have also added complexity to the power wheelchair business:

• Physician’s progress notes requirements place an added burden on physicians, leading to a higher rate of denials.

• Medicare’s 9-Step Algorithm determines a beneficiary’s eligibility for a power mobility device based on their ability to perform Mobility Related Activities to Daily Living (MRADLs), decreasing the number of potential power wheelchair beneficiaries.

• PECOS – Medicare’s Provider Enrollment, Chain, and Ownership System which places the responsibility for educating physicians on the enrollment process in the hands of providers or face unwanted denials.

• Manual audits that deny claims based on minor technicalities.• Restricted cash flow resulting from Medicare reimbursement spread out over 13 months.• Bid for Manual Wheelchair’s and Power is included…..


one code does not fit allCan’t continue to follow the “cookie cutter” approach• What may you not have thought about is that improper product

alignment/coding and branding yourself as a “one size fits all: company can spell disaster for your business.


steady decline


The past decade has seen a dramatic drop in both reimbursement amounts and utilization for K0823 power chairs.

denials


A recent quarterly review of claims for K0823 chairs in Medicare Jurisdiction A revealed a denial rate of more than 80%.

IMPACT?Even if you have 10% denial rates you’ll still be under water unless

you adopt a new path.

DENIAL RATEK0823 CHAIRS 80%

real world example


A large national provider of power wheelchairs• Continuously billed the same billing code - K0823, • Increased audits • Continued same “cookie cutter” approach• Out of business?

a new way forward


Matching the patient to the correct product is a combination of functional completion of MRADL’s and lifestyle utilization.

patient 1st


OLD WAY

NEW

WA Y

the new way forward


Code Low Reimbursement High Reimbursement Average Reimbursement

(based on 100 Bid Areas)

K0814 $1,658.18 $2,572.22 $2,030.49K0816 $1,808.21 $2,787.33 $2,313.84K0821 $1,776.12 $2,762.71 $2,216.43K0822 $1,903.25 $2,590.61 $2,163.53K0823 $1,490.11 $2,272.41 $1,889.48K0825 $2,216.38 $2,296.21 $2,555.21

Based on new reimbursement, providers have a better opportunity than ever to match the correct product to the patient. Let me show you how. Understanding how to match the correct product to the patient is the path to success in today’s Medicare reimbursement climate

picking the right productGROUP 1 PWC VS GROUP 2 PWC


Are you aware that the Medicare coverage criteria and documentation requirements are identical for Group 2 and Group 1 PWCs? During the process to develop new codes for power mobility devices in 2004-2005, CMS and Medicare enlisted the expertise and input from various industry stakeholders, referred to as the Technical Expert Panel (TEP), to assist with this project.

As a result of this process, based on the different performance characteristics between a Group 1 and Group 2 PWC, the concept of assigning intermittent use language for a Group 1 PWC was adopted by the TEP. Although this language would have distinguished and established specific criteria for the appropriate provision of Group 1 PWCs, Medicare dropped this intermittent use language and decided that the medical coverage criteria and documentation requirements would be the same for Group 1 PWCs and Standard Group 2 PWCs.

(The Challenger Way is to provide the correct product to achieve optimal patient outcomes)

patient scenarios


Betty Jones Profile • 67 years old• 5’3” - 170 lbs..• CVA• Lives at home – large and ADA compliant• Fatigues easily and loses balance frequently

and loses functional ability to ambulate by mid/late-afternoon.

• Has progressed from cane to crutch…etc.

Product Solution: K0800 Scooter – Average Reimbursement $838.78

patient scenarios


Mike Smith Profile • 70 years old• 5’6”, 315 lbs..• COPD, obesity• Lives in large retirement community in

California• Utilizes O2 and is no longer able to propel a

manual wheelchair

Product Solution: K0801 Scooter – Average Reimbursement $1578.98

patient scenarios


Harry Levin Profile • 74 years old• 5’11”, 185 lbs..• Diabetes• Lives with wife in small home in L.I. and

travels to winter home in AZ for 4 months of the year

• Has only utilized a cane up to this point• Has dialysis once a week

Product Solution: K0814/K0816 Group 1 Power Chair Average Reimbursement $2030.49/$2216.43

patient scenarios


Sherry Washington Profile • 65 years old• 5’9”, 155lbs• Congestive heart failure, circulation

complications• Lives at home with her husband in Ohio and

spends 4 months a year at their beach home in Florida

• Has been using a walker for mobility

Product Solution: K0821 Group 2 Power Chair Average Reimbursement $2216.43

patient scenarios


Scott Johnson Profile • 65 years old• 160 lbs.• Double amputee, arthritis• Recently lost his wife• Lives with his son’s family in rural Kentucky• Has been in a manual wheelchair for 15 years

and can no longer efficiently self propel

Product Solution: K0822 Group 2 Power ChairAverage Reimbursement $2163.53

patient scenarios


Frank Bush Profile • 68 years old• 5’8”, 255lbs• Rheumatoid arthritis• Lives in an Assisted Living Facility since falling

and breaking his hip• Has been using a scooter for the past 7 years

but no longer has the strength and dexterity to functionally operate

Product Solution: K0823 Group 2 Power Chair Average Reimbursement $1889.48

patient scenarios


Ruth Walters Profile • 66 years old• 5’1” 295 lbs..• Congestive Heart Failure, Obesity• Lives in affordable housing, small but ADA

compliant• Has had previous Pwr. W/C that is out of

service. Currently using back-up Manual W/C

Product Solution: K0825 Group 2 Power Chair Average Reimbursement $2,555.21

picking the right productGroup 1 PWC vs. Group 2 PWC


• Since the coverage criteria and documentation requirements are the same for standard PWCs, other factors come into play when deciding which PWC is the most appropriate for your patient. Selection should be based on several factors.

• First and foremost, consider the medical needs of the patient to determine the appropriate Power Mobility Device (PMD). Required medically necessary options may not be available on all PWCs.

• Second, determine how and where the patient will be using the PWC, keeping in mind that the differences between a Group 1 and a Group 2 PWCs are strictly based on the performance characteristics of each Group . A Group 1 PWC may provide the necessary performance to adequately meet the patient’s in-home environmental needs. (i.e. living space is an Assisted Living Facility (ALF) consisting of linoleum floors and low pile carpet). However, for patients that qualify for a PMD for indoor use but also require features (portability) or better performance for outdoor use, may be better suited with a higher level PWC. Considering the patient’s indoor and outdoor activities in selecting the appropriate PWC that will be able to handle the intended use, will not only better satisfy the patient but will significantly reduce non-reimbursable service calls and repairs.

• Lastly, the decision to provide a certain model PWC will be based on the individual supplier’s PWC selection and the patient’s individual preference.

adding accessories


Part of successfully matching the product to the patient includes pairing the scooter or power chair to the appropriate accessories. Accessories add functionality and versatility to power wheelchairs. In addition, these accessories can be great items for cash sales. Or, some of these items are also billable through Medicare. Either way, combining accessories with a higher reimbursement chair can significantly boost profit. Also note that several components that are included with a power chair are reimbursable as separate items.

Accessory HCPCS Code Dealer Price CB Avg. Reimbursement

Adjustable Height, Detachable Armrests E0973 Included with chair $102.00/pair

Elevating Leg Rests (pair)* K0195 $100.00/pair $114.00/pair

Battery (12 to 24 AH) K0733** Included with chair $28.00/ea

Battery (U1) E2365 Included with chair $104.00/ea

Battery (22NF) E2361 Included with chair $71.00/ea

Cane/Crutch Holder E2207** $33.00/ea $47.00/ea

Oxygen Holder E2208 $43.00/ea $77.00

Swing-Away Joystick E1028 $45.00/ea $131.00/ea

*Because ELRs are Capped Rentals for Capped Rental bases, if the power chair is returned (based on continued medical need) before the 13 month payment and transfer of ownership, the ELRs can be reissued with the power wheelchair base for a different beneficiary without having to purchase again.

**Code not included as part of Competitive Bidding. Previous reimbursement amount listed.

additional services to consider


• Product Support• Warranty• Peace of Mind (POM)• Technical Service

• Delivery Options• CFO Programs • Reimbursement Consulting Services• Retail program development• E-commerce

bringing it home…


Matching patient to product.Dotting the i’s and crossing the t’s.

-Follow the detailed CMS billing framework and guidelines to minimize risk.

Great outcomesOptimal results __Patient

__Physician and clinician __Payer__Provider

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Winning Strategies for Group 2 Consumer Power David Moon

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