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Permobil Blog / March 8, 2018

Q & A's: Insurance and Reimbursement Part 2

 


Part 2 in our series Wheelchair Seating and Positioning Misconceptions in Wound Care: Q & A's where Lindsey Sharpe PT, DPT answers questions asked by participants of the webinar by the same name. This week we're focusing on the rest of the questions about insurance and reimbursement. See Part 1 here.


 

4. Insurance companies seem very uptight on getting approvals done as quickly as possible. Any tips on this getting approved quickly?

The best tip I can give on getting approved quickly and avoiding denials is to be sure to include ALL needed information to justify the equipment in your documentation. Please refer to the answer under question #1 for the information needed. In addition, remember that we are the advocates for our patients and the voice to the insurance company explaining why this piece of equipment IS medically necessary. 

 

Here are some additional tips:

  • When stating the diagnosis, provide a simple explanation of what this means functionally.
  • Remember to always translate your evaluation results, i.e. strength, spasticity, balance, sensation, etc. into function and seated posture.

  


 

5. In the home health setting, will Medicare cover the cost of these wheelchairs for patients with a pressure injury to be positioned correctly?

When considering a patient with a wound, it is often associated with immobility. This is where you can refer to the answer in question #1 about how to know if your patient qualifies for a wheelchair. Remember, by providing your patient with an appropriate wheelchair, cushion and back support, you can increase the healing time of a wound while promoting independence and function. This should always be our goal!

 

So contact a local ATP/Dealer to help you problem solve whether your patient qualifies and be the advocate to get them the most appropriate equipment!

 


 

6. In home health care, I have difficulty getting insurance to approve the therapist’s evaluation of client needs, let alone a more expensive chair. Suggestions?

It may seem intimidating, but Medicare/Insurance have specific guidelines that will qualify a patient for a wheelchair. It is all about medical necessity. Please refer to the answers under question #1 and #4 for these guidelines, and also develop a relationship with a local ATP/Dealer who can help you sort through the requirements!

 


 

7. Insurance companies tend to wait until the wounds are already worse, would you agree?

Yes, unfortunately, you are right. The presence of a pressure injuryeven a stage 1 automatically qualifies a client for a skin protection cushion. However, additionally a patient may qualify for a skin protection cushion if he/she has a diagnosis that places them at risk for skin breakdown as well as has impaired sensation OR is unable to carry out a FUNCTIONAL weight shift/fully offloaded pressure relief. In this instance, I have had many patients who can attempt pressure reliefs, but when I place my hands on the ITS and/or use the pressure map for feedback regarding how much pressure is actually being relieved, I have found that many people with poor trunk control, hardware in the thoracic/lumbar spine, etc. are unable to perform a FUNCTIONAL/complete weight shift/pressure relief. We have a diagnosis search tool on our website where you can search the diagnosis to see what your client actually qualifies for based on diagnosis alone; this is also where it is so important to develop a strong relationship with a local dealer with an ATP (assistive technology professional) on staff who can help you problem solve and figure out what your client qualifies for.

 

Here is the link for the diagnosis search:

https://www.comfortcompany.com/icd_decision_tree

 

Here is the line to help you find a local dealer:

https://www.comfortcompany.com/find_a_retailer

 


 

Next week we'll look at the first set of the questions relating to specific products and proper fit. 

 


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Lindsey Sharpe, PT, DPT
Lindsey Sharpe graduated with a BA in Exercise and Sport Science from the University of North Carolina at Chapel Hill in 2007 and with her Doctor of Physical Therapy from Elon University in 2010. Lindsey was a practicing clinician for seven years primarily focusing on neurological conditions and wheelchair seating and positioning.

Lindsey was first introduced to wheelchair seating and positioning during her time on the spinal cord injury team at the University of Virginia's acute rehab hospital where she discovered her interest in and passion for this niche in the therapy world. Lindsey went on to open a brand-new seating clinic with Carolinas Healthcare System in Concord, NC where she advanced her knowledge and skills performing both inpatient and outpatient seating evaluations for clients of all ages having a variety of diagnoses.

Categories: clinical education department, wheelchair seating, seating & positioning

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