Copyright 1999, 2000, WheelchairJunkie.com

While every effort has been made to ensure all information in this article is accurate, it is for educational purposes only and shouldn’t be attempted or used as an alternative to professional advice and services.

Show Me The Money!
A WheelchairJunkie's Guide to Funding
By Mark E. Smith

With the average powerchair in the U.S. costing $10,000, no wonder it’s so difficult to secure funding for a new set of wheels.  Nevertheless, by understanding how the rules of the funding game work, you can dramatically decrease the amount of time and frustration that often goes with funding a new wheelchair.

Going into the process, remember that you are the one in control, and you’re the one who must see that you get the funding you’re entitled to.  As many of us know all too well, insurers have funding limits, which have become lower and lower in recent years.  While durable medical equipment (wheelchairs), only account for 1% of insurance spending, cost controllers see a big red flag waving when a claim for a $17,000 powerchair lands on their desk, so it’s no surprise it can be a battle.  The more educated and tactful you are, the more likely your chance of avoiding the dreaded rejection stamp.

OK, here’s the game plan:
1.  Determine your funding (insurance) coverage.
2.  Decide on the chair that meets your needs.
3.  Develop a thorough written equipment justification (prescription).
4.  Establish a contact person for funding.
5.  Submit claim.
6.  Success or denial.
7.  If denied, appeal and/or find alternative funding source.

1.  Determine Funding Source and Limits
We all hear the horror and success stories, but don’t assume your insurer will or won’t fund the chair you need.  To start, find out the limits of your funding by reading your policy or calling the funding source to inquire about limits.  It’s not always easy to find out your coverage -- especially with such subjective, ever-changing programs as Medicare/Medicaid -- but it’s worth the effort to know you’re home free or in for a fight over the chair you need.  If you’re lucky, the chair you need fits within your insurer’s guidelines -- and believe it or not, many users get new chairs out of their funding source without any hassle -- but if you find out you're only covered to a point well below your needs, don’t despair.  Private insurers are often more flexible than they want you to know, and even governmental programs allow appeals.  Also, explore all possible sources; for example, in California, MediCal won’t fund a Permobil, but if you’re eligible for disability related job training, Vocational Rehabilitation has no qualms about buying you a $18,000 powerchair if it’s needed for educational or employment access.

Private Insurers
Private insurers (including managed care organizations), are notorious for giving members a hard time over wheelchairs.  After all, they need to cut costs to stay in business, so why spend big bucks on wheelchairs?   Put simply, while you’re looking out for your needs, they’re looking out for expenses and profits.  Insurers also must make sure vendors (dealers), are reputable so they aren’t scammed  (as we know too well, dealers tend to dive into deep pockets), so this, too, adds tension to the purse strings.   Many times a good doctor within the organization can help move your claim through, knowing the prescription needed to clear the almighty cost control.  Alternatively, you can request a case manager, a person who works within the company -- or sometimes brought in from an outside agency -- as your advocate.

Medicare and Medicaid
Medicare has very specific spending limits on wheelchairs, budgeting to the political whims of Congress.  Medicare views wheelchairs as a large expense -- though, again, wheelchairs only account for 1% of its spending -- so approval is very difficult.  Currently, any powerchair is difficult to fund through Medicare, and as for one over $10,000. . . well, you might have a better chance of winning your state’s lottery.  Worse yet are state Medicaid programs, which in some states won’t fund any wheelchair, period.

Vocational Rehabilitation
Voc Rehab is a terrific funding source that many wheelchair users in need overlook as a funding source.  If you are qualified for education or job-related training through Voc Rehab, you are entitled to funding for a wheelchair if it’s needed to pursue employment goals.  Some states have a total spending cap as low as $16,000 (though, compared to Medicare/Medicaid, that’s a fortune!), while other states spend whatever it takes to meet your needs.  Of course, it’s not a free ride -- you must attend school and pursue employment.  Nevertheless, if you’re a motivated adult pursuing a career, you may be able to fund  a new set of dream wheels, with little hassle.

VA
If you’re a veteran, the VA is probably your best funding choice.  The VA purchases more wheelchairs than any other funding source in the U.S.  Even more, the PVA (Paralyzed Veterans of America), is an active political, watchdog group, ensuring that veterans have their needs met.  The PVA is a great informational resource toward acquiring wheelchair funding from the VA.

2.  Decide on the Chair that Meets your Needs.
With at least one possible funding source at hand -- and knowing your funding limits -- you should determine your wheelchair needs.  Since you are an educated WheelchairJunkie, I shall assume you’ve got this area under control.

3.  Develop a Thorough Written Equipment Justification (Prescription).
If you’re like most users needing a new chair, you get a prescription from your doctor that simply reads, “Powerchair needed,” which you take along with your insurance card to your dealer.  The fact is, there’s a lot more to the prescription than meets the eye.  What dealers and therapists never speak of to clients is the “justification” process.  Knowing how insurance companies work -- and of course wanting to sell high-profit chairs -- dealers write up a justification, a detailed report that describes your medical condition, lifestyle, and mobility needs.  Now here’s the industry's dirty secret:  The dealer types up the justification with your doctor’s name and address,  sends it to him for his signature, and then submits the document -- which appears entirely written by the doctor -- to the unsuspecting insurance company or funding source.  Although this shady system works, it’s risky and time consuming.  No one knows your needs better than you, so the dealer often will miss important information.  What’s more, whenever you mail a document to a doctor for his signature, you can expect lengthy delays, and often the document is never returned.  Remember, you are in control, and with that in mind, you should write your own justification and obtain the doctor’s signature during an office visit before you see your dealer.  

There aren’t any fixed rules as to justification format -- you can use paragraph form, bullet form, or a combination of the two -- as long as you provide all important details.  It ain’t brain surgery, and as long as you understand your condition and needs, and can write a basic business letter, you can no doubt do better than your dealer.  Here’s a sample of Count Cripula’s justification for a Permobil, using a combination of formats:



                                                               September 1, 1999
                                                                Prescription Form

                                                                                                            Joe Boxer, MD
                                                                                                            123 Glory Lane
                                                                                                            Glory Hole NV 89997
                                                                                                             (555) 555-5555
Patient:
Count Cripula
123 Dungeon Road
Bleak  NV  89996

Diagnosis:
Cerebral palsy

Prognosis:
Lifetime disability

Equipment Prescribed:
Heavy-duty powerchair with tilt seating system.

Medical Status:
Mr. Cripula is a 28 year old male, with a diagnosis of cerebral palsy resulting in abnormal muscle tone and severe spasticity of all four extremities and trunk, which limits range of motion throughout.  From age 7 to present, Mr. Cripula has used a powerchair for all mobility.  For the past five years, he has used a Bounder powerchair, which no longer meets his seating needs, resulting in pressure sores, for which he has been treated seven times in the last two years.  His current chair cannot be retrofitted to prevent pressure sores and promote proper seating.

Following is the mobility system and seating chosen and why:
Power Mobility: PERMOBIL CHAIRMAN CORPUS
Size: 16X16

The equipment will be used:
     • At home full time
     • At school, then work full time
     • In the community full time
 Mr. Cripula commutes 120 miles per day on public transportation to attend University, and is the primary shopper for his family, which relies solely on public transportation.

A small turning radius is required for environmental access.

A narrow width is required for environmental access.

Powerchair Base:
Heavy duty required for client’s need to travel long outdoor distances on a daily basis, requiring increased durability to pursue his active lifestyle.

Specified seat height is required for table and desk access.

Backward seat tilt: 55 degree power tilt
Manufacturer: PERMOBIL CORPUS
Required for:
     • Facilitation of postural control
     • Repositioning
     • Pressure relief
     • Management of spasticity
     • Relief from gravity
     • Rest periods

Arm style: Adjustable and flip back
Required for:
     • Change of height/angles for variable activities, including work station access  
     • Push ups/transfers
     • Upper extremity support

Foot/Leg Support: and Elevating (power)
Required for:
     • Comfort
     • Durability
     • Transfers
     • Proper foot placement
     • Proper leg placement

Wheels/Casters:
The casters/forks needed are 9X2.75.
Required for:
     • Durability
     • Use over rough terrain
     • Decreased pain from road shocks
     • Decreased spasms from road shocks

Additional Options:

The batteries needed are MK GROUP 24 GEL and are required for:
     • Powerchair operation
     • Long distance driving
     • Full day operation of power seat functions
     • Compliance with transportation regulation

A swing away or retractable joystick is required to allow table access and to allow special placement at work stations.

A lighting package is required for safety during frequent night time operation of powerchair while commuting to and from public transportation.

A seat belt is required for positioning and safety.


                    JOE BOXER, MD       MED#8675309CA         9/01/99



Again, the format is flexible, requiring little more than a detailed list of why you need each aspect of the chair.  I’ve seen a one page justification that got a Permobil approved, while a ten page justification for a Quickie P200 was rejected.  In the end, the trick is to spell out your condition, demonstrate a health need for the new chair, and give bulletproof reasons why you must have every feature requested.  At the top of the page, center the date, and centered below it, type, “PRESCRIPTION FORM.”  Then, place your name and address on the left side of the page under the heading, “PATIENT,” on the left margin, and on the right margin, put the doctors name, address, and phone number.  Once you get his signature, medical license number, and date at the end of the justification (which is rarely no more difficult than saying, “I need you to sign this for my new wheelchair”), you’re on the way to the dealer.  In most cases, the dealer will be thrilled (as long as you wrote a competent justification, and not a rambling manifesto!), because he can submit the paper work immediately, without hassling with a justification.  Of course, the “Don’t Ask, Don’t Tell” policy applies:  “Here’s a detailed prescription from my doctor!”  Everyone wins.

Note, some physical therapists/dealers put together a huge packet of funding, client, and justification letters.  However, all my sources say that as long as you submit a thorough justification letter from the doctor, you should fare well without the extra fluff on top.  If you need to appeal, then you’ll want to add letters from specialists, medical records, and so on.

4.  Establish a Contact person for Funding.
Find out who will review/process your funding request, and be the nicest person they’ve ever met.  While they’re bound by rules, cost controllers and adjusters are people, too, and they’re personal knowledge and appreciation of your situation goes a long way.  The “Pity Me” routine doesn’t fly, but if you’re a sincere, cordial person, trying to get a new chair to attend school and raise your children, chances are the contact person’s knowledge of your situation will speed up the process.  The last thing you want to do is make legal threats, as they’ll never help you get anywhere.  

5.  Submit claim.
In most cases, your dealer submits the request for funding.  If you’ve done the ground work, there shouldn’t be a delay on your dealer’s part.  You should call your contact person, and make sure the claim was received and suggest that if there are any questions, they can contact you.  It doesn’t hurt to reiterate how badly you need the chair.  Any questions that go through the dealer eat up time, so it’s good to deal with the contact person directly whenever possible.

6.  Success or Denial.
Let’s hope your claim was approved and your chair will arrive in four to six weeks.  In many cases, questions will be volleyed back and forth, but approval comes eventually.  Still, claims get rejected all the time.  

7.  If Denied, Appeal and/or Find Alternative Funding Source.
If your claim is rejected, find out why and assess whether you have a good chance of winning an appeal.  If you submitted a claim to Medicaid for a $26,000 OmegaTrac, forget it -- no matter what you do, you can’t win.  But if you were rejected by a private insurer over a $9,000 Quickie that you truly need, you’ll almost surely win.  Interestingly, private insurers are well-known for rejecting valid claims, hoping you’ll give up; however, following the appeals procedure often gets you the funding requested.  The funding source that rejected you should supply you with their appeals procedure at your request.  As a last resort, contact your state’s insurance commissioner and appeal to your congressman for his help (again, friends in high places get things moving, especially with governmental funding sources).

If you come up short of funding options, consider alternative sources.  Many banks offer low-interest, no down payment loans for medical goods.  Educational scholarships and grants often may be used for wheelchairs.  And family members are often glad to pitch in to help out.  (A friend’s father bought her siblings cars, and she opted for a Permobil.)


If you take control of the funding process and work your game plan, you will be ridding high in a new set of wheels sooner than you ever expected -- or so we hope!

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