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.
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).
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
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 (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 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,
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.
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
3. Develop a Thorough Written Equipment Justification (Prescription).
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|
Joe Boxer, MD
123 Glory Lane
Glory Hole NV 89997
123 Dungeon Road
Bleak NV 89996
Heavy-duty powerchair with tilt seating system.
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
The equipment will be used:
• At home full time
• At school, then work full
• 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.
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
Manufacturer: PERMOBIL CORPUS
• Facilitation of postural control
• Pressure relief
• Management of spasticity
• Rest periods
Arm style: Adjustable and flip back
• Change of height/angles for variable activities, including work station access
• Upper extremity support
Foot/Leg Support: and Elevating (power)
• Proper foot placement
• Proper leg placement
The casters/forks needed are 9X2.75.
• Use over rough terrain
• Decreased pain from road shocks
• Decreased spasms from road shocks
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
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
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.
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.
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!