Wheelchairs are vehicles to freedom, independence, and life in the community. An issue of the Disability Services Beacon in Fairfax, Virginia covered the basics of what most users need to know about the different kinds of wheelchairs, what to consider when getting a wheelchair, and how to get and pay for one.
Wheelchairs are either manual or electric. Manual wheelchairs are lighter than electric chairs and require physical force to move them, although they can often be customized so as to require the least amount of force. Electric wheelchairs are heavier because their motors provide the power from large rechargeable batteries.
Wheelchairs must be customized to fit their users' needs. They are expensive, costing anywhere from several hundred dollars to as much as a new car. Many wheelchair purchases are financed through Medicare or Medicaid, so what follows is primarily applicable to Medicare and Medicaid and can vary for private insurance carriers.
Wheelchairs as Medical Equipment
A wheelchair is a piece of durable medical equipment. Consequently, getting a wheelchair usually starts with a written prescription from a physician, a physician's assistant, a nurse practitioner, clinical nurse specialist, or other medical specialist. Medicare and other carriers require a face-to-face evaluation of the person and a report on the relationship between the user's mobility needs and the specific wheelchair recommended. In most cases, Medicare, Medicaid and private insurance require documentation of mobility difficulties sufficient to impair participating in activities of daily living - activities such as toileting, feeding, dressing, grooming, and bathing - to authorize payment. In addition to documenting physical limitations that prevent normal mobility in activities of daily living, insurance also requires that the prescription or supporting clinical information contain information on the user's mental and physical capabilities to safely and adequately use the wheelchair; the suitability of the user's home environment for a wheelchair; and the user's willingness to use the wheelchair routinely. This information should be included in the written prescription. Some of the issues that must be considered when choosing a wheelchair include:
- Where it will be used and for how much of the day it will be used ;
- Any space limitations;
- How the user will get in and out of the wheelchair;
- The user's strengths and needs, both physical and intellectual.
The supporting clinical documentation can be any pertinent parts of the individual's medical record to support the medical necessity for a wheelchair. These may include a medical history, physical examination, diagnostic tests, and summaries of findings, diagnoses, and treatment plans. As of April 2006, the Centers for Medicare and Medicaid Services no longer require a "Certificate of Medical Necessity". A written prescription and supporting clinical documentation is now considered sufficient.
Fitting and Ordering a Wheelchair
The treating medical practitioner sends a written prescription and supporting clinical information to a vendor/supplier of durable medical equipment. Some durable medical equipment vendors have credentials through either the Rehabilitative Engineering Society of North America (RESNA - www.resna.org) or the National Registry of Rehabilitation Technology Suppliers (NRRTS - www.nrrts.org) as Rehabilitation Technology Suppliers, which means that they have additional training on wheelchair features and capabilities and a high level of professionalism.
Vendors must be enrolled in Medicare and have a Medicare supplier number in order for Medicare to reimburse them. Without a supplier number, Medicare will not pay. Additionally, the vendor should be a participating supplier in the Medicare program, which means the vendor will accept "assignment" -- that is whatever Medicare authorizes for payment. If the enrolled vendor is not a participating supplier, the user will have to pay anything over and above the Medicare authorized amount.
In the case of Medicaid eligible users, the vendor must be licensed or certified by the Virginia Department of Medical Assistance Services (DMAS), and have a signed participation agreement and a provider identification number. An additional consideration for Medicaid in Virginia involves pre-authorization. Generally, manual wheelchairs do not require pre-authorization. However, because of the complexity and cost involved, power wheelchairs do require pre-authorization to validate the medical necessity for the wheelchair and that it meets the DMAS criteria for reimbursement. The pre-authorization request is made by the enrolled supplier and submitted to the DMAS pre-authorization contractor. Virginia Medicaid will not pay if pre-authorization is required but not obtained.
In the past, medical practitioners requested independent seating and sizing evaluation by either a licensed occupational or physical therapist in order to determine exactly what type of wheelchair would best meet their patients' needs. However, new regulatory guidance enables any medical practitioner who is qualified to do so to send the prescription directly to the enrolled supplier without first getting a seating and sizing evaluation. However, individual medical practitioners may still prefer that their patients get a seating and sizing evaluation. These evaluations are usually available at your local hospital or rehabilitation hospital.