Power Struggles as Insurers Delay Power Wheelchair Approvals

posted on Oct 27 by Guest Author in the Disability News, Healthcare category

Insurers and Medicare are increasingly delaying and denying requests for more expensive and customized power wheelchairs, placing fraud prevention and cost cutting above improving the quality of life for persons with disabilities. As a result, patients are often forced to settle for lesser chairs that don’t adequately meet their needs or be confined to bed while waiting months–or longer–for an appeal decision.

Sometimes that wait can be tragically too long. Nexus Medical technology professional called an amyotrophic lateral sclerosis (ALS) patient to give her the news that her request for a new chair had been approved–after months of battling with her insurer–only to be told by her son that she had passed away.

Fortunately for 27-year-old Samantha Lorey, she did get her power wheelchair approved before it was too late, but only after 3 appeals and many months of denials. Lorey has spinal muscular atrophy, a disease that progressively causes muscle weakness and degeneration and death. According to doctors, Lorey shouldn’t have made it past the age of 2, yet she lived long enough to now need the third wheelchair in her life–a powerchair that can aid her in attempts to keep her mobility, despite her disease’s progression of immobilizing her. At this point, she can move her hands just enough to maneuver her a motorized wheelchair, but she can’t raise them if her arms fall in her lap, and she cannot move her legs at all.

To say that time is precious in Lorey’s life is an understatement, a concept that her insurance company never seemed to grasp. Lorey’s condition had deteriorated severely in the time it took to get approved and fitted for her current power wheelchair. It had become too painful to sit in her old chair, which was falling apart. She required more support to sit upright. She attended her third appeal hearing on a windy day she feared would harm her fragile lungs.

“They went through every nut and bolt on this chair,” according to Lorey’s mother of their third appeal. A few days later, Lorey’s request was approved, and the long ordeal was over, but the entire experience left Lorey drained and frustrated.

“We had all the documents in order,” she said. “It’s like they didn’t even look at it. They denied it to deny it.”

Insurers dispute patients’ claims that denial rates are higher than ever, insisting that they merely are doing what they have to do in order to curb fraud and make sure money is spent wisely. One insurer told the Philadelphia Inquirer that they denied only 38 claims for power wheelchairs in 2010, a denial rate he considered “fleetingly small.” A spokesperson for Lorey’s insurer, who refused to discuss her case, also defends insurers, saying that it can be difficult to determine what accessories and equipment requests are “medically necessary.”

Insurers claim it’s not personal; they are simply looking out for the bottom line. Power wheelchairs can cost more than $17,000, and the total amount of insurance funding for motorized chairs increased from $59 million to over a billion in 2003, at which time the government began to crack down on fraud. Medicare’s motorized wheelchair spending steadily decreased to $728 million in 2010, with another $300 million spent on manual wheelchairs. A Medicare official said the crackdown was necessary to curb “significant over-utilization.” Now Medicare limits funding to wheelchairs a patient can use in their homes, not the more complex ones that can improve quality of life and enable a person with disabilities to go work or go to school. Private insurers are following Medicare’s lead.

The people who are involved in submitting claims tell a different story, however. One occupational therapist said she spends almost 40 percent of her time writing appeals, more than she ever did in her 20-year career. Another physical therapist shared similar experiences, averring that insurers have made it difficult for people to get equipment they truly need. She said that she never submits a claim unless she’s certain the patient qualifies, saying she believes none of the claims should be denied.

Source:
http://articles.philly.com/2011-09-27/news/30208745_1_wheelchairs-insurers-medicare

Image sources:
www.philly.com
www.insurancequotes.com

Medicare’s Wheelchair and Scooter Benefit page:
http://www.medicare.gov/publications/pubs/pdf/11046.pdf