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Wheelchairs and Other Specialized Medical Equipment
Every year new inroads are made in technology used to assist the disabled gain much needed independence. Wheelchairs that improve accessibility and reach, overhead lifts with remote controls, household appliances and storage allow greater access to areas in the home. Much of this equipment did not exist ten years ago but is now commonplace in many markets.
Many families are not aware that most of these items may be covered by their private (or state) insurance programs. Items covered range from smaller disposable items such as gloves, catheter syringes or incontinence supplies to larger technology including custom wheelchairs, ceiling track lifts and bathing equipment.
The process used by many companies for ordering special equipment can often be confusing and frustrating. By following a few basic steps consumers can smooth out the process and make it easier to obtain the equipment, and the maintenance for the equipment they need.
Do Your Homework
Contact Your Insurance Carrier
We've all heard horror stories about how bad insurance companies can be to work with. Don't assume your company is going to fall into that category. Give your company the benefit of the doubt. Contact your benefit specialist, customer service representative, general information number, or your assigned case manager and ask some specific questions regarding what your policy will, and won't, cover.
Confirm you are using a facility and dealer covered by your policy. You don't want to find yourself using an out-of-network provider and being left with the bill when your policy will cover an approved network provider. If the insurance company does not have an in-network provider that carries the equipment you need they should be able to refer you to an out-of-network provider they have contractual agreements with. Many companies will cover at least part of their services.
Be sure to ask what your out of pocket percentage will be for the costs incurred. If the amount is significant you may need to consider alternate financing options. Be sure you know what your responsibility will be.
Contact Your State Medicaid Office
Individuals with Medicaid benefits will also need to contact their local Medicaid office. Medicaid requirements and benefits vary by state. Many state programs will not fund certain types of equipment at all while others will pay 100%. Others still may prefer paying a percentage AFTER a private carrier has been billed. It is your responsibility to contact your state Medicaid program to find out what your state will cover. Be sure to ask about their appeals process should you need it.
Helpful Hint: Educate yourself about your insurance company policies and any Medicaid programs you qualify for. Locate their network provider lists, follow case management procedures for authorizations, ask questions and read your manual. These are the best time saving and most of all, money saving, things a parent can do. If you have followed the above noted steps call customer service or your company Human Resources representative to clarify any further questions you may have. Never assume an item is covered. Ask questions first then place your order.
Meet With An Approved Specialist
Once your phone calls have been made and preliminary referrals received, the next step will be to see the expert. This is the person who will do all the evaluations, contact your physician with evaluation results, and make needed recommendations. Most often this will be an occupational therapist/physical therapist and a supplier or dealer. They will assist you with the initial documentation process and in ordering whatever it is your child needs once an approval has been received from your insurance company. Be sure to obtain a prescription and a letter of necessity from your primary care physician before ordering any high dollar equipment. A pre-authorization letter may also be required. This is important documentation required by all medical insurance carriers.
If At First You Don't Succeed...
Don't be discouraged if your insurance carrier initially denies funding for your equipment. Most carriers don't want to admit they have more flexibility than first appears. Even most governmental programs allow appeals. Your best offense is a great defense. Do your homework; work with capable, knowledgeable professionals and follow your insurance carrier or Medicaid program guidelines.
If, after you've done all the work and your claim is rejected or denied, APPEAL! ALWAYS APPEAL A DENIAL! Find out why your claim was denied, assess your chances of success and appeal your case. Don't be discouraged if your insurance carrier initially denies funding for equipment. Most private insurance carriers don't want to admit they have more flexibility than first appears. Many often expect consumers to "give up". Don't quit, ask for specific documentation stating the reasons for the denial and then appeal. Even most governmental programs allow appeals.
Case in point. Our daughter received her first wheelchair at age 5. When we submitted the first approval request for the purchase of an Invacare pediatric power wheelchair it was immediately denied. When we contacted the insurance representative her response to our questions was a surprise. The company did not want to fund a $14,000.00 wheelchair for a growing 5 year old who would need a larger wheelchair base fairly quickly. They preferred purchasing adult bases that would not need frequent replacing!
After some discussion with the equipment representative and our daughter's therapists it was decided our daughter could use an adult wheelchair base combined with a pediatric custom seating system attached. We filed an appeal with the changes. It passed! The insurance company agreed that was a reasonable compromise and the chair was purchased.
If you are unable to obtain funding through private insurance or Medicaid programs consider alternate resources.
What To Do When Your Child's Equipment Arrives
Once your child's new equipment arrives the therapist and equipment representative will assist you with any necessary adjustments to ensure a proper fit. It is imperative to have a good fit, whether it is a wheelchair, standing frame or a foot brace.
Be sure you understand required safety precautions. Can you safely operate your equipment? Do you know where the brakes are? What should you do if certain parts fail? Understand how to operate your equipment safely and what the required maintenance schedule is.
You will also need to know specific daily maintenance instructions required for everyday use. Does the equipment need to be plugged in to a charger every night? How often should it be cleaned? What should you use to clean it? Any specific precautions you need to take? How often does your equipment need to go to the shop for routine maintenance? When is an immediate repair needed? How long is your warranty and what does it cover? When it comes to equipment, there are no stupid questions.
When the session is over you should have a good understanding of how to use and maintain your new equipment, know who to call with questions and where to go for service.
Remember. It is important to take control of the process. Ask questions. Be informed. By educating yourself in the equipment approval process required by your insurance provider, available funding programs, then being persistent and creative your loved one should obtain the equipment you'll need to make life easier.
(For more information on dealing with insurance companies click the "INSURANCE" link.)
© June 2004-September 2022 Special Needs Resource Project