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Finally gonna try to use Medicare to get a chair

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  • #46
    Originally posted by funklab View Post
    This is so absurd. I mean I totally get that insurance companies (Medicare especially) doesn’t want to pay for medically unnecessary stuff. But a frame that is 2# lighter offers at least the potential of benefit, at least let us pay for the upgrade. I double the bright pink anodizing you’re planning on getting is going to put any less strain on your shoulders.
    OK, I'm sure I'm missing a few bricks cause I ain't never been real bright guy!
    But, a chair frame, any material built out of is still a chair frame! If it's coded by CMS as passing their testing it makes no sense it ain't covered!
    Profit! DME's cover their rears with piece by piece billing for everything on a chair.
    They have outside company, in most cases, do their billing to Medicare and insurance companies, right?
    Someone other than end user is one decides what is ordered or billed in their good old time while end user just waits and waits!
    Then here comes the ABN form so DME makes sure they don't lose out a extra penny and that penny turns into any amount.
    I think we the end user should have a form for DME to sign that every day past 90 day Face to Face with getting order for chair ought have pay us! Would that not give them incentive to get on the ball?

    Comment


    • #47
      There are many layers to this subject, and it's not entirely CMS's "fault". CMS doesn't care about frame material, as far as I can find. I've found a number of DME policy statements from private insurers (I.e. Blue Cross of NC) who have explicitly decided titanium frames are not medically necessary; citing a lack of credible research and the fact a titanium chair can weigh more than a cheaper aluminum chair. There is no guarantee a titanium chair will be lighter, but there is a guarantee it'll be ~30% more expensive. Medicare has no such policy that I can find. They have a list of codes, with reimbursement amounts for each, and manufacturers apply to have their products "registered" to that code so dealers can use the code to get the reimbursement amount. That's about it.

      The current state of affairs began when CMS discontinued the K0009 code in ~2013. That code had the highest possible reimbursement amount, and worked well for more costly titanium frames, like the ZR and TR. When the 'K9' code went away, the remaining "ultra-light wheelchair" code was K0005, which had ~30% less potential reimbursement than K9. Reimbursement for K9 codes chairs was very difficult to get via Medicare but wasn't explicitly impossible. It happened, but not often, and not without effort and appeals, etc, but it did happen when the need was genuine and advocacy strong.

      Since K9 went away, manufacturers (like TiLite) changed their product-code associations for their ultra-light chairs from K9 to K5. At the same time TiLite also changed their order form to make 'titanium frame' an "option" on the ZR, with a separate billing code (K0108 I think). This allowed dealers to make back the additional reimbursement they used to get from the old K9 coded chairs, now coded K5, plus additional reimbursement for the cost of the titanium upgrade code.

      They had to do this because the base reimbursement value of K5 is only ~$2,000, which probably doesn't even cover dealer cost on a complete TiLite ZR chair. Bottom line is this: titanium chairs are expensive and without proven medical benefits inside the home. K5 doesn't cover the cost of these chairs so "the industry" got creative with the coding (adding K0108 to K0005) so they could cover their costs and still have a profit.

      Fast forward 3-4 years and CMS discovered, after discontinuing K9 code (ostensibly to save money and standardize benefits) this use of an additional code (K0108) to cover costs they considered already paid by the K5 code. This is the "unbundling" of a single code into multiple codes in order to get more money, when a single code covers the item. That is Medicare fraud since the time the "unbundling" policy statement was issued (late 2016 or 2017, I forget which).

      So, this tale isn't about how the govt/CMS doesn't want us to have titanium wheelchairs. They don't care. They just don't want to pay for frame material twice. They also don't seem to want to pay more than ~$2,000 + medically necessary options and accessories, which, to all of us, seems WAY too low. Although, since one of my "medically necessary" accessories is a $7,000 SmartDrive...it would seem spending money isn't the problem, it's "medical necessity within the home" and "unbundling" that are the obstacles.

      We need credible research, IMO. With some private insurers now explicitly denying titanium, like BCBS of NC, I don't think it'll be too long before that becomes wide spread, without credible research showing titanium being a genuine difference maker.

      But, for clarity, I've found NO CMS publication that says titanium is not covered, just not covered as a separately billable option, and covered only within the reimbursement value of K0005, which effectively means no DME can sell one without losing money. It's a cluster.
      Last edited by Oddity; 03-19-2019, 11:48 AM.
      "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

      "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

      "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

      Comment


      • #48
        Cut to...some more time has passed...

        I've decided not to proceed with the titanium frame option. The DME (Tycon Medical, recommended) has worked me a terrific deal on the chair, in aluminum, Roho CF backrest, SmartDrive, and cushion, so I've decided to take it. This was mostly an exercise in the process than anything. I always new I'd end up in an aluminum chair, and told them so during the very first seating eval, so I'm content. (See my post history for my opinions on the benefits/value of titanium for wheelchair frames; TL;DR: I'm not a huge fanboy. It has its uses.)

        Just waiting to see a copy of the order form submitted, and the CAD after my mark-ups, to seal the deal.
        "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

        "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

        "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

        Comment


        • #49
          Oddity, thank you for taking the time to write all this out... these are some of the best explanations, much appreciated.

          Also going through this process.. but have medicare and medicaid... so not allowed to use an ABN as medicaid is means tested etc.. but still trying to figure it out.

          Originally posted by Oddity View Post
          Cut to...some more time has passed...

          I've decided not to proceed with the titanium frame option. The DME (Tycon Medical, recommended) has worked me a terrific deal on the chair, in aluminum, Roho CF backrest, SmartDrive, and cushion, so I've decided to take it. This was mostly an exercise in the process than anything. I always new I'd end up in an aluminum chair, and told them so during the very first seating eval, so I'm content. (See my post history for my opinions on the benefits/value of titanium for wheelchair frames; TL;DR: I'm not a huge fanboy. It has its uses.)

          Just waiting to see a copy of the order form submitted, and the CAD after my mark-ups, to seal the deal.

          Comment


          • #50
            Originally posted by Oddity View Post
            Cut to...some more time has passed...

            I've decided not to proceed with the titanium frame option. The DME (Tycon Medical, recommended) has worked me a terrific deal on the chair, in aluminum, Roho CF backrest, SmartDrive, and cushion, so I've decided to take it. This was mostly an exercise in the process than anything. I always new I'd end up in an aluminum chair, and told them so during the very first seating eval, so I'm content. (See my post history for my opinions on the benefits/value of titanium for wheelchair frames; TL;DR: I'm not a huge fanboy. It has its uses.)

            Just waiting to see a copy of the order form submitted, and the CAD after my mark-ups, to seal the deal.
            Two big advantages with titanium are weight and no maintenance. I want to resurrect my Quickie Titanium because it is significantly lighter than anything else I ever used. Doesn't make any difference except for one thing. My shoulders feel the difference when transferring the chair in and out of the car. That's just one thing. But it's a biggie.

            Comment


            • #51
              TL;DR: I'm not against titanium, there is room for lots of materials, IMO, but the advantages of titanium alone remain untested, are based on marketing and anecdotes, while the additional cost is guaranteed. I question the value proposition more than the functionality

              Yeah, the Quickie Ti was insanely light. Titanium helped enable that but it was mostly design that achieved the result. Ti allowed the use of very skinny OD, very thin walled, tube, which was indeed light. It also flexed like crazy and some parts were engineered past the edge IMO (like the axle plates) and had higher than typical failure rates. It's all a balancing act. Titanium alloy can enable certain designs.

              Whether or not a titanium chair is lighter is an engineering outcome, not a solely a materials outcome. Light weight engineered titanium tubes have to be made thin, else they'd be heavier than identical aluminum tubes, and aren't any more durable as a result. It costs more, guaranteed, and any given chair isn't necessarily lighter than any other just because it's titanium. Weight (and durability) is mostly about accessories, hardware, and design. The lightest, strongest, chair I know of was made from chromolybendum steel. Damn cheap and very strong. But, I guess "Chromoly" just doesn't have the ring to it that "aerospace grade titanium" does.

              Originally posted by August West View Post
              Two big advantages with titanium are weight and no maintenance. I want to resurrect my Quickie Titanium because it is significantly lighter than anything else I ever used. Doesn't make any difference except for one thing. My shoulders feel the difference when transferring the chair in and out of the car. That's just one thing. But it's a biggie.
              Last edited by Oddity; 05-02-2019, 09:42 AM.
              "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

              "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

              "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

              Comment


              • #52
                https://hub.permobil.com/blog/did-yo...rough-medicare

                Any truth to this?
                May 2000, T4-5 Complete.

                Nam-Myoho-Renge-Kyo

                Comment


                • #53
                  Originally posted by Oddity View Post
                  any given chair isn't necessarily lighter than any other just because it's titanium.
                  I'm on board with everything else you're saying (and I'll freely admit my bias for titanium isn't fully rational), but if the manufacturer (such as TiLite) lists an aluminum version as 1.8 pounds heavier than the titanium version, surely titanium is necessarily lighter when comparing the two options.

                  Comment


                  • #54
                    Absolutely. Unassigned billing is handy. Risky, but handy.

                    Things that can (I've witnessed) go wrong:


                    - Claim denied because DME does not file correctly (on behalf of patient instead of themselves). Patient stuck with full cost paid up front and no help trying to recover reimbursement from Medicare (DME has their $ and didn't want to work for free to re-submit claim paperwork)

                    - Chair comes with wrong specs/other problem. Again, like above, DME has zero skin in the game, having been paid in full up front. If you think DMEs are hard to deal with, when they stand to make some money off you, try working with them when they don't.

                    - Claim is denied for some other reason. Patient stuck with full cost.


                    Those are 3 occurrences I know of; 1st hand, but there are undoubtedly others. Most revolve around the patient having to pay entirely up front and getting stuck with either that cost, a chair that's not right, or BOTH, without much recourse.

                    One small snag is an unassigned claim can only be billed at a 15% premium over the base reimbursement amount, which might not be enough additional $ to cover whatever margin the DME wanted in the first place. I'm only passingly familiar with the unassigned vs assigned rules so I'm going to do more research.


                    Bottom line: I think it's worth pursuing to someone on Medicare, with plenty of cash on hand, must have titanium, and can manage the potential risks. To be clear, though: Unassigned Billing is a MUCH better deal for the DME! BUT, it can help patients who have cash, don't mind the premium, and can't/don't want to be bothered taking on filing the claim form themselves.


                    Post Script line: For me, if I satisfied those conditions, it would be WAY easier just to pay up front, then file the claim myself. I'd save the 15% unassigned premium, the time waiting for DME to work up/submit the paperwork, and however good of deal the reimbursement is, into my pocket, would be based on however good of a deal I could negotiate, myself, with the DME, for the final chair price. I'd be in complete control of my own fate, spend less money, and get exactly what I wanted.

                    Basically, If you're willing to learn how to file a claim yourself (if you can do your own taxes, then you're fine; it's not rocket science; it's just filling out a form correctly), then you can get whatever K0005 chair you want. Using "unassigned billing" is a half-way measure, IMO, that carries similar risks as self-filing, but costs a 15% premium. That premium could easily be worth it to some folks, though.

                    Thanks for sharing the article! That kind of info is what makes this place so helpful.
                    .
                    Last edited by Oddity; 05-08-2019, 09:15 AM. Reason: Words
                    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

                    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

                    "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

                    Comment


                    • #55
                      The way TiLite makes their chairs, absolutely. I can't imagine the business case for a company, named TILite, to make and market lighter aluminum chairs. Titanium is a heavier (but stronger) element than Aluminum. Widgets are made lighter by being made thinner than aluminum can be, while maintaining similar strength, with the thinner tube walls.

                      So, what I meant was, unless the Ti is engineered to its strengths, it'll in fact be heavier (but stronger) than the same piece out of aluminum. That's a fact of atomic weight. When it is engineered to its strengths, a titanium widget CAN be made to be lighter than the same one made from naturally lighter aluminum, but then it's not necessarily stronger. It's all about the engineering potential of the material, not the material. Granted, it maintains its beneficial property of not micro-fracturing under stress, like aluminum, but whether that makes a difference in the expected lifetime of a wheelchair (5 years to TiLite) is unproven.

                      Between brands, it's even less of a "sure thing". E.g. One buddy has a Top End Crossfire T7 (7000 series aluminum) that is a full 2lbs lighter than another's ZR. It cost 1/3 the price and has the same warranty. That's what I mean by "just because its titanium doesn't mean it is lighter" (or stronger).


                      (Interesting aside: TiLite frame warranties are the same for aluminum as for titanium. If their titanium chairs were, in fact, stronger and more durable, you'd think they'd have assigned longer warranty periods to reflect that benefit to the consumer. They aren't.)

                      (Another interesting aside: Do they make an identical ZR frame in aluminum? Is that even an option? If they're comparing their ZR to, say, their Aero Z, then is that even a relevant claim - beyond its marketing value? I dunno...)

                      Ultimately, I like that titanium chairs are available. My next out of pocket chair is gonna be a HoC titanium, just because. I don't dislike it, I just don't revere it either. There is much hype and little data based evidence.


                      Originally posted by funklab View Post
                      I'm on board with everything else you're saying (and I'll freely admit my bias for titanium isn't fully rational), but if the manufacturer (such as TiLite) lists an aluminum version as 1.8 pounds heavier than the titanium version, surely titanium is necessarily lighter when comparing the two options.
                      Last edited by Oddity; 05-08-2019, 09:05 AM. Reason: Words
                      "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

                      "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

                      "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

                      Comment


                      • #56
                        I am embarking on the process of getting a new chair through medicare. This thread is very helpful!

                        Comment


                        • #57
                          Let us know how it goes! I've been pleased with how easy it's been. One doctor's visit, one OT eval, one meeting with DME. Everything (except noted) approved first pass. (Including options I thought they'd balk at, like fixed backrest canes and Roho back.) As a T12 SCI patient, getting a decent new chair, in my area, using Medicare, wasn't much of a chore, at all. The professionals I partnered with, in the process, did very well for my interests, IMO.

                          Originally posted by Tetracyclone View Post
                          I am embarking on the process of getting a new chair through medicare. This thread is very helpful!
                          "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

                          "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

                          "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

                          Comment


                          • #58
                            Originally posted by Oddity View Post
                            TL;DR: I'm not against titanium, there is room for lots of materials, IMO, but the advantages of titanium alone remain untested, are based on marketing and anecdotes, while the additional cost is guaranteed. I question the value proposition more than the functionality

                            Yeah, the Quickie Ti was insanely light. Titanium helped enable that but it was mostly design that achieved the result. Ti allowed the use of very skinny OD, very thin walled, tube, which was indeed light. It also flexed like crazy and some parts were engineered past the edge IMO (like the axle plates) and had higher than typical failure rates. It's all a balancing act. Titanium alloy can enable certain designs.

                            Whether or not a titanium chair is lighter is an engineering outcome, not a solely a materials outcome. Light weight engineered titanium tubes have to be made thin, else they'd be heavier than identical aluminum tubes, and aren't any more durable as a result. It costs more, guaranteed, and any given chair isn't necessarily lighter than any other just because it's titanium. Weight (and durability) is mostly about accessories, hardware, and design. The lightest, strongest, chair I know of was made from chromolybendum steel. Damn cheap and very strong. But, I guess "Chromoly" just doesn't have the ring to it that "aerospace grade titanium" does.
                            While a titanium chair isn't necessarily lighter than an aluminum chair, it is easier to make it lighter with titanium than aluminum.

                            Comment


                            • #59
                              How so? It's harder to extract from the Earth. It's harder to process as ore. It's harder to manufacture into workable alloy materials (billets, tubes, etc). It's harder to fabricate with. It requires extra product engineering to overcome its ~60% heavier weight by volume vs aluminum. I wouldn't call it easier to do anything with titanium vs aluminum. All that "easier" adds up to ~3-4x the cost, even though it's one of the most abundant elements in the Earth. It costs so much precisely because of how much more difficult it is to work with, vs aluminum, up to, and including, making a lightweight wheelchair.
                              "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

                              "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

                              "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

                              Comment


                              • #60
                                Easier not in the sense of manufacturing challenges but in the sense of design possibility. Titanium has superior tensile strength, which enables using less material (less weight) for the same strength. In other words aluminum cracks before titanium cracks for the same weight so aluminum needs to be heavier for the same strength. I'm no materials guy so don't ask me for an engineering analysis. This is just my understanding.

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