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This presentation goes over the basic steps on how to get a standing frame/stander covered by public or private insurance. Topics include the process to obtaining a standing frame, team players (PT, …

This presentation goes over the basic steps on how to get a standing frame/stander covered by public or private insurance. Topics include the process to obtaining a standing frame, team players (PT, OT, DME Supplier, consumer/family) and their roles, how to write a successful letter of medical necessity/justification, research studies on the benefits of standing, and how to appeal a denial for a stander and use resources such as PAAT and AT projects.

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  • Here is a quick overview of topics I’d like to cover today.
  • It’s imperative to understand the basic acquisition process for CRT. Here are the basic steps we suggest to the consumer on our website. You’d be surprised how many new clinicians don’t know this process.
  • A trial of the stander is always important. For insurance Payers and self pay. You want to make sure the device works for you!
  • I will be going over LMN details further in the presentation.
  • QUESTIONS?
  • Roles and Responsibilities of team members
  • If the physician does write a separate RX and/or addendum letter, MAKE SURE it says the same thing as the LMN from the clinician. QUESTIONS???
  • Sit to Stand Standing Frame, One position Standing Frames Supine, Prone, upright, Multi Position Standing Frames (Prone, Supine and upright) and Mobile Standing Frames all require similar documentation…this is where we start.
  • You’d be surprised how many clinician’s leave off basic info, like client ht. & wt.
  • Reviewers need to understand the process of elimination we (the team) did in our head…what we considered not necessarily trialed.
  • Resources that are available to you 24/7 on our website. Snap shot of the Funding Tab on the website
  • Here’s a sample LMN that is one method of set up. Note; top of page gives the reviewer a quick snapshot of the client
  • Note; this LMN also does a nice job of briefly disscussing what other standers were considered and why they were rejected or worked.
  • Know your payers source and what documentation they need/want.
  • We do our best to share successful tools with clinician. Here is a ROM chart that has worked well in displaying ROM changes with a Standing program.
  • Another form that has worked with payers who required a home trial. QUESTIONS ON LMN/J??
  • Sit to Stand Standing Frame, One position Standing Frames Supine, Prone, upright, Multi Position Standing Frames (Prone, Supine and upright) and Mobile Standing Frames all require similar documentation…this is where we start.
  • Website snap shot; Research. Each of these topics has a number after it, that number represents the number of studies listed under that topic. Once you click on a topic it opens to look like this…let’s open Cerebral Palsy…
  • Each of these abstracts has a link to PubMed. We are not able to post full article on our website due to publication laws, but can share with individual clinician. If you are interested in the full article contact me directly.
  • Here is a sample LMN that includes research citations.
  • If you can read it on a website, so can a payer. Please do not copy sample letter. Instead use them to assist you in developing your own template. QUESTIONS???
  • Okay, so you’ve done an excellent LMN, but the CRT supplier has just gotten back to you stating that the equipment was denied. What now… talk with the consumer, they must agree to lead the appeal. If they choose to appeal, here is the basic process.
  • Compare the verbage in the denial to the documentation submitted. What did they not understand?
  • Large appeal that I was involved in had a PAAT attorney, Parent, underage consumer, Supplier, with live phone testimony by the physiatrist and written testimony by treating PT and OT. It was successful after the appeal went to the Attorney General’s (AG) office. About a year for this process to be completed. This one appeal was able to changed the way power and manual w/c’s were provided through MN Medcaid. Don’t assume your appeal is for just your needs…it may change the lives of others also.
  • How many know what PAAT is?
  • Also on our website; PAAT & AT project directory
  • Another resource for CRT
  • Blurb about where their dollars come from

Transcript

  • 1. Funding and Documentation for Standing Frames By Nancy Perlich COTA, ATP
  • 2. Overview
    • Process for Obtaining a Stander
    • Team Players
    • Stander Documentation LMN/J
    • Research
    • Appeals/Resources
  • 3. Step 1
    • Always start by getting approval from your physician.
    • Make sure that it is medically safe for you to stand.
    The Process
  • 4. Step 2
    • Locate a local medical equipment supplier.
    • From whom to trial, purchase and set up the stander.
    The Process
  • 5. Step 3
    • Gather your team (therapist, supplier, caregiver & yourself) and schedule an evaluation for a stander.
    • Trial the standing equipment.
    • Insurance payer (trial information is necessary in justification).
    • Private pay/cash (you want to
    • make sure the device works for
    • you).
    The Process
  • 6. Step 4
    • Normally, your therapist will write the letter of medical necessity/justification including the trial process.
    • The physician co-signing the letter.
    • For best results, the initial letter should be clear and concise to avoid having to write more justification.
    The Process
  • 7. Step 5
    • The letter of medical necessity is then given to your supplier.
    • The Supplier will complete details on the stander order form then submit all documentation for prior authorization to your funding source(s).
    The Process
  • 8. Team Players
  • 9. Consumer
    • The consumer is the person who could benefit from a
    • standing weight bearing program. It is the consumer or their
    • legal guardian that is truly the leader of the funding process.
    • Their role and/or responsibilities can include:
    • As the leader, they need to follow up on progress of the funding process through its conclusion.
    • Choosing their rehab technology supplier.
    • Trialing and determining the standing equipment.
    • Being present for the final fit.
    • If an insurance appeal is necessary, the consumer or legal guardian must start the appeals process (often they are the only person who can start the appeals process).
    • Consumer must follow through on their standing program to receive the outcomes expected.
  • 10. Caregiver/Family
    • The parent, legal guardian, or caregiver of the consumer may
    • be the leader of the funding process if the consumer is unable.
    • Handling the role of the consumer if they are unable so themselves or under 21 years of age.
    • Providing support and feedback to the team on transfer techniques, activities of daily living and other pertinent
    • client details.
  • 11. Rehab Technology Supplier
    • Your Rehab or Durable Medical Equipment Professional (ATP
    • CRTS) specializes in complex rehab technology (CRT)
    • helping you to find the most appropriate standing technology
    • to meet your needs. The role and or responsibilities of a DME
    • or Rehab Supplier/Professional can include:
    • Providing trial rehab equipment or scheduling to trial rehab equipment (stander) with a local manufacturer's rep.
    • Acquiring prior authorization with insurance company or your payer source(s).
    • Providing evaluation, assembly, delivery and adjustments to individual fit.
    • Assisting with the insurance appeal process if necessary.
  • 12. Clinician
    • Clinicians on your team can consist of one or more of the
    • following members that usually have an emphasis in Assistive
    • Technology (AT): Physician, Physical Therapist (PT),
    • Occupational Therapist (OT) Assistive Technology
    • Professional (ATP) Speech Therapist, Special Education
    • Teacher, etc. Their role and/or responsibilities can include:
    • Physician must approve that it is medically safe for you to stand.
    • Clinician may recommend weight bearing/standing device and program.
    • Clinician may review standing equipment options and make recommendations.
    • Clinician usually writes the letter of medical necessity including trial process.
  • 13. Clinician (cont)
    • Physician usually co-signs the therapist’s letter of medical necessity or writes an additional prescription.
    • Clinician usually attends and assists in the final fit and adjustment of the standing equipment.
    • If payer source denies standing device, clinician may write addendum or new letter of medical necessity and/or attend appeals hearing (via teleconference, in person, or recorded testimony).
    • Monitor the client's ongoing standing program.
  • 14. Letter of Medical Necessity (LMN) & Other Documentation
  • 15. LMN Outline
    • Detail the client: Who is this person medically, functionally, and socially.
      • Include client name, date of birth, diagnosis, onset, height, weight, primary funding.
      • Provide a brief, but complete description of the client’s level of function (i.e. ambulation, transfers, ADL’s, living environment, mobility, school/employment, and transportation).
      • Describe your client’s medical issues that will be affected by the standing technology and outcomes expected (i.e. abnormal muscle tone and reflexes, range of motion, systemic functions, loss of bone density, etc).
  • 16. LMN Outline
    • 2. Explain how the standing frame will help achieve functional goals/outcomes.
      • What is the client's current therapy program at home, school, and/or work?
      • What are their functional goals?
      • What other less costly alternatives were considered (i.e. ROM, splints, other methods of weight bearing)?
      • What other medical intervention may be necessary if your client cannot receive a standing frame (i.e. surgeries, bracing, etc.)?
  • 17. LMN Outline
    • 3. Describe the trial use of the proposed stander.
      • What types of standing technology were considered and rejected?
      • What standers were trialed ? Why was each trial either approved or rejected?
      • Provide the client's history of standing compliance.
  • 18. LMN Outline
    • 4. Describe your recommendations for standing equipment.
      • What type of standing technology is being recommended and why?
      • What options/accessories are being recommended and why (i.e. lateral supports to assist with symmetrical alignment of the upper body, ankle straps for L/E alignment and safety, etc.).
      • What is the prescribed standing program (i.e. minutes/hours per day, days per week)?
      • Include the date and both the therapist's and doctor's signatures.
  • 19. LMN Outline
    • 5. Include supporting material & media.
      • If needed, present photos & videos to convey the information along with written documentation.
      • Include supporting documents: clinical studies, research, and a resource list.
      • Other Tips:
      • Be complete, but concise: reviewers don’t have time to read a novel.
      • Re-submit and appeal when denied.
  • 20.
    • www.easystand.com//lmn
  • 21.
    • www.easystand.com//lmn
  • 22.
    • www.easystand.com/lmn
  • 23. Minnesota Medicaid Form
    • www.easystand.com//lmn
  • 24.
    • www.easystand.com/downloads
  • 25.
    • www.easystand.com/downloads
  • 26. Research
  • 27.
    • www.easystand.com/research
  • 28.
    • www.easystand.com/research
  • 29.
    • www.easystand.com/lmn
  • 30.
    • www.easystand.com/lmn
  • 31. Denied? What now? Appeal!
  • 32. Basic Appeals Process-Medicaid
    • 1. Don't take "No" for an answer. Appeal if denied!
    • 2. Start by reviewing the documentation that was submitted.
      • Was it complete? For example, does it include the equipment trial process?
      • If further documentation is needed, go to your clinician for help. Photos and/or videos may help convey the information.
    • 3. Request an appeal in writing. This written request must be received by the payer within a specified time frame, usually 0-90 days (check with your state). Make sure to send a copy of the Medicaid notice of denial with the payer appeal letter. The notice includes needed information such as recipient's name, address, and ID number. Be sure to keep a copy of all documentation for your own personal file.
  • 33. Basic Appeals Process-Medicaid (cont.)
    • 4. An appeals referee will be assigned to hear your insurance appeal. She or he may schedule a telephone hearing. You have the right to an in-person hearing, which is usually preferable. You can, in fact, state in your letter that the hearing be held in person.
    • 5. Identify potential expert witnesses such as a Physical Therapist, Occupational Therapist, a Physiatrist, etc. In-person testimony is desirable; however, it is acceptable to have testimony by phone or in a written letter of medical necessity.
    • 6. It is helpful to have assistance from an advocate or attorney. PAAT (Protection Advocacy for Assistive Technology) attorneys are a free resource available to assist persons with disabilities and their families as they seek funding for Assistive Technology (AT).
  • 34. Basic Appeals Process-Private Payers
    • 1. Know the insurance appeals process for your payer source by calling your payer source or checking in your policy manual. Generally, there are four types of insurance that may be funding resources for Assistive Technology.
      • Health Insurance
      • Disability Insurance
      • Worker's Compensation
      • Liability Insurance
    • 2. The process and criteria may vary among insurance policies; most, however will specify a process similar to Medical Assistance/Medicaid’s prior authorization and appeal process (see above).
  • 35. PAAT Who they are and how they can help
  • 36. PAAT (Protection Advocacy for Assistive Technology) Attorneys
    • PAAT (Protection Advocacy for Assistive Technology) attorneys and advocates are a free resource available to assist people with disabilities and their families as they seek funding for standing frames or Assistive Technology (AT). PAAT locations throughout the US offer support, resources and guidance through the appeals process. A list of PAAT locations by state is available on the National Assistive Technology Advocacy Project’s website:
    • http://www.nls.org/
  • 37. AT Project Who they are and how they can help
  • 38. AT Projects
    • Each state in the U.S. has a Technology Assistance Project that has information on the assistive technology resources for that state. AT Projects work to increase access of assistive technology to people of all ages and disabilities. Some of the services that may be provided include:
    • • Awareness activities about Assistive Technology and its uses.
    • • Advocacy for individuals & their families on their rights to AT services.
    • • Funding resource information based on the person’s needs (sometimes low cost loans specific to AT).
    • • Technical assistance in selecting the appropriate AT devices.
    • • Short term loan of AT equipment to try out at work, home, school, etc.
    • • AT resource information & referral to other programs.
  • 39. Final Thoughts
    • Obtaining funding for a standing frame is sometimes a
    • challenging task, depending on what state you live in,
    • your insurance coverage, and your persistence. Over the
    • years we have helped thousands of people better
    • understand funding and documentation for standing
    • equipment. We understand the health benefits that
    • standing brings to people who use wheelchairs for
    • mobility, and know that the outcomes are worth the work.
  • 40. Questions? Contact me [email_address] or call toll free at 877.844.1172 www.easystand.com