Funding for Standing Frames
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Funding and Documentation for Standing Frames By Nancy Perlich COTA, ATP
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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, 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.
Transcript of Funding for Standing Frames
Funding and Documentation for Standing FramesBy Nancy Perlich COTA, ATP
Overview
• Process for Obtaining a Stander
• Team Players
• Stander Documentation LMN/J
• Research
• Appeals/Resources
Step 1
• Always start by getting approval from your physician.
• Make sure that it is medically safe for you to stand.
The Process
Step 2
• Locate a local medical equipment supplier.
• From whom to trial, purchase and set up the stander.
The Process
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
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
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
Team Players
ConsumerThe 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.
Caregiver/FamilyThe 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.
Rehab Technology SupplierYour 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.
ClinicianClinicians 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.
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.
Letter of Medical Necessity (LMN)
& Other Documentation
LMN Outline
1. 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).
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.)?
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.
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.
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.
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Denied? What now?
Appeal!
Basic Appeals Process-Medicaid1. 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.
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).
Basic Appeals Process-Private Payers1. 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).
PAATWho they are and how they
can help
PAAT (Protection Advocacy for Assistive
Technology) AttorneysPAAT (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/
AT ProjectWho they are and how they
can help
AT ProjectsEach 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.
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 formobility, and know that the outcomes are worth the work.
