These comments are being submitted on behalf of the national, consumer-led coalition known as the “ITEM” Coalition, an acronym for Independence Through Enhancement of Medicare and Medicaid. The ITEM Coalition was formed in 2003, and its 74 member- organizations include a diverse set of disability organizations, aging organizations, other consumer groups, labor organizations, voluntary health associations, and non-profit provider associations.

The ITEM Coalition’s purpose is to raise awareness and build support for policies that will improve access to assistive devices, technologies, and related services for people of all ages with disabilities and chronic conditions. From coverage for hearing aids to augmentative communications devices (AACs) to advanced artificial limbs to screen readers for people with vision impairments, the Coalition’s mission is a broad one with implications for virtually every person with a disability who relies on assistive devices to be healthy, functional, and independent.

Over the past year, the ITEM Coalition has been involved with the Centers for Medicare and Medicaid Services (CMS) initiative to reduce waste, fraud and abuse in the Medicare wheeled mobility benefit while simultaneously creating more comprehensive and satisfactory coverage criteria. Throughout the process a consistent theme has emerged; greater participation from clinicians with expertise in assessing an individual’s need for a particular wheelchair is beneficial to both the Medicare program and the beneficiary. We believe expert clinical input is not only necessary in determining the model, amenities, usage and safety measures appropriate for the potential wheelchair users, but it also extremely important in the effort to fight fraud in the system.

However, it appears that the Local Coverage Decision (LCD) for Occupational Therapy proposed by Blue Cross and Blue Shield of Alabama (BC/BS Alabama) does not take into account the value of the clinical team and the expertise necessary to conduct an appropriate wheelchair assessment. We fear the LCD for Occupational Therapy proposed by BC/BS Alabama will actually result in fewer rigorous evaluations by trained clinicians. Providers would not be required to purchase these services as a condition of providing a wheelchair to a Medicare beneficiary and the cost of such an evaluation would be included in the Medicare payment for a wheelchair to the supplier. This is contrary to current practice.

As we understand the BC/BS Alabama proposal, it is problematic for two primary reasons: 1) it places clinicians in a compromised position by requiring occupational therapist to seek reimbursement for their services from the supplier; and, 2) it creates incentive for the supplier to phase out the role of the clinician in the wheelchair assessment.

Currently, occupational therapists and other clinicians can be reimbursed for their services by Medicare when they conduct a wheelchair assessment, allowing the clinical teams to create objective assessments. The proposed LCD seeks to eliminate an occupational therapist’s ability to bill Medicare for their services when conducting a wheelchair assessment. This will likely have a negative effect on a Medicare beneficiaries’ ability to acquire an appropriate wheelchair in Alabama. Moreover, the BC/BS Alabama proposal would force clinicians to essentially become employees of the suppliers if they wish to participate in the seating and positioning process when a Medicare beneficiary has a medical need for a wheelchair, thereby making the clinician an interested party to the assessment.

In conclusion, we feel that the proposed LCD is inconsistent with CMS’s goal of reducing waste, fraud and abuse in the Medicare program as it will serve to provide less oversight and clinical expertise in wheelchair assessments. Additionally, we feel the proposal would reduce the quality of services provided to Medicare beneficiaries by reducing expert clinical input and follow-up during the wheelchair assessment and training process. Ultimately we fear this policy change will lead to an increase in the rate of abandonment of wheelchairs by individuals that obtain equipment without an assessment conducted by a clinical team working independent of provider interest.

We thank you for this opportunity to provide comments on the proposal. Please contact Emily Niederman at (202) 349-4260 with any questions.

Sincerely,

Henry Claypool Advancing Independence: Modernizing Medicare and Medicaid ITEM Coalition Steering Committee Member		Paul W. Schroeder American Foundation for the Blind ITEM Coalition Steering Committee Member
Peter W. Thomas Consortium for Citizens with Disabilities Health Task Force ITEM Coalition Steering Committee Member		Lee Page Paralyzed Veterans of America ITEM Coalition Steering Committee Member
Kim Glaun Medicare Rights Center ITEM Coalition Steering Committee Member