Funding Assistive Technology Services and Systems

Chapter Outline

Key Terms

PUBLIC SOURCES OF FUNDING

PRIVATE SOURCES OF FUNDING

In addition to public funding sources, there are private sources of funding. These vary by country. Examples of U.S. sources are identified in Box 5-1. Private sources of funding in Canada are shown in Table 5-1. Other Australian sources of funding include nongovernment schools, charitable sources (lotteries, service clubs [e.g., Rotary, Lions, Variety]), philanthropic organizations, private health insurance, and worksafe programs. The availability of these programs, the specific coverage, and the eligibility criteria vary across the country.

OTHER SOURCES OF FUNDING

There are alternative sources for funding that do not fall under the categories of public or private agencies (see Box 5-1). These sources include service clubs, private foundations, and volunteer organizations. There are various community service clubs (e.g., Kiwanis, Rotary Club) that may be a source of funding for a local individual who has no other means of funding. Service clubs are more likely to provide funding if one of their goals is to help certain disability groups or if the consumer is a member of the club or personally knows someone who is a member. Examples are two funds created by the Muscular Dystrophy Association that allow individuals with neurodegenerative diseases such as MD or ALS to receive up to $2000 to facilitate access to a speech-generating device and up to $2000 to facilitate access to a mobility device.

There are foundations related to a specific disability group that directly supply equipment and services to individuals with that particular disability. Other disability-related foundations provide partial funding or assist the consumer in obtaining funding. The American Federation for the Blind provides low-interest loans, for example, to individuals who are visually impaired and need to purchase equipment (Matheis et al, 1991). There are also a number of volunteer organizations (e.g., Telephone Pioneers of America) that may contribute by fabricating a custom device. Usually the labor is provided and the consumer pays for the cost of materials. Similar benefits are provided by the Canadian National Institute for the Blind.

FUNDING PROCESS AND GUIDELINES FOR PROCURING FUNDING

To obtain funding for assistive technology devices services, individuals with disabilities must follow the procedures and guidelines established by each program for which they are eligible and that covers the items being requested. ATPs play a crucial role in this process. Most often it is the ATP who must make the case for funding by conducting assessments, preparing reports, gathering prescriptions and other documentation, and communicating with equipment suppliers and funding program staff. If there is a trial period, the ATP will generally supervise it and report the results to establish the potential benefit of the device. ATPs also are the primary liaison between the client, the supplier, and the funding sources. If funding is denied, ATPs are often called on to coordinate appeals, which may involve representation of the client or soliciting and then working with a professional advocate who will pursue the appeal on the client’s behalf. Although most of these tasks are not compensated, funding has to be pursued, ATPs have to do it, and it has to work for the consumer to receive the services and devices.

A complicating factor is that consumers may be eligible for multiple sources of funding, each of which may have different rules and procedures. This is particularly true because funding and benefits programs have been created to serve very specific purposes, yet health services are able to serve broader goals. Thus, the same services may be covered by multiple programs (e.g., occupational therapy will be covered as a special education–related service and a health benefit within health insurance) or by Medicaid (in the United States). It also is not uncommon for individuals to have multiple sources of health care coverage (e.g., private health insurance and Medicaid or Medicaid and Medicare). Coordinating the benefits of these programs is important to ensure maximum benefit to the consumer.

Over time, the ATP may be called on to seek funding for the same client and for the same item or service multiple times. Funding will be sought to pay for the initial assessment, for purchase of a device, for payment for training and other services; for repairs or modifications to the device; for periodic reassessment of needs; and ultimately for device replacement. Most programs that pay for equipment purchase or rental also will pay for equipment repair and, as necessary, replacement.

Soft technology services such as training are important for many types of assistive technologies, both for the device user and caregivers. Funding for these services, however, is not always covered, even if device purchase is covered. Obviously, the provision of a device without these services can have adverse consequences for the individual. The ATP may be called on to identify alternative sources for these services, such as training offered by supplier sales representatives.

The several points during the service delivery process at which funding may need to be pursued are shown in Figure 4-2. To the novice ATP, funding programs can appear as a dense or even impenetrable web, but the funding process is navigable. Care and attention to detail are required, but this is not different from the general obligations of the ATP in all his or her professional activities.

IDENTIFYING THE FUNDING SOURCE

The various funding sources are described earlier in this chapter and in Chapter 1. This section provides guidelines for navigating the U.S. process of obtaining funding. This process also applies in broad terms to other countries. In general, consumers will know what programs they are eligible for. If they are eligible for Medicaid, Medicare, private insurance, or Tricare, they will possess a wallet card stating their eligibility. (Suppliers may require photocopies of both sides of this card to be submitted along with the other documentation to support a funding request.) Those who are veterans will know they are eligible for DVA services. Children with disabilities are likely to already have been identified and referred to the early intervention or special education systems. The only program where an ATP is likely to be a valuable asset regarding initial program eligibility is vocational rehabilitation. The client’s ability to demonstrate a potential to work may be dependent on access to assistive technology, and it will be the ATP’s evaluation and report that both identifies that need and establishes eligibility for the broader range of vocational rehabilitation services. From this list of potential funding programs, the ATP must begin to coordinate the justification and documentation process. Specific evaluations and reports may be required by each program. Great care must be taken to prepare written reports to ensure that the standard of need for each program or unique program vocabulary is stated. For example, each of the agencies that provide funding for assistive technologies may have a different standard of need. Educational agencies will fund assistive technology that provides a student with access to education. Medicare and Medicaid only fund durable medical equipment that is medically necessary, such as wheelchairs and seat cushions. In state vocational rehabilitation agencies, there is a standard that the assistive technology must significantly contribute to the individual’s ability to be productive at work for it to be funded. The role of the ATP is to know which programs are likely to fund the particular types of services and devices that are required by an individual consumer. These can then be matched to the benefits provided by the programs for which the consumer is eligible. Assistive technology equipment suppliers are aware of the funding sources that can be used for reimbursement of their products, and they can be useful sources of information to the ATP and the consumer. ATP reports describing “needs” must be written with care and written with the expectation the reviewer will be looking for vocabulary that is consistent with the reviewer’s program’s purposes.

Dealing with the multiple public or private agencies is a challenge. Procedures for obtaining funding for assistive technologies, levels of funding, and staff familiarity with the scope of and need for assistive technology and related services vary from agency to agency. For example, some funding agencies require that equipment and services be purchased from an approved list of vendors. Other funding agencies require approval for services and equipment before implementation. It is the responsibility of the consumer and the ATP to locate for each agency the regulations that apply to assistive technology and pursue funding on the basis of those regulations. Another important consideration is the principle of “payer of last resort,” which requires a specific sequencing of multiple benefits or funding programs. The Medicaid program is identified by statute as the payer of last resort in relation to other health benefits programs. For this reason, if a consumer has both Medicaid and Medicare or Medicaid and private health insurance, the procedures related to obtaining payment from Medicare or from the private insurance must be followed first before a claim can be submitted to Medicaid. In general, the procedure for sorting the relationship between multiple funding programs is called “coordination of benefits.” Another characteristic of benefits and funding programs, particularly those that provide health benefits, is that they compartmentalize coverage. Specific services will be provided, such as durable medical equipment, occupational therapy, physical therapy, or speech-language pathology. However, not all these services may be covered. Thus, a program may pay for an item of durable medical equipment but not cover the assessment to establish need for the item or training in its use. These limitations force the ATP to be alert for alternative sources of funding so that all the person’s needs can be met.

As a practical matter, an ATP may not only be interacting with multiple funding programs for the same item or service if a person has dual eligibility and both programs cover the service but also may be working to secure multiple items or services for the client at the same time. The following case study provides an example of a person with multiple funding programs and multiple needs.

To simplify the process of obtaining funding, it is recommended that a funding strategy be developed for each consumer. Beukleman and Mirenda (2005) identify five steps in developing such a strategy:

Keeping current on funding information is time consuming but absolutely essential for the ATP. Every state has a technology assistance project (see Chapter 1) that disseminates information on funding resources and strategies. For contact information, refer to the Rehabilitation Engineering and Assistive Technology Society of North America Technical Assistance Project Web site (www.resna.org). Assistive Technology: A Funding Workbook (Morris and Golinker, 1991) also provides information on funding resources and strategies. The independent living centers found in each state are another source of funding information and advocacy. Networking with other assistive technology professionals at conferences, by listservs, and over the phone are other invaluable resources.

JUSTIFYING FUNDING FOR ASSISTIVE TECHNOLOGY SERVICES AND DEVICES

Third-party payers require adequate documentation and proof of need before they will approve funding for assistive technology services or equipment. The essential question funding sources want answered is how this technology will improve the individual’s functioning. Whether it is a medical, vocational, or educational need, there are essential components that should be included in any written justification. Golinker and Mistrett (1997) identify components to address when justifying a medical need for a device, but these elements can apply to other justifications as well. These components are summarized as follows:

A specific criterion for funding under Medicare, Medicaid, and private health insurance is medical necessity. This requires that the justification include “identification of a medical diagnosis, or condition, that is specifically coupled to the functional impairment being addressed by the device” (Golinker and Mistrett, 1997, p 217). A physician’s prescription is required for devices that are medically necessary. Appendix 5-1A provides an example of a form to use to justify funding for augmentative communication devices and Appendix 5-1B shows an example of a justification form for seating and wheeled mobility systems.

When funding is being pursued through a vocational rehabilitation agency, it is important that the written justification specify how the device will enhance the individual’s ability to function in a work setting. For assistive technology services and equipment to be considered, they need to be part of the consumer’s IPE. Similarly, when funding is being pursued through special education, the justification needs to address how the equipment will give the child access to a free and appropriate education in the “least restrictive environment.” All assistive technology services and equipment must address goals written in the child’s IFSP for children from birth to 2 years old or in the IEP for children aged 3 to 21 years. For children in school, an additional comment is appropriate. Many health services also are school-related services. Typically, schools provide these services. If a child needs more health services than a school offers, health services programs such as Medicaid or insurance will be sought as a supplemental benefit. For Medicaid-eligible children, Medicaid will often pay the school for its provision of certain related services that also are covered by Medicaid, such as audiology, occupational therapy, physical therapy, speech-language pathology, and nursing services.

It is likely that the staff person reading the funding justification has never met the consumer and may not have had any experience with a person with a disability or with assistive technology. It is important that the justification be easily understood and that it clearly depict who this person is, what the needs are, and how the system can help. It may be helpful to include a picture or videotape of the consumer with the system being recommended.

APPEALING THE FUNDING DENIAL

At any point in the funding process, a denial for funding may be received. When requests for funding have been denied, it helps to be persistent and to submit an appeal for the denial. It is through this persistence that funding sources may eventually include assistive technologies as a regular part of the support they provide.

Every funding agency has an appeals process whereby the client, ATP, family member, or a professional advocate can appeal a funding denial. The first step taken is to determine the procedure for an appeal and the time limitations related to appeals. The next step is to find out why the request was denied. Almost all funding programs will provide an explanation to the client in writing. By knowing the reason for denial, all persons working to help the client can develop an appeal plan. It will be based on a comparison of the denial reason to the facts, to the scope of benefits offered by the program, including program definitions and guidance, and wherever possible, to a comparison of the funding program’s past actions when the same item or service was sought. In short, an appeal plan allows for the development of a specific statement of why the denial is wrong and why it should be reversed. It also will allow for identification of any missing information or clarifying statements to supplement what already has been submitted. Implementation of the plan will be an appeal that specifically addresses the denial reason and thus decreases the likelihood of the appeal being denied as well. Sometimes a request is denied because a piece of information was inadvertently omitted, such as a billing code, and resubmission of the request with the necessary information is all that is needed. Or, the denial may have been made because the agency believes that the plan or policy does not include such a benefit, or it may be based on the fact that the provider does not think that the request meets the criteria for funding.

Mendelsohn (1996) discusses typical grounds for appeal and the format that appeals may take. The purpose of an appeal is to convince the funding agency that the denial was erroneous and to have the decision reversed. The appeal should be made in writing to the funding source. It should explain why the denial for funding was inappropriate and provide any additional information that may have been omitted in the initial request (Golinker and Mistrett, 1997). During the appeals process it may be necessary to ask for assistance from a skilled advocacy layperson or an attorney.

BILLING AND CODING FOR SERVICES

Preparing the billing form correctly and using the proper codes on billing forms are necessary to ensure payment. Medical payers require that the provider use diagnosis codes and procedure codes when services are billed. Diagnosis codes are used to describe the person’s condition or the medical reason for the services being requested; it is this condition that is the key to establishing medical necessity. The most widely used diagnosis coding system in the United States is The International Statistical Classification of Diseases and Related Health Problems, tenth revision (World Health Organization, 1992).

In the United States procedure codes are used to describe the services that the provider implemented or the equipment delivered and that are being billed. The Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS) is the most commonly used procedure coding system. It has three levels: (1) the American Medical Association’s physician’s CPT is referred to as Level I HCPCS, (2) Level II HCPCSs are the HCFA-developed alphanumerical codes, including codes for durable medical equipment, prosthetics, orthotics, and supplies, and (3) Level III HCPCSs are local codes created as needed by Medicare and other carriers (Acquaviva, 1998). Example CPT codes relevant to assistive technology devices and services are shown in Box 5-4.

The CPT codes are a set of five-digit codes that pertain to the medical service or procedure performed by physicians and other service providers. The CPT Editorial Panel of the American Medical Association establishes the CPT codes, which have become the industry standard for reporting, and updates them on an annual basis. There is a physical medicine and rehabilitation section of the CPT codes under which occupational, physical, and speech therapy can bill for certain procedures that may encompass assistive technology intervention. The codes in this section are defined in 15-minute segments. For example, an occupational therapist who has instructed a consumer with a visual impairment on the use of sensory aids to increase independence in self-care can bill using CPT code 97535 (“Selfcare/Home management training [e.g., ADLs and compensatory training, meal preparation, safety procedures, and instruction in the use of adaptive equipment direct one-on-one contact by provider, each 15 minutes”). Practitioners may use codes in any section of the CPT as long as the service is within the scope of practice for the practitioner (Acquaviva, 1998). A new code specific to assistive technology has been drafted and is in the process of getting approved as an addition to the CPT codes.

PAYMENT PRACTICES

The traditional method of payment for health care has been fee for service. Under this method of payment, providers are paid a certain rate per unit of service (American Occupational Therapy Association [AOTA], 1996). As a result of skyrocketing health care costs in the United States, however, payment practices in the health care field have changed significantly over the last decade. Managed care has emerged as a means of controlling health care costs. The term managed care is used to describe “any method of health care delivery designed to reduce unnecessary utilization of services, and provide for cost containment while ensuring that high quality of care or performance is maintained” (Rognehaugh, 1998, p. 134). Managed care plans are now a major part of private health insurance offerings, as well as part of publicly funded insurance programs such as Medicare, Medicaid, Workers’ Compensation programs, and CHAMPUS.

Several measures are used by managed care plans to limit either provider payments or enrollee use of services. The primary cost-cutting mechanism used in managed care is capitation. Negotiating with providers for a prepaid amount gives providers a direct stake in controlling their costs. In this arrangement the managed care organization (MCO) agrees to pay the provider a set amount of money on a per-member basis in exchange for the provider’s assuming responsibility for furnishing all or certain health services to a patient for a specified period of time (AOTA, 1996). The provider takes the risk that the capitation rate will be sufficient to cover all the costs of care for the members. An enrollee in the MCO’s plan is restricted to using providers that have a contractual agreement with the MCO.

Other measures used by MCOs to control costs include precertification or preauthorization, mandatory second opinions, case management, and use of a third-party administrator (AOTA, 1996). For ATPs, the implications of managed care are many. Primarily it makes it difficult or impossible to get paid for services if the ATP does not have a contract with an MCO or is not part of a group that contracts with an MCO. The ATP also should determine whether the provider requires preauthorization or second opinions before carrying out any services with the consumer. Case managers are being used more often, particularly in situations where the individual has had an injury or accident resulting in a long-term disability. Most case managers in the United States are nurses who may have limited experience with assistive technology. The case manager is a gatekeeper who controls access to the services that are provided to the individual, including assistive technology. One way for ATPs to learn more about case management and conversely to educate case managers about assistive technology is through the Case Management Society of America (CMSA) and its on-line forums, which can be accessed at the CMSA Web site (www.cmsa.org).

Consumers and ATPs need to continually be involved in educating funding sources and advocating for the inclusion of assistive technology equipment and services in agencies’ policies. As discussed in Chapter 4, ATPs need to expand their documentation of the benefits and outcomes of assistive technology. This documentation provides helpful information when advocating for increased allocation of funding by public and private agencies.

SUMMARY

The various sources of funding for assistive technology services and equipment are described in this chapter. Sources of funding for assistive technology are either public or private and include programs such as Medicare, Medicaid, vocational rehabilitation, education, private health insurance, low-interest loans, and grants. The ATP should be knowledgeable about the different funding sources and the process for successfully obtaining funding. This includes identifying the appropriate funding source for the consumer, writing a funding justification, billing and coding for assistive technology, and appealing denials as needed. Furthermore, it is important that the ATP advocate at the public policy level for increased coverage of assistive technology services and equipment.

APPENDIX 5-1

References