MILWAUKEE — After a driver ran a red light in 2006 and hit the car Samantha Troyer was in, she became paralyzed in various places, from the base of her skull down.
That was when she first learned, getting what she needed to function in everyday life would not be easy.
"The first time around it took six months to get a new wheelchair," Troyer told the I-Team.
Six months to get a powered wheelchair more than a decade ago -- four months to get this latest one in 2021.
"Do you think that's acceptable?" the I-Team's Kristin Byrne asked Troyer.
"Well, I mean, I've been at this for so long, I'm like, 'Oh it's shorter. It wasn't six months this time!’” she said.
"You have to go in for a wheelchair evaluation. So first, you have to go to your doctor and they say, ‘Okay, you can go get a wheelchair evaluation,’ which takes like an hour or so and they have to move your limbs and write down every bit of detail about the functionality that you have into the paperwork. Then that gets sent to the doctor, then the doctor looks that over and then that gets sent to the insurance company. Sometimes, it can be like the PTs and the OTs send it to the doctor," she explained.
"I've had to call the provider and ask them if they've sent the paperwork in," she said. "You really have to advocate for yourself rather than just sitting and waiting for it to happen."
Troyer knows from serving as a mentor to others with disabilities at Froedtert, her case isn't the worst.
"There's one individual who had been waiting years for a new wheelchair,"said Troyer.
With COVID-19 taxing the healthcare system, additional delays are expected. But the I-Team learned, there are multiple steps patients need to take to get a new wheelchair. In most cases, you need to get a prescription from a doctor, get prior authorization from your insurer and make a doctor's appointment. And in some cases, you also have to do all of these steps when you need a repair.
"What we're really seeing is a process that was already broken just get worse because we're in a tougher situation," said Charles Sargeant. He's the Chief Revenue Cycle Officer for a complex rehab equipment supplier called National Seating and Mobility or NSM.
His company is one of two major providers of power and manual wheelchairs and their repairs or replacement parts in Wisconsin.
(The other company is Numotion. The I-Team reached out to Numotion for comment on delays patients are seeing. See their response below.)
"Why every single time do we have to get a prescription to repair something that was already justified and approved?" he asked.
The I-Team took those questions to Wisconsin's Department of Health Services and the Centers for Medicare and Medicaid Services (CMS), since many patients with disabilities have coverage either through Medicare, Medicaid or both.
A spokesperson with DHS told us its rules comply with federal guidelines, and said, "...for example, 42 CFR 440.70 requires a prescription for durable medical equipment. This includes for the rental and purchase of wheelchairs and wheelchair repairs..."
Read DHS's entire response to the I-Team here:
"Our state team seeks to make sure that every member of Wisconsin Medicaid receives the supplies and equipment they need when they need it, while following the rules about durable medical equipment at the federal and state levels. These requirements are intended to verify the member has a medical condition that requires the device, ensure the correct device is being given to the member, and in the case of repairs, that it is appropriate to repair the device rather than replace or get a new device.
Our processes are set at the state level but they are designed to comply with federal regulations. For example, 42 CFR 440.70 requires a prescription for durable medical equipment. This includes for the rental and purchase of wheelchairs and wheelchair repairs. It also requires a physician face-to-face visit for the initial prescription for some durable medical equipment specified by Centers for Medicare & Medicaid Services (CMS). This includes many power wheelchairs. In addition, CMS reviews our programs regularly to ensure we are implementing the benefit appropriately and that our processes are not more restrictive than their standards.
Not all equipment requires all three of the steps you mention to get repaired. For example, many items only require prior authorization after a dollar threshold or quantity threshold. DHS tries to be flexible in how requirements are met. For example, when a physician’s visit is required, we have encouraged members and providers to utilize available technology to fulfill the requirement through a telehealth visit if possible.
Sometimes delays occur because providers may not understand what they are being asked, fail to collect necessary information, or do not follow the information outlined in our handbooks. There is a provider service line available to help with any questions.
We strive to create processes that ensure quality review is completed so that quality care can be delivered. We work with stakeholder groups to improve our processes. Our intention is not to cause undue stress or burden. We encourage providers to participate in their respective groups or call the provider service line to notify us of any concerns. We also hold a biannual meeting with advocates on durable medical equipment to share information, identify barriers, and find solutions for the common goal of meeting members’ needs."
Read the Center for Medicare and Medicaid Services comments for this story here:
"Medicare fee-for-service only requires prior authorization for the initial rental (or purchase) of the wheelchair. Prior authorization for repairs or replacement parts is not required. The process for Medicare Advantage (MA) plans may vary depending on each MA plan. As it relates to prior authorization for the initial rental/purchase of a wheelchair, prior authorization helps ensure Medicare requirements are met before an item or service is provided and the claim is paid, without creating any new documentation requirements for providers. Prior authorization can give the beneficiary, the provider, and CMS the assurance that the item or service is medically necessary and whether Medicare will pay for the item or service.
Under the Medicaid program, items like wheelchairs, and their repairs, are considered medical supplies, equipment, and appliances and states have broad flexibility to set durable medical equipment requirements as long as they operate within federal parameters. Federal regulations do not require that a beneficiary have an additional face-to-face appointment with their medical provider for repairs or service of medical appliances and equipment. States may establish utilization controls, such as prior authorization to monitor repairs and service of medical supplies and equipment. States also have the flexibility to implement their own operational procedures to monitor repairs and service of medical appliances and equipment. I recommend that you reach out to the state Medicaid agency with your question since these requirements are set at the state level."
The state also told us, "sometimes delays occur because providers may not understand what they are being asked, fail to collect necessary information, or do not follow the information outlined in our handbooks."
The I-Team also spoke with some frustrated patients who feel the product providers are mainly to blame and not the insurance companies.
The I-Team asked NSM and Numotion to respond to claims that their companies play a big role in the delays.
Sargeant with NSM provided the below response:
"I can understand people’s perception, and of course we play a significant role. When excellent we (we also includes the required therapist and physician involvement and paperwork) make it as fast as the insurance created process allows. When we are less than excellent, we make an already overly complex process take longer. With all of that said, it still starts with the difficulty of the Payer dictated requirements. In the most simple world (retail), someone picks something and pays. They can get their product on the spot and it is difficult for the seller to make the process take longer. The CRT world is a long way from that example. Approval for CRT equipment requires involvement from many stakeholders, significant paperwork requirements, purchasing of custom solutions, and an authorization process. While we may never see a similar scenario to the retail example, we could see a process that makes it much faster and easier for clients to get their equipment and that process is dictated by the Payer. The proof can be seen in specific Payer examples. With the same supplier, some Payers’ orders take 5 months for new equipment delivery and some take just over 1 month on average. The Supplier is the same and their process is the same. The difference is the model established by the Payer. As you can imagine, it is never the goal of a Supplier to make the process take longer. The Supplier doesn’t get paid until a claim can be submitted and a claim cannot be submitted without a delivery. Considering all of the time and expense associated with the delivery that the Supplier incurs (as well as an important person that needs their solution), they / we are very motivated to make the delivery as soon as possible."
NSM also added, "Yes, on average we are seeing a 3 to 4 day extension in timing due to supply chain and labor constraints. This is still less impactful than the timing for payer approval. Depending on the product, it can be significantly longer (30-60 days) in the current supply chain environment."
Below is a statement from Numotion’s Chief Operations Officer, Bud DeGraff.
“Mobility and independence are absolutely critical to our customers. We know that delays in providing products and services impact our customers in ways most people never have to experience. Unfortunately, our industry, like so many others, is being hit hard by global supply chain issues and labor shortages. We are working tirelessly with our suppliers to ensure we receive the necessary parts and equipment to service chairs as quickly as possible. In the meantime, we are relying heavily on innovative service delivery models that we pioneered, and we are making significant investments. For example, we've ramped up the number of remote service interactions. We've invested in increased inventory to stock more common parts than we've ever had on our shelves before. We're aggressively hiring new team members to meet the demand. Our customers have our full commitment to do everything we can to help alleviate the burden of the current economic environment.”
"There's a lot of finger-pointing and no accountability being held on anyone's part," said Tara Schubert.
A car crash in Oak Creek left her 18-year-old son paralyzed from the chest down. She waited two and a half months for his wheelchair. She feels it would have been longer if she didn't strongly advocate for her child.
"With my son's injury, he was in the hospital for a month. I think it's not too much to ask for him to be able to have it to come home," Schubert said. Instead, she spent time answering questions from her insurer, like if she had a ramp at her home.
"They will send two or three questions, we'll answer it and then they'll send the same two or three questions back worded differently," she said.
Troyer's custom-made chair cost $40,000. It has hundreds of parts and just like with any machinery, repairs or replacements are an expectation. Troyer's new chair squeaks when she reclines it.
"It's like getting a new car and having the clutch break right away or something," said Troyer.
But she feels going through all the hoops to get it fixed isn't worth it. She'll deal with the noise for now.
"You kind of become complacent with how things function after such a long time of dealing with it," Troyer said.
"But do you think it should be that way?" the I-Team's Kristin Byrne asked her.
"Well, it should just function like a clock. You go, you put it in, and you should get your product," she said.
"There's all of these different mechanisms to getting the product, and all of them are working in different ways, but not wanting to work together."
Suppliers like NSM say you can be your own advocate to try and help speed up the wait time. If you need a repair and you're required to get a doctor's visit, see if scheduling a video visit would get you in sooner. The same thing applies with the suppliers, see if you can do a virtual visit instead of an in-person meeting.