News & Inspiration / Posted on

Why You Need to Ask for Your Cushion by Name

Guest blog post by Bob Vogel

In my experience with DME (durable medical equipment) dealers, competition leads to quality. I was injured in 1985 — a T10 complete paraplegic — my first cushion and wheelchair were covered by Medicaid and provided by a local DME dealer. In the 90’s I worked as a sales rep for a wheelchair manufacturer, selling to and working with DME dealers. After that I worked as a sales rep for a DME dealer.

In my experience, a good DME dealer has the knowledge and takes the time to properly fit and provide the best cushion, wheelchair, etc., to meet their client’s needs. DME dealers strive to provide the best service and best products to meet our needs because it’s the right thing to do, and because it’s good business. We have the power to take our business to another DME dealer and word of mouth — good or bad — is powerful when it comes to business.

Unfortunately, because of competitive bidding, this paradigm is changing. The CMS (Centers for Medicare and Medicaid Services) competitive bidding program has DME dealers bidding to see who can provide equipment in a certain category for the lowest price — for you and I this category complex rehab, from cushions  and wheelchair backs to manual chairs and high-end power chairs. Round I of competitive bidding is already in place in 9 regions. Round II of competitive bidding is looming on the near horizon with 91 regions including the largest cities in the country.

Under competitive bidding, instead of Medicare beneficiaries having five to ten Medicare providers to choose from that compete based on the quality of the products and service they provide, we may only have one in our region — eliminating the competition and the need to provide quality products and service. Have a local DME dealer who didn’t win the bid that you have been going to for years? Tough. Don’t like the way the winning bid DME dealer does business? Tough. It’s not just Medicare — Medicaid and many private insurance companies have track records of following the Medicare competitive bidding guidelines.

The way competitive bidding is set-up encourages DME dealers that are only concerned with profit to underbid DME dealers that are truly concerned with providing the right product for their client. As an example, let’s take a look at a common type of cushion. Let’s say your skin and seating requires a ROHO® HIGH PROFILE® Single Compartment Cushion — the government HCPCS (Healthcare Common Procedure Coding System) code for this type of cushion is E2622. Now let’s say there is a dealer who is only in it for profit, winning the bid, and becoming the only game in town. Medicare’s Pricing, Data Analysis and Coding (PDAC) for E2622 includes 915 different cushions. According to this data, every cushion on the list will protect your skin just the same. If dealer only who is in it for profit carefully goes through the list they will find some real “bargains,” including a layered foam cushion with a 1/4″ gel cover that retails for $39. But hey, it fits into the code so it “should” protect your skin just like a ROHO HIGH PROFILE Single Compartment Cushion — right? Wrong!

When I left rehab in 1985, my therapist sent me home on a memory-foam cushion saying it “should” protect my skin just as well as the ROHO HIGH PROFILE Single Compartment Cushion I had requested. Despite regular weight shifts, I developed a tiny pressure ulcer within 3 months. Regular mirror-skin checks enabled me to catch it right away — I got the ROHO Cushion and was able to heal at home, feeling like I had dodged a bullet.

A dealer only interested in profit could submit a lowball bid of say $250 for this category — win the bid and start shoving $39 cushions under clients while collecting $250 per cushion from Medicare.

This is why it is vital that you, working with your clinician, request the exact cushion that you need on a doctor’s prescription/documentation. Because even if you are in an area that already has competitive bidding, there is a clause in competitive bidding that says if a doctor’s prescription specifies the make, model and product, then the winning bidder — the DME dealer — has to provide that cushion, or find another winning bidder DME dealer that will provide the cushion. As competitive bidding looms, it is more important than ever for each of us to advocate for our proper seating. Make sure your prescription includes exactly what your seating needs are, for example ROHO® HIGH PROFILE® Single Compartment Cushion (4″). Make sure the size of the cushion needed is included on the prescription, for example 16″ x 16″.

In addition, there is still time to phone, email, or write your representative and senators and tell them you do not want competitive bidding. Explain that while competitive bidding may save money in the short term, the wrong cushion risks life threatening pressure ulcers that will cost taxpayers in excess of $50,000 per occurrence in hospitalization alone.

So what can you do to change the outcome?
1. Send letters to your representative and senators. It’s OK if you don’t know what to write, we have a letter already written and all you have to do is fill in the blanks.
2. Go to competitivebiddingconcerns.com and fill out a form to record your personal struggles with getting mobility equipment.

To view the list mentioned in this blog, go to the Medicare Pricing, Data Analysis and Coding list (PDAC) https://www.dmepdac.com/dmecsapp/do/search. Next, scroll down to the green bar that says “Search DMEPOS Product Classification List.” Under the green bar to the right, type in E2622 and click on the purple GO button and all 915 cushions that meet the criteria for this code will appear.

___________________________________________

Bob VogelBob Vogel, 51, is a freelance writer for the ROHO Community blog. He is a dedicated dad, adventure athlete and journalist. Bob is in his 26th year as a T10 complete para. For the past two decades he has written for New Mobility magazine and is now their Senior Correspondent. He often seeks insight and perspective from his 10-year-old daughter, Sarah, and Schatzie, his 9-year-old German Shepherd service dog.

Share Button