The long-awaited provision allowing consumers to upgrade beyond the Medicare allowable, according to several industry executives, is just around the corner. Or maybe around the corner and down the street a little.

In any case, the good news is that the Health Care Financing Administration is finalizing a provision that would allow users of home medical equipment to pay out of pocket for features that otherwise would not be covered under Medicare. That would be a boon for wheelchair users, manufacturers say, but it would also represent new sales opportunities for the industry.

Just when such a provision will go into effect depends on the specific language that's approved. Regulators are trying to find the right balance between allowing people to get the solutions they want and ensuring they are protected from abuse and fraud. Also in question is exactly how the provision should be implemented.

"We don't expect it to actually impact our business for the next six to 12 months," predicts Julie Jacono, senior product manager, power wheelchairs, Invacare.

Whenever that new rule becomes active, revenue from power wheelchairs predictably will increase, manufacturers say. "You are going to see a lot of options and accessories being purchased by the beneficiary above and beyond what Medicare's allowable amount is," says Martin Szmal, general manager of reimbursement services, Pride Mobility Products. Examples include faster speed packages, elevating seat lifts and larger batteries.

Such features, which are considered convenience items, are the ones that stand to gain. "It's the things that consumers would see a benefit in and that would enhance their lives but are not medically justifiable," notes Mark Greig, senior product manager, power wheelchairs, Sunrise Medical.

The upgrade provision might also help patients get certain combinations of features that are medically significant but difficult to justify to payers as medically necessary, Jacono predicts. For instance, she says it's very difficult to get a tilt-and-recline combination system funded. Clinically, it's more common to justify only one or the other, so she expects people will get the tilt feature funded and then opt to add recline themselves. "I think there will be a lot of people who will take advantage of [the upgrade option]," Jacono says.

Certainly, allowing out-of-pocket upgrades allows a wider range of solutions. "It's a good thing because in some cases you get just the bare minimum, and it would allow the consumer more flexibility to get the product that fits him best medically," says DuWayne Kramer, president, Leisure-Lift.

Battery Sales Get a Positive Charge

CHANGING ATTITUDES among funding agencies are about to have a positive effect on sales, manufacturers predict. Thanks to the coordinated effort of Sunrise Medical, Invacare and MK Battery, some of the roadblocks to providing gel/sealed batteries are going by the wayside.

Specifically, medical directors of durable medical equipment regional carriers B and C are starting to understand that the existing Gel K code should not be automatically down-coded to wet-battery rates.

Cost has always been an issue because a high-quality gel/sealed battery can cost 80-100 percent more than a wet battery. Yet, there are plenty of safety reasons to prefer gel/sealed batteries, manufacturers say. It can be dangerous for someone with tremors or limited strength or dexterity to use open-cell batteries. Then there is the whole issue of safety during transport.

The three manufacturers brought such safety issues before the DMERCs and helped justify the need for gel batteries. Life-cycle issues were raised as well. "The maintenance needed on a wet-cell battery leads to someone not keeping up with the maintenance and therefore having a battery that lasts a couple of months instead of a year," explains Julie Jacono, senior product manager, power wheelchairs, Invacare.

Now, while they still will not automatically justify them, the two DMERCs say they will consider gel-cell batteries as a necessity - if the provider submits paperwork explaining that the patient cannot maintain a wet-cell battery or has other good reasons not to use one. Similarly, they will also allow larger, Group 24-size batteries if the need is sufficiently explained.

The end of automatic down-coding - at least by two DMERCs - relieves a burden many providers assumed by supplying customers with gel batteries despite reimbursement difficulties. "Before the reversal of Medicare reimbursement policy, the dealers frequently absorbed that as a cost of doing business - which has never been right," says Dennis Sharpe, director, national HME, MK Battery. "Dealers should be paid for what they supply."