Start Your Engines

I am sure you are familiar with the “Golden Rule.” It goes something like this: “He who has the gold makes the rules.” This is certainly the case with the new policy for mobility assistive equipment that the DMERCs are implementing. Who else would have come up with such a complex procedure to see if a cane or walker or wheelchair is reasonable and necessary?

Prescribing MAE is now based on “an algorithmic approach.” A good analogy would be to think of the questions prescribing physicians or practitioners must answer as the steps you must take to start your car. You must have an engine, gas, keys and a charged battery. If any of the items fail, or are not present, then the car will not start.

The same goes for the qualification of an MAE item. To qualify for a walker, for example, several conditions must exist based on the questions that must be answered about that walker. If, at any point during the qualification process, you end up at “not reasonable and necessary” for your answer, the item that was prescribed will not be covered.

By looking at the stepped MAE questions, you might also determine that a different piece of equipment is required than what the physician ordered. Say, for example, the physician ordered a manual wheelchair, but then he, a physical or occupational therapist or clinician answered Question 6 on the MAE — Does the home environment support the use of wheelchairs? — with a “no.” Since the home does not support the use of a wheelchair, the wheelchair would be considered “not reasonable and necessary.”

Another example would be if a power wheelchair were ordered. The physician may have answered all nine MAE questions, but he indicated that the recipient cannot operate the power wheelchair safely. In this case also, the chair would be considered “not reasonable and necessary.”

There are many points in the new coverage procedure that can “stop” a provider from considering an item ordered to be “reasonable and necessary.” Be sure you follow the MAE and that you have physician notes to back up the answers that are given by the physician, PT, OT or clinician.

I would recommend getting these notes as part of your normal intake process. It will be far easier to get them at intake than months, or even years, later. Nothing is worse than getting an audit letter and then finding out that the doctor has retired and you cannot get the additional medical justification for the item you put out.