Life on Wheels (50 page)

There is no reason you can’t question a policy that you consider inappropriate or unfair. The worst your funder can do is say no. But if you can make a good case, you just might be able to convince an insurer to reconsider. Dr. Michael Boninger, of the Human Engineering Research Laboratory at the University of Pittsburgh, specifies chairs for people. He advises: “If your policy only allows you a $200 wheelchair, then challenge it. If you fight hard enough, you might get the insurer to make an exception.”

Funding agencies and organizations generally do not think proactively. They tend to resist paying for something now, even if it will prevent problems—and save money—later. For example, an insurer might not want to pay for a contoured back to help control the trunk of a rider’s body. Contoured backs can reach prices of up to $800, but, for some people, their use can prevent the need for more expensive equipment or corrective surgery later on.

Stanford University occupational therapist Jody Greenhalgh is closely involved in specifying wheelchairs for people. More than once, she has encountered someone with pressure-sore problems who has had expensive surgery. She finds that these problems could have been avoided if a better wheelchair and positioning system had been configured in the first place, as in this worst-case example.

The insurance companies seem to be shortsighted, preferring to spend money on surgical intervention rather than paying for the right cushion and specialized wheelchair—which would ultimately save dollars and help the patient return to a productive and independent life. Because the insurer who pays for the wheelchair is likely to not have to pay for future surgeries or extended nursing home stays (since you are likely to move to another company or a government program like Medicare), they are not as motivated to be proactive in this way.

You might need to enlist the help of your physician, occupational or physical therapist, or other medical professional. The initial wheelchair prescription typically includes a “certificate of medical necessity,” which is signed by the physician. If your funder denies the chair specified on your prescription, ask for help from your medical team. Your doctor or therapist can write to your funder, explaining in detail why that particular chair is medically necessary for you. Greenhalgh is an experienced advocate:

It is increasingly common for insurance companies and funding agencies to assign your file to a case manager. The case manager should be your advocate, putting your medical interests first above all. He may or may not be a nurse or otherwise medically experienced. Your case manager will talk with doctors and therapists, confirm the policies and limits of your coverage, shop for the best prices (which is part of what makes case managers appealing to the insurer), and even contact social workers to seek out additional sources of funding or equipment if the policy does not cover you.

Sometimes case managers are on staff, or the insurer might have a contract with an outside provider of these services. If there is not a case manager assigned to you, ask for one. You do not have a legal right to a case manager, but it’s likely your request will be granted, especially if you are pleasantly persistent. If possible, try to get a case manager with specific background in rehabilitation equipment and your specific disability.

Following are additional suggestions for how to overcome a denial of funding:

Submit an official appeal. Your funding contact person should be able to provide you with the appropriate procedure.

If coverage is employer provided, enlist the help of your employer’s benefits department.

Write to the state insurance commissioner.

Contact an appropriate advocacy group.

Appeal to your congressional representatives.

Take your case public. Local television or newspaper reporters might be interested in reporting about a funder who is denying coverage for clearly needed equipment. Funders don’t like negative publicity, so they might be persuaded to do the right thing. Even if you still don’t get funding, the report could flush out other forms of help, such as a generous donor or someone with a used chair that meets your needs.

Another way you can help yourself is to research a wide variety of manufacturers. For instance, smaller producers are very aware of the need to increase business by making their products a more attractive option to funding sources, so they try to offer good solutions at lower costs. If you can find a less-expensive solution to your needs by doing this kind of research, it might reduce complications in dealing with your funding source and make it easier for you to get approval.

If you are unable to deal with funding problems, perhaps a family member, friend, case manager, or social worker would be willing to invest the effort to overcome resistance you might encounter from payers. Many local centers for independent living offer advice or active assistance with funding issues.

If your funding source is refusing to pay for a particular chair or feature, you must decide how long you will fight the good fight. At some point it might make sense to take what they give you and enhance it on your own. The following are some possible sources of funding or finding a chair if you have to “do-it-yourself”:

Your church or other community group might be able to contribute to a purchase or stage a fundraiser on your behalf.