Complex Rehab

Complex or custom rehabilitation technology services are highly specialized services and products designed to assist patients with disabilities to help perform activities of daily living (ADL’s). In the DME world, in terms of DMEPOS, most of the equipment and supplies that fall into this category are used for mobility. Customized wheelchairs with specialized seating surfaces and controls are the products that are most commonly provided.

These customized chairs include fitted surface areas designed to prevent pressure sores and controls designed to enhance the patient’s ability to move around and participate in society. Patients with muscular dystrophy, spina bifida, cerebral palsy, and spinal cord injuries are candidates for these products and services. They earn the “complex” moniker because they often feature parts that are custom fabricated in machine shops. These shops are sometimes in the DME and/or products are sometimes purchased wholesale by the DME from various manufacturers. Regardless of who fabricates the components, the DME provider is responsible for the final assembly which usually involves a rather detailed measurement and assessment process.

The final products can cost in the thousands on the lower end of the spectrum and easily in the tens of thousands approaching $100,000 at the higher end. They require multiple hands to put them together including specialized “ATP’s” to perform the assessments and fittings.

ATP’s are “assistive technology professionals”, duly certified by RESNA (Rehabilitation Engineering & Assistive Technology Society of North America). RESNA has been around since the 1970’s and the credentialing program is even younger than that. ATP’s are typically folks who worked in the DME (or rehab) industry to begin with and eventually sought and earned the credential. The ATP certification involves attending classes, timeframe requirements working in the field, and continuing education, as well as a tough credentialing exam. The exam and the credential have true credibility and well-deserved recognition by payer sources, including Medicare.

These complex chairs aren’t something you go pick out on a showroom floor at a local pharmacy or medical equipment store. The process for getting a chair like this typically involves:

• A professional evaluation by a team including an ATP, a physical and/or occupational therapist, and a physician—usually done at a clinic, school, or hospital.
• The ATP “writes up” the patient’s needs and plans the chair on paper.
• The DME provider takes the ATP’s report, along with physician notes, and submits to the payer/insurance for approval.
• Once approved, the chair is built. This can take days, weeks, or even months.
• Fitting/evaluation—often done multiple times during the construction of the chair.
• Delivery/final fitting. The patient learns how to operate the chair and navigate their world.

The model for this business has many challenges. ATP’s are hard to find in some parts of the country and often travel from branch to branch for an organization. Billing is highly specialized and requires medical billers expert in the jargon and trade. And as far as money goes, the margins are sometimes very slim and companies are required to invest sizeable amounts of money to build chairs that cost significant amounts to recoup their money months later.

All accreditation standards apply. In addition to the traditional accreditation standards for “full DME”, accrediting bodies have standards specific to the niche industry. At HQAA, the service-specific standards are:

RE 1—APPROPRIATE SUPPLY: The organization must ensure an adequate supply of products and supplies for their customers. This includes “demo units” for trial periods. Obviously, the organization doesn’t maintain complete manufactured chairs for every eventuality, but they must have ready access to parts and supplies, along with demo units for new customers to see and try out.

RE 2—SELECTION, DELIVERY, AND MAINTENANCE: The organization must have written policies and procedures regarding their equipment management including storage, delivery, repair, etc. They should have a repair area and/or access to repair centers that they coordinate with when equipment needs adjusted or repaired.

RE 3—EQUIPMENT/DEVICE FITS: The organization must have a reliable process to “fit” the equipment to the patient and ensure that product is assembled properly based on a care plan developed with the team (including physician, PT, and OT). If the fittings are done at the DME, the location should have a private, clean, safe room or area for the assessment, fitting, and teaching.

RE 4—TRAINING: The organization trains staff and ensures that staff training meets the needs of the patient. Staff such as ATP’s must be competent and competency should be assessed on a regular basis by someone qualified to assess their competency. This standard also specifically requires ten hours of continuing education annually specific to rehab technology.

RE 5—POWER EQUIPMENT & TOOLS: Many of these providers that fabricate components use power tools. If applicable to the organization, they must have policies and procedures that address the safe use of the tools and equipment. This is a standard that talks about OSHA guidelines in the shops along with the use of PPE, safety goggles, etc.

The survey process includes all the expected activities that occur during a DME survey. The home visit is often to a clinic, where the majority of these assessments take place. The surveyor will want to talk with and observe the ATP, review patient records for both patient assessment and medical record review and billing as well.

While this niche market has significant challenges, it also has great rewards. These include improving the quality of life for a mobility impaired patient/customer in often dramatic and profound ways. Seeing the delight on the faces of patients and their caregivers when the products are delivered is unforgettable and it serves to remind us why we got into this profession in the first place.