Preventive maintenance and timely repair of assistive technology (AT) is essential
to people requiring AT to obtain and maintain employment, and to contribute as
independent members of society. Various stakeholders – users, vendors, funding
agencies and healthcare practitioners have repeatedly expressed concerns regarding the
current process. However, a thorough literature review of disability and rehabilitation
issues reveals that there has been no recent study on the maintenance and repair of
assistive technology devices, even though several articles mention that it is a serious issue
and merits further research.
The purpose of our project is to study the current process of maintenance and repair of
assistive technology devices, identify areas of concern, and find possible methods to
improve the current system.
Therefore, as part of our initial research effort, we organized the first symposium Perspectives on Maintenance and Repair of Assistive Technology – on November 9,
2004. There were two overall objectives for the symposium. The first was to learn the
specific experiences, activities and responsibilities for each of the groups that is involved
with maintenance and repair of AT. Panelists focused particularly on devices that
enhance mobility. The second objective was for each of the constituencies to identify
specific issues or problems (from the perspective of the specific constituency) that
affected the maintenance and repair process.
The groups that were identified as central to the issue of maintenance and repair of
assistive technology mobility devices included:
 Users of assistive technology
 Durable medical equipment repair and maintenance providers
 Insurance and health maintenance organizations
 Government support agencies
 Healthcare practitioners
We present below a summary of the issues highlighted at the symposium.
Summary of Experiences, Activities, and Responsibilities
USERS
User experiences with maintenance and repair related at the Symposium can be
summarized by the following list:
 Lengthy time for repairs (more than 1 month for simple repairs such as tire
replacement)
 Confusion about repair process
o What is the process?
o Who is involved?
o Who pays for what?
 Lack of back-up equipment when repair is lengthy
 Problems with equipment on delivery common, particularly because of model
changes in AT which do not work with other AT in use. For example, a change in
wheelchair model may mean that the tie down system used in the user’s van may
not work without modification
 Travel problems common, particularly when traveling via commercial airplane
 Lack of familiarity of technicians with specific equipment
 Lack of preventive maintenance
 Lack of emergency service
 Limited choices for repair
Finally, users felt that in addition to the DME providers, consumer experience and review
could be an important source of information regarding choice of appropriate AT. Such
review is currently lacking in any organized fashion.
DURABLE MEDICAL EQUIPMENT PROVIDERS
Durable Medical Equipment (DME) provider experience with maintenance and repair of
AT can be summarized as follows:
 Reimbursement rates from Medicaid and private insurance companies do not
cover expenses incurred by the DME in providing the repair service
 Number of repairs needed versus the ability of the DME to complete repairs
means that repairs have to be prioritized based on the medical needs of the user
 Complexity and time delays associated with approval process from agencies
providing reimbursement for repair services
 Need for back-up equipment, however, no support for it
 Lack of consistency among different manufacturers
 Difficulty with repair because of individualization and customization of
wheelchairs
HEALTHCARE PRACTITIONERS
Healthcare Practitioners experience with maintenance and repair of AT include:
 Lack of understanding by consumers of need to consider multiple sources for
support of AT
 Insufficient funds to cover needed activity
 Lack of standardization of insurance policies
 Fragmentation in current system
 Delays from requirement for a physician’s signature on justification letter
 Therapists often in advocacy role for user
INSURANCE AND GOVERNMENT SUPPORT AGENCIES
Insurance company and government support agency experience with maintenance and
repair includes:
 Insurance companies face problems with misunderstandings of what AT is
“medical necessary” versus AT that will facilitate activities of daily living
 Confusion because law does not mandate that insurance providers must provide
AT
 Lack of understanding of process by consumers
 Differences in level for prior authorizations
Summary of Issues Identified with Current Maintenance and Repair Process
Shown in Table 1 below is a tabulation of the issues that were identified from each of the
different constituents. As illustrated, each of the constituent groups identified issues with
the complexity of the current system. For example, all groups indicated that the Prior
Authorization (PA) approval process needed to be improved.
The time necessary to complete repairs was also identified as an issue by all constituents.
Procurement of parts is a problem for both the user and DMERP. Again, the time
necessary for approval was identified as an issue by all groups.
The DMERP and Organizations providing funding for maintenance and repair identified
user abuse as an issue.
All parties identified lack of emergency services as a problem. Users and the healthcare
practitioners identified lack of back-up equipment as a significant issue. The DMERP
indicated that they would provide back-up equipment if funds existed for support of
back-up equipment.
Lack of preventive maintenance was identified as a problem by users and the DMERPs.
Lack of manufacturing standards and means of independent equipment evaluation was
cited by all groups.
And finally, users indicated that independent repair facilities, not direct equipment
providers, was an issue.
Constituent
Issues Identified
A. COMPLEXITY
1. Paperwork
2. PA and Approval
3. Funding structure
4. Number of steps
5. Inability to
understand system
B. TIME
1. Time to bring chair
for assessment
2. PA and Approval
3. Procurement of
Parts
4. Time to complete
repair
C. USER ABUSE OF
EQUIPMENT
D. EMERGENCY
SERVICES
E. LACK OF LOANER
EQUIPMENT
F. LACK OF
PREVENTIVE
MAINTENANCE
G. LACK OF
MANUFACTURING
STANDARDS
H. LACK OF
CONSUMER
REPORTS
I. LACK OF
INDEPENDENT
REPAIR FACILITIES
Users
DMERP
Organizations
Providing
Funding for
Maintenance
and Repair
Healthcare
Practitioners
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
Would
provide if
adequate
funding
available
√
√
√
√
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Table 1: Issues with the current system for maintenance and repair
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The symposium provided us with enough material to start our research. The primary
issues identified were thoroughly researched and our findings are presented below.
A. COMPLEXITY :
Funding Process for Repair of Durable Medical Equipment
As mentioned earlier, each stakeholder agreed that more than one of the elements of the
funding process is a pressing concern. We were unable to find any study on the subject.
And, have tried to outline the basic steps that need to be followed without getting into the
details of each subset of funding agencies that may be involved. However, it is useful to
keep in mind that each step outlined could have compounding time effect if more than
one agency has to approve the application.
The following flow-charts indicate how a user addresses his need for repair of AT device.
Problem with AT Device
Select Appropriate Durable Medical Equipment Repair Provider (DMERP)
Identification of problem by vendor along with user
Verify whether qualify for funding based on
the eligibility criterion and
the exclusions list of insurance providers
Prepare a funding request
Apply for Prior Authorization
PA Denied
Follow Appeal Process
PA Denied
Do not need Prior Authorization
PA Approved
Get Repairs for
AT Device
PA Approved
1
1
Procedure codes with the "RP" modifier do not require prior authorization (PA) if all of the following are true:



The DME is more than one year old. Claims submitted with the "RP" modifier without PA during the first year will be
denied.
The charge for the repair parts is $50.00 or less.
Wisconsin Medicaid purchased the DME being repaired.
Check which agencies are willing to provide funds and
how much of the total expenses they will cover
Private
Medicaid
Medicare
Medicaid
Private
Medicare
Medicaid
2
2
Out-of-pocket payments are not possible if the user is covered by Medicaid which is the funding agency
of last resort. Further, with more than one funding agency picking up the bill, there could be a cascading
effect.
Prepare a Funding Request
Determine if Prior Authorization needed
PA: Applicable to Medicaid
for repair costs greater than $49.99
in uncoded HCPC parts
or for repair requiring
greater than 5 units of labor
Can back-date the PA
and go through with repairs
No PA: Applicable to Medicaid
for repair costs less than $49.99
in uncoded HCPC parts
and requiring less than 5 units of labor
Also to Medicare and
Private insurance for all repairs
I
II
I
Process I: Requires PA
Applicable to Medicaid for repair costs greater than $49.99 in uncoded HCPC parts
or repair requiring greater than 5 units of labor
(i) Certificate of Medical Necessity (CMN):
Valid referral or prescription from your
primary physician or primary care provider
to establish medical necessity,
Or a form provided by DME company
that is to be signed by the physician
Medicaid validity : 6 months
(ii) Submission of eligibility documents,
CMN and funding request
by vendor with valid ID to Medicaid
Submission by fax or web options available
XX
* Time limits may vary from one insurance provider to another
XX
Contd.. PA process
Medicaid time limit for decision – 10 days from the time a consultant gets it
This does not include mail time, lag in attending to the request etc.
so 30-45 days is a reasonable estimate for response time
PA approved
(iii) Initial Denial: If the PA is denied
May be asked to
submit missing documentation
or further clarification
Reconsideration: May resubmit the PA
for reconsideration based on
additional documentation
(not submitted in the initial PA request)
Approved
Not Approved
B
A
B
Process (iv): File a written request for an
Administrative Law Judge hearing (ALJ) to ask for a review
of the funding denial decision
Time limit for request - 60 days after decision
Time limit for decision - no time limit,
a fair estimate is that the hearing
will be held six to nine months after the request is filed,
and the decision will be issued two to three months later.
Monetary threshold in dispute - $100 or more
Submit justification letter and certificate of medical necessity
Additional documents or oral statements at the hearing can be submitted
A favorable decision is a reasonable expectation
Approved
A
Not approved
C
C
Process (iv): Request review by
the Departmental Appeal Board
Time limit for request - 60 days after ALJ decision
Time limit for decision - no time limit,
Expect about six to nine months or longer
Monetary threshold in dispute - $100 or more
Advocate or attorney will submit a memorandum of law
explaining why the ALJ decision is incorrect
Unless some significant new fact or circumstance arises,
no opportunity to submit new information at this level of appeal.
Approved
Not approved
A
D
3
D
Process (v): Final Appeal :Request for judicial review
Time limit for request – 60 days after DAB decision
Time limit for decision - no time limit,
Monetary threshold in dispute - $1000 or more
Approved
A
3
Not approved
Notified of denial in writing
The closest paper that we could find on the subject was Parsons (1991) which discusses that this
“complex adjudication mechanism consumes a great deal of time…On average, an individual who pursued
all internal appeal mechanisms faced an internal processing delay of approximately 10.4 months in 1982. It
is important to point out that this lag does not include the applicant's own response lags at the various
stages…Of those who were initially denied in 1978, 41.7 percent appealed the decision. Of appellants
The other possibility is a process that does not need a PA.
II
Process II: PA not required:
(Less than $50 for Medicaid)
Following documents needed:
HIPAA form
Rx form
CMN for
certain coded
parts under
Medicare
Submission of above-mentioned documents by vendor
If there is an assigned code for the part required,
then follow corresponding Medicare/ Medicaid guidelines
A
A
Vendor carries out repair work
Vendor submits reimbursement request
Reimbursed by Medicaid / Medicare /
Private Insurance company / co-payment
as the case may be
Notification process
Medicaid:
No notification provided
Medicare:
Notified after billing submission
Private insurance companies:
Mostly notification provided
denied eligibility at the “reconsideration” stage, almost half (48.0 percent) appealed to the administrativelaw-judge level.”
B. TIME:
Repair Process and Employment Outcomes:
Fishman (1991) points out that “Developments in information technologies and
assistive devices have enabled people with disabilities to engage in work that they
could not have done in the past, as well as created new types of jobs that some people
with disabilities are capable of performing.” There is consensus among writers in the
field as well as attendees of the seminar that delays in repair of AT devices inhibit
users from being able to carry out their daily activities and work.
Thus, we are conducting an empirical study of the effects of the current AT
maintenance and repair system on employment outcomes of users. Our literature
review guided us that “…the type of disability that appears to be driving the observed
overall decline in real wages of disabled workers relative to nondisabled, post-ADA,
is musculoskeletal. The real wages of workers with musculoskeletal disabilities
declined 4 percent more than for workers without disabilities post-ADA…”
(Hotchkiss, 2003). Also, Stern (1996) explains that “programs that affect the supply
index of disabled people are much more efficient than those that equally affect the
demand index for disabled people”. Therefore, decreasing missed days of work due to
inefficiencies in maintenance and repair would contribute to increasing the labor
supply of disabled persons. Lower absenteeism also increases the value of disabled
persons to employers. Another paper by Oi (1996) suggests that greater customization
of AT devices is likely to boost labor supply in two ways: increasing daily time
available for both work and leisure as well as reducing disability specific work
inconvenience.
The following chart captures the inter-relationship between repair of AT devices and
employment outcomes.
Repair & Labor
Long and
highly variable
absence
Direct employer
costs: turnover,
replacement workers,
other absenteeism
costs
Direct employee
cost:
Lost wages
Fewer job
opportunities and
self selection
Indirect employee
cost:
Lower wages offered
Long and highly
variable repair times
Public insurance
AT repair
Lower employment and income
of disabled persons
Estimates
We examine two measures of potential gains to be made through improving employment
outcomes of the disabled population:
1. Lost wages due to absence
2. Lower income and employment
We use the U.S. Census Bureau, 2000 Census of Population and Housing, 1% Public
Use Microdata Sample. And, classify individuals in the following categories:
•
General Population : Persons without any physical disability
•
Population with Disability: All individuals who answered YES to the following
two questions:
Does this person have any of the following long-lasting conditions:
A condition that substantially limits one or more basic physical activities such as
walking, climbing stairs, reaching, lifting, or carrying?
Because of a physical, mental, or emotional condition lasting 6 months or
more, does this person have any difficulty in doing any of the following
activities:
(Answer if this person is 16 YEARS OLD OR OVER.) Working at a job or
business?
We summarize our methodology and findings here. We sorted the census data by age,
income and population.
1. Used ‘typical’ hourly wage by age for each population sub-group:
Found that if 10% of the individuals in the disability group miss work due to AT
repair, the direct cost in terms of lost wages was $14 million per day in 1999.
2. Used ‘typical income gains’ resulting from reduced ‘employment gap’:
Found that the annual US gains would be $10 million for every 1% reduction in the
employment gap.
However, these are merely preliminary estimates and we have no data on the number of
days that a person with work and physical disability misses on average. Therefore, our
next step is to conduct a national survey to answer these questions.
The Mobility Device Repair Survey: Individuals with Disabilities is an ambitious
project of our research team that aims to gather data that can be used for further analysis
of the specific problems that users face when obtaining repairs for AT devices.
The survey questions can be broadly separated into the following categories:
1. questions related to the time component of repair
2. questions related to funding of the repair
3. questions related to impact of AT problems on user’s activities especially work
4. questions related to user’s feedback on the current AT repair system
5. demographic information of the user
We are posting the survey on various bulletin boards on the internet and also contacting
various independent living centers across the country. We expect to have the survey
responses collected within the next three months. After that we plan to analyze the results
so that we can get a deeper understanding of the issues involved and consequently make
informed progress towards finding solutions o the current shortcomings.
References:
•
•
•
•
Fishman, Michael E., Framing the Issues: Economic Research on Employment
Policy for People with Disabilities, Employment and Disability Institute
Collection, Cornell University, October 1999.
Hotchkiss, Julie L., The Labor Market Experience of Workers with Disabilities:
The ADA and Beyond, W.E. Upjohn Institute for Employment Research,
Kalamazoo, Michigan, 2003.
Oi, Walter Y., Employment and Benefits for People with Diverse Disabilities.” in
Disability, Work and Cash Benefits, ed. by Jerry L. Mashaw, Virginia Reno,
Richard V. Burkhauser, and Monroe Berkowitz, Kalamazoo: W.E. Upjohn
Institute for Employment Research, 1996.
Parsons, Donald O., The Health and Earnings of Rejected Disability Insurance
Applicants: Comment, The American Economic Review, vol. 81, no. 5, Dec. 1991,
1419-1426.