Individual Advocacy: How an AOTA Member Made a Big Difference
By Stephanie Yamkovenko
For nearly 15 years, Medicare was reimbursing for driving evaluations at the rehabilitation hospital in New York where Donna Stressel, OTR, CDRS, works. Then in 2008, Stressel learned that the Medicare contractor who serves New York State, National Government Services, specified in a revision of their local coverage determination (LCD) that driving assessments were on the list of non-covered services. Stressel had no choice but to require clients to self-pay for driving evaluations. The new policy also affected Medicare beneficiaries in Connecticut, Kentucky, Illinois, Indiana, Michigan, Ohio, Virginia, West Virginia, and Wisconsin.
When Stressel noticed the impact of the policy, she decided to take action. AOTA talked with Stressel to find out how she successfully advocated to improve coverage of occupational therapy assessments that address driving.
Q: What happened at your clinic after the Medicare contractor changed their LCD?
A: Of the clients who were referred to us, about 60% of them didn’t use our services when they heard it was self-pay. Unfortunately it was a mix of people that I think we could have helped the most. Sometimes it was people who did not have the money, and they had to choose between a driving assessment and their medication and the very basic necessities. It really changed the number of clients we saw.
Q: Why did you decide to contact the contractor?
A: I really wanted to write an appeal. I had thought about it, but I waited until just last year before I did anything and that was partly because I didn’t think I could make a difference. All over the country you hear people say that driving evaluation is a non-covered service and there’s nothing you can do about it. Then I heard that the LCD in Vermont had removed driving evaluation from the non-covered list in the previous year, and that was the impetus that got me to decide to do something about it.
Have you ever written a letter to ask for an LCD reconsideration* like this before? How did you learn about the process?
No. To be honest I didn’t even know what an LCD was. I had heard of CMS [the Centers for Medicare & Medicaid Services] but I did not understand that depending on where you live you have intermediaries [or contractors] that interpret CMS rulings. I had no clue what I was doing when I started. I started educating myself. I went to the CMS Web site and I read what “medical necessity” means. I went to my LCD Web site and read everything I could possibly read about occupational therapy services, the codes, what was covered, what wasn’t covered, the medical necessity, what was reasonable and necessary, etc. I did due diligence in trying to find out what the issue was, and I kept saying to myself “driving should fit into this.” I couldn’t see why it would be excluded.
Where else did you go for help before writing the letter?
I got support from AOTA staff. I read AOTA documents on the issues. I also looked at all of the intermediaries [LCDs] across the country to see if they covered driving or if they specifically excluded it. I found out that many of them didn’t have any language that specifically excluded driving. That doesn’t mean necessarily that they cover driving evaluation, but only a few LCDs had driving as a non-covered service.
What did you include in the letter of reconsideration that you sent?
I looked at all the possible arguments that they might have for it to be a non-covered service and responded to those issues. I specified how long driving assessments would take, the outcomes you could expect, who a qualified professional was, etc. I made argument by argument as to why I felt that driving met their criteria. They said in their documents that a service couldn’t be experimental, so I included current articles that showed the research on the issue.
How long did it take for them to respond to your letter?
I submitted the letter in November 2010. In March 2011 I got a letter saying they would remove it from the list of non-covered services. When I got the letter part of me was surprised, but part of me was thinking that it is what should have happened. It doesn’t necessarily mean they will cover driving assessments, but basically we can submit claims to Medicare now. They also gave me some guidelines about medical diagnoses and documentation requirements that could assist me when submitting claims.
What advice would you give other members who want to do individual advocacy such as asking for a reconsideration or otherwise advocating with their contractors?
Don’t feel that just because you’ve been told that this is the way it is, that it doesn’t matter. Take a chance. Even if I had been unsuccessful, the education that I got from this was fantastic. It’s very easy to think, “I’m just a therapist working in this, what difference could I make?” Believe in yourself, believe that you can do something, and you have no idea what can happen. Just try it.
Why is it important for occupational therapy practitioners to be advocates?
When you’re looking at a specialty area, we know it better than the people who may know the political scene. We know the [clinical] issues and we have the desire to make the changes. If I hadn’t done something about this issue, our program was at risk of closing. That’s my livelihood. But I also really felt that the people I thought I could help the most were missing out on the services. If I didn’t fight for it, then nobody else would. I thought I was in the best position to do it.
Read this AOTA analysis of the National Government Services LCD revision.
*A reconsideration request is a formal request that can be filed to ask for changes in a Medicare contractor’s policy. There are specific rules and guides for how to file such requests and how the contractor must respond.
Stephanie Yamkovenko is AOTA’s staff writer.