Some patients require medical equipment for in-home care. Home medical equipment may be necessary but it isn’t always inexpensive.
Neidi Mack, Vice President of Ancillary Services for Prism Health Care Services, explains what home care medical equipment is covered by Medicaid, Medicare and insurance.
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What Home Medical Equipment Does Medicare, Medicaid and Insurance Cover?
Featuring:
Neidi Mack
Neidi Mack is Vice President of Ancillary Services for Prism Health Care Services. Transcription:
Melanie Cole (Host): Some patients may require medical equipment for in-home care. Home medical equipment may be necessary, but it isn’t always inexpensive. My guest today is Neidi Mack. She’s the vice president of Ancillary Services for Prism Healthcare Services, the Alden Network’s home and durable medical equipment transitional care partner. Neidi, welcome to the show. So, tell us a little bit about how great the need is for home medical equipment. What are you seeing going on out there today?
Neidi Mack (Guest): Well, what we are seeing is that we are seeing an aging population that wants to stay at home and be able to continue living out their daily living activities in a safe manner and so home medical equipment or durable medical equipment is a key component to being able to keep those patients and caregivers safe in the home.
Melanie: What types of durable medical equipment are we talking about?
Neidi: Well home medical equipment can really range anywhere from a basic walker all the way through key respiratory items such as home oxygen, ventilators, noninvasive ventilators and CPAP machines for sleep apnea.
Melanie: What does it mean Neidi when we hear durable equipment? What does that even mean?
Neidi: Well durable medical equipment is really a canned term provided by the Centers for Medicare and Medicaid Services. It essentially means, or definition is that it can withstand repeated use. So, most durable medical equipment is typically rented out to patients for as long as they need it or until the insurance caps that piece of equipment.
Melanie: So, the patients don’t own this equipment once the insurance company approves the claim and we will talk more about the insurance part of it all; but they don’t own it.
Neidi: Not necessarily. It depends on the type of equipment. So, typically, what we essentially call bent metal. Typically bent metal or equipment that requires frequent servicing for safety reasons is typically going to be rented. So, for example, home oxygen requires maintenance to ensure that we are keeping the equipment functioning properly, that the filters are clean and that we are preventing a home fire essentially from happening. And so those types of pieces of equipment that need that frequency servicing for safety reasons typically are not capped or purchased by insurance companies.
Melanie: And you mentioned the increasingly aging population. Who else can benefit from durable medical equipment?
Neidi: You know I think the whole entire patient population. I mean I think we are at an age now where we are seeing patients all the way from pediatrics who are patients that are born with disabilities that may need a basic walker or a wheelchair to be able to independently move around to enteral feeding. We have a lot of pediatric children that are tube fed all the way up to seniors that are really just trying to stay at home and living independently in a safe environment and in the comfort of their own home. Medicare and most insurance payors will cover items as long as they are medically necessary so essentially what that means is that the payor is looking for the patient to have seen their physician and for the physician to establish some reason, some medical reason that the equipment is needed.
Melanie: How does it all work? Who starts the application process?
Neidi: Well, typically most of the referrals are typically coming from an acute care environment meaning a hospital, but we also have referrals that come in directly from physician offices. So, the referral process typically starts with the medical necessity need being established by the healthcare professionals such as the doctor or an advanced nurse practitioner, physician’s assistant and once that medical documentation is documented in the patient’s medical record; typically someone from the hospital such as the case manager or discharge planner will start that referral process on behalf of the patient and they will start the discharge process directly with the durable medical equipment such as Prism Healthcare Services. So, that information can come either through email, it can be faxed in or it can be called in depending on how the hospital – what their discharge process typically looks like.
Melanie: Now let’s speak a little bit about Medicaid and Medicaid Managed Care organizations. What kinds of durable equipment do they cover and how does that process work?
Neidi: Well Medicaid will typically cover a few items that Medicare does not cover so for example, some of the common items that Medicaid will cover that Medicare does not are some bathroom equipment such as raised toilet seats, toilet safety rails, those are items that Medicare considers convenience items whereas the Medicaid programs do not consider those to be just convenience items. And so those are the types of products that we are seeing. They may cover a blood pressure cuff, they might cover other pieces of equipment that typically other payors will not cover. Really Medicaid and the managed care organizations are always considered the payor of last resort and so they will always – they tend to cover items that are typically not covered by Medicare. Some other items that Medicaid will cover that typically are not covered by Medicare are incontinence items such as briefs they will cover anywhere from a pediatric population all the way to an adult population as well.
Melanie: So, now what is the process for receiving this durable medical equipment once the doctor has submitted the required information and it’s all gotten started; then what happens?
Neidi: Well, that’s a really great question. One of the things that I think a lot of the population doesn’t understand about durable medical equipment is that we are typically dealing with a fairly sick patient population that typically is homebound. So, the hospital or the skilled nursing facility or the home health agency are really trying to keep that patient at home safe so really the value add that we provide is that we are accredited organizations and we also have employees that have to receive competencies in every single piece of equipment that we provide. Their job is to go ahead and deliver that equipment to the home, educate the patient on the equipment making sure that they are completing and appropriate return demonstration and then also really assessing the home environment to make sure that that home environment indeed is safe for the patient to use that home medical equipment. So, the best example I can provide in terms of safety and the home medical environment would be wheelchairs. So, for example, one of the main things that we find is that perhaps the doorways are not large enough to accommodate the wheelchair or perhaps the patient may not be able to do a pivot turn in their kitchen to be able to complete their daily living activities. So, in those situations, that’s really key that we have trained professionals that are providing that education and are really assessing to make sure that the patient indeed is going to be able to use the equipment in the home.
Melanie: What happens if the equipment breaks down or needs repair?
Neidi: As long as the equipment is rented, which typically most insurance companies will rent up to thirteen months before they purchase. That equipment just immediately gets exchanged by the home medical equipment or durable medical equipment provider. There is no additional fee. That is part of the fee that the insurance company is paying from month to month.
Melanie: And how often would the insurance provider replace the equipment if it completely breaks down?
Neidi: The rule for replacing equipment is typically five years. And that is typically coinciding with the manufacturer warranty for the equipment. It doesn’t always coincide and work out that perfectly. But typically, every five years, the insurance company will go ahead and replace the equipment. There are situations in which perhaps the patient has had some kind of adverse event in the home so perhaps maybe there was a home fire, or someone broke into the home. In those scenarios if we are within that five years, as long as we are submitting the confirmation or the documents to the insurance payor, which we would obtain from the patient; typically, the insurance company will make exceptions in those situations.
Melanie: Neidi I’m sure that patients ask this question all the time. But once the process starts, how long does it take, because sometimes if they are leaving the hospital or a short-term rehab; they need this stuff when they get home. So, how does that part work as far as timing?
Neidi: It’s critical that the equipment be at the home when the patient arrives and in some cases, we are actually delivering that equipment to the hospital. So, a good example of when we would deliver to the hospital would be when we are dealing with life sustaining equipment such as home oxygen to avoid having the patient go home via ambulance which typically that’s a significant out of pocket cost. We will deliver oxygen tanks to the hospital to ensure that the patient can then transport safely to the home and then once in the home, we are always providing enough tank oxygen until our driver or healthcare professional arrives at a home to go ahead and set up the stationary oxygen unit so that the patient could then go ahead and start and resume therapy in the home.
Melanie: Neidi, wrap it up for us with your best advice and information for families and patients about what you would like them to ask when it comes to durable medical equipment and getting their homes set up so that the patient can live a relatively normal life and go about their daily activities. What would you like to hear them ask you?
Neidi: I think it’s always important – there are really two key components especially in this day and age where insurance companies and how insurance companies go about covering. The first thing is we really need to make sure that we have an educated consumer regarding what their financial responsibility is. That is something that we take very seriously at Prism Healthcare Services. It’s important for the patient to be able to provide consent and that they truly understand what out of pocket costs they are going to have for that equipment so that they can make an informed decision about receiving that care in their home. And so, part of our process is and that is actually the first step when we receive the referrals, we complete that insurance verification, we obtain all the documents, we obtain the prior authorization so that we are able to communicate all of that information prior to delivering the equipment. The second piece of that is really the quality of the equipment. And so, at Prism Healthcare Services, we really take pride that regardless of any payor cuts that we really have never sacrificed on quality. It’s important for us to be able to provide equipment that is safe, that is really the market leader because ultimately, what we are looking for is to have a great patient outcome and a great patient outcome really comes down to that patient not being re-hospitalized and being able to live out their life independently at home without any further visits back to the hospital for the same condition in which they were discharged.
In addition, I would like to add that at Prism Healthcare Services, we are one of the few home medical equipment providers in the Chicagoland area that has a 2000 square foot state of the art showroom which enables all of our patients and caregivers to come in Monday through Friday 8 -5 p.m. and look, touch and feel all of the equipment. This is really important because of the rising out of pocket costs and deductibles with the insurance payors. There are patients and caregivers that may have deductibles that are up to $10,000 and so there are times that they may chose to upgrade the equipment and prior to making that decision, I think it’s really important for them to come in and see what those options are. In addition, in that showroom, we also have four private consultation rooms where we are able to see and fit all of our patients that are on CPAP therapy for obstructive sleep apnea. We do those setups in the home as well, but that’s also a great location where those patients can see what additional accessories we have for CPAP therapy to really kind of improve their compliance and insure their success with that therapy.
Melanie: Thank you so much Neidi for being with us today. This has been such great information. Thank you for telling us today about what Medicare, Medicaid and insurance cover when it comes to this durable home medical equipment. You’re listening to the Alden Network podcast. For more information on any of our other services, please visit www.thealdennetwork.com, or to hear more podcasts in this series please visit www.thealdennetwork.com/podcast, that’s www.thealdennetwork.com/podcast. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): Some patients may require medical equipment for in-home care. Home medical equipment may be necessary, but it isn’t always inexpensive. My guest today is Neidi Mack. She’s the vice president of Ancillary Services for Prism Healthcare Services, the Alden Network’s home and durable medical equipment transitional care partner. Neidi, welcome to the show. So, tell us a little bit about how great the need is for home medical equipment. What are you seeing going on out there today?
Neidi Mack (Guest): Well, what we are seeing is that we are seeing an aging population that wants to stay at home and be able to continue living out their daily living activities in a safe manner and so home medical equipment or durable medical equipment is a key component to being able to keep those patients and caregivers safe in the home.
Melanie: What types of durable medical equipment are we talking about?
Neidi: Well home medical equipment can really range anywhere from a basic walker all the way through key respiratory items such as home oxygen, ventilators, noninvasive ventilators and CPAP machines for sleep apnea.
Melanie: What does it mean Neidi when we hear durable equipment? What does that even mean?
Neidi: Well durable medical equipment is really a canned term provided by the Centers for Medicare and Medicaid Services. It essentially means, or definition is that it can withstand repeated use. So, most durable medical equipment is typically rented out to patients for as long as they need it or until the insurance caps that piece of equipment.
Melanie: So, the patients don’t own this equipment once the insurance company approves the claim and we will talk more about the insurance part of it all; but they don’t own it.
Neidi: Not necessarily. It depends on the type of equipment. So, typically, what we essentially call bent metal. Typically bent metal or equipment that requires frequent servicing for safety reasons is typically going to be rented. So, for example, home oxygen requires maintenance to ensure that we are keeping the equipment functioning properly, that the filters are clean and that we are preventing a home fire essentially from happening. And so those types of pieces of equipment that need that frequency servicing for safety reasons typically are not capped or purchased by insurance companies.
Melanie: And you mentioned the increasingly aging population. Who else can benefit from durable medical equipment?
Neidi: You know I think the whole entire patient population. I mean I think we are at an age now where we are seeing patients all the way from pediatrics who are patients that are born with disabilities that may need a basic walker or a wheelchair to be able to independently move around to enteral feeding. We have a lot of pediatric children that are tube fed all the way up to seniors that are really just trying to stay at home and living independently in a safe environment and in the comfort of their own home. Medicare and most insurance payors will cover items as long as they are medically necessary so essentially what that means is that the payor is looking for the patient to have seen their physician and for the physician to establish some reason, some medical reason that the equipment is needed.
Melanie: How does it all work? Who starts the application process?
Neidi: Well, typically most of the referrals are typically coming from an acute care environment meaning a hospital, but we also have referrals that come in directly from physician offices. So, the referral process typically starts with the medical necessity need being established by the healthcare professionals such as the doctor or an advanced nurse practitioner, physician’s assistant and once that medical documentation is documented in the patient’s medical record; typically someone from the hospital such as the case manager or discharge planner will start that referral process on behalf of the patient and they will start the discharge process directly with the durable medical equipment such as Prism Healthcare Services. So, that information can come either through email, it can be faxed in or it can be called in depending on how the hospital – what their discharge process typically looks like.
Melanie: Now let’s speak a little bit about Medicaid and Medicaid Managed Care organizations. What kinds of durable equipment do they cover and how does that process work?
Neidi: Well Medicaid will typically cover a few items that Medicare does not cover so for example, some of the common items that Medicaid will cover that Medicare does not are some bathroom equipment such as raised toilet seats, toilet safety rails, those are items that Medicare considers convenience items whereas the Medicaid programs do not consider those to be just convenience items. And so those are the types of products that we are seeing. They may cover a blood pressure cuff, they might cover other pieces of equipment that typically other payors will not cover. Really Medicaid and the managed care organizations are always considered the payor of last resort and so they will always – they tend to cover items that are typically not covered by Medicare. Some other items that Medicaid will cover that typically are not covered by Medicare are incontinence items such as briefs they will cover anywhere from a pediatric population all the way to an adult population as well.
Melanie: So, now what is the process for receiving this durable medical equipment once the doctor has submitted the required information and it’s all gotten started; then what happens?
Neidi: Well, that’s a really great question. One of the things that I think a lot of the population doesn’t understand about durable medical equipment is that we are typically dealing with a fairly sick patient population that typically is homebound. So, the hospital or the skilled nursing facility or the home health agency are really trying to keep that patient at home safe so really the value add that we provide is that we are accredited organizations and we also have employees that have to receive competencies in every single piece of equipment that we provide. Their job is to go ahead and deliver that equipment to the home, educate the patient on the equipment making sure that they are completing and appropriate return demonstration and then also really assessing the home environment to make sure that that home environment indeed is safe for the patient to use that home medical equipment. So, the best example I can provide in terms of safety and the home medical environment would be wheelchairs. So, for example, one of the main things that we find is that perhaps the doorways are not large enough to accommodate the wheelchair or perhaps the patient may not be able to do a pivot turn in their kitchen to be able to complete their daily living activities. So, in those situations, that’s really key that we have trained professionals that are providing that education and are really assessing to make sure that the patient indeed is going to be able to use the equipment in the home.
Melanie: What happens if the equipment breaks down or needs repair?
Neidi: As long as the equipment is rented, which typically most insurance companies will rent up to thirteen months before they purchase. That equipment just immediately gets exchanged by the home medical equipment or durable medical equipment provider. There is no additional fee. That is part of the fee that the insurance company is paying from month to month.
Melanie: And how often would the insurance provider replace the equipment if it completely breaks down?
Neidi: The rule for replacing equipment is typically five years. And that is typically coinciding with the manufacturer warranty for the equipment. It doesn’t always coincide and work out that perfectly. But typically, every five years, the insurance company will go ahead and replace the equipment. There are situations in which perhaps the patient has had some kind of adverse event in the home so perhaps maybe there was a home fire, or someone broke into the home. In those scenarios if we are within that five years, as long as we are submitting the confirmation or the documents to the insurance payor, which we would obtain from the patient; typically, the insurance company will make exceptions in those situations.
Melanie: Neidi I’m sure that patients ask this question all the time. But once the process starts, how long does it take, because sometimes if they are leaving the hospital or a short-term rehab; they need this stuff when they get home. So, how does that part work as far as timing?
Neidi: It’s critical that the equipment be at the home when the patient arrives and in some cases, we are actually delivering that equipment to the hospital. So, a good example of when we would deliver to the hospital would be when we are dealing with life sustaining equipment such as home oxygen to avoid having the patient go home via ambulance which typically that’s a significant out of pocket cost. We will deliver oxygen tanks to the hospital to ensure that the patient can then transport safely to the home and then once in the home, we are always providing enough tank oxygen until our driver or healthcare professional arrives at a home to go ahead and set up the stationary oxygen unit so that the patient could then go ahead and start and resume therapy in the home.
Melanie: Neidi, wrap it up for us with your best advice and information for families and patients about what you would like them to ask when it comes to durable medical equipment and getting their homes set up so that the patient can live a relatively normal life and go about their daily activities. What would you like to hear them ask you?
Neidi: I think it’s always important – there are really two key components especially in this day and age where insurance companies and how insurance companies go about covering. The first thing is we really need to make sure that we have an educated consumer regarding what their financial responsibility is. That is something that we take very seriously at Prism Healthcare Services. It’s important for the patient to be able to provide consent and that they truly understand what out of pocket costs they are going to have for that equipment so that they can make an informed decision about receiving that care in their home. And so, part of our process is and that is actually the first step when we receive the referrals, we complete that insurance verification, we obtain all the documents, we obtain the prior authorization so that we are able to communicate all of that information prior to delivering the equipment. The second piece of that is really the quality of the equipment. And so, at Prism Healthcare Services, we really take pride that regardless of any payor cuts that we really have never sacrificed on quality. It’s important for us to be able to provide equipment that is safe, that is really the market leader because ultimately, what we are looking for is to have a great patient outcome and a great patient outcome really comes down to that patient not being re-hospitalized and being able to live out their life independently at home without any further visits back to the hospital for the same condition in which they were discharged.
In addition, I would like to add that at Prism Healthcare Services, we are one of the few home medical equipment providers in the Chicagoland area that has a 2000 square foot state of the art showroom which enables all of our patients and caregivers to come in Monday through Friday 8 -5 p.m. and look, touch and feel all of the equipment. This is really important because of the rising out of pocket costs and deductibles with the insurance payors. There are patients and caregivers that may have deductibles that are up to $10,000 and so there are times that they may chose to upgrade the equipment and prior to making that decision, I think it’s really important for them to come in and see what those options are. In addition, in that showroom, we also have four private consultation rooms where we are able to see and fit all of our patients that are on CPAP therapy for obstructive sleep apnea. We do those setups in the home as well, but that’s also a great location where those patients can see what additional accessories we have for CPAP therapy to really kind of improve their compliance and insure their success with that therapy.
Melanie: Thank you so much Neidi for being with us today. This has been such great information. Thank you for telling us today about what Medicare, Medicaid and insurance cover when it comes to this durable home medical equipment. You’re listening to the Alden Network podcast. For more information on any of our other services, please visit www.thealdennetwork.com, or to hear more podcasts in this series please visit www.thealdennetwork.com/podcast, that’s www.thealdennetwork.com/podcast. This is Melanie Cole. Thanks so much for listening.