Getting the Right Gear

GETTING THE RIGHT GEAR:

Taking Charge of Obtaining Durable Medical Equipment

Erin Schwier OTD OTR/L, Senior Policy Analyst, Occupational Therapist June Isaacson Kailes MSW, Associate Director Center for Disability Issues and the Health Professions Western University of Health Sciences 309 E. Second Street, Pomona, CA 91766 Voice/TTY 800.832.0524, Fax 909.469.5503, e-mail:

Last Updated 2/20/06

Funded by a grant from The California Endowment

INTRODUCTION

Getting your durable medical equipment (DME) can be a challenging and time consuming process. Using the following information can help to make the process go a little faster, and reduce the chance of denial of coverage by your health insurance carrier.

It is important for you to take charge of getting your DME. You know best what you need and it is your responsibility to make sure you get equipment that will work for you. This process can go more smoothly if you attend to the details.

This document gives you tools and suggestions to help you through the process of getting the right gear, and provides answers to these questions:

¨  What is considered DME?

¨  Who can get DME?

¨  What are the steps in getting DME paid for?

¨  What are the most common reasons for denial of payment?

Who Uses DME?

Many people use durable medical equipment (DME). In fact, in a 2001 survey, over 15 million Americans with disabilities reported using DME (National Institute on Disability and Rehabilitation Research, 2001). In a survey conducted by the American Association of Retired Persons (AARP, 2003), one-third of persons surveyed who were 50 years of age and older reported using some type of equipment or assistive technology. Almost one-quarter of persons 50 and older who are disabled but who do not use any specific equipment said that items such as a hearing aid, wheelchair, cane, or walker would improve their lives (AARP, 2003).

The process of getting the right kind of DME to suit your needs can be confusing, frustrating and difficult. Not having the right DME can limit your ability to live and work independently and can lead to preventable conditions such as pressure sores, infections and falls. If you understand what is involved, the process of getting your gear will make more sense.

This document provides general information that is common among most health insurance carriers, including procedures used by insurance companies to determine whether or not they will pay for DME. In this paper the word “insurance” will be used to refer to private health insurance as well as Medicare and Medicaid/ Medi-Cal. For specific information about what your insurance carrier generally covers, consult their “explanation of benefits” information, or contact their customer or member service department.

WHAT IS DURABLE MEDICAL EQUIPMENT (DME)?

Durable medical equipment (DME), according to the Centers for Medicare and Medicaid Services (CMS), is a health care device that helps a person with a mobility limitation to conduct activities in their home and community. This includes such items as wheelchairs, walkers, oxygen tanks, communication devices and hospital beds. The Centers for Medicare and Medicaid Services (CMS) defines durable medical equipment (DME) as any equipment that:

1. Can withstand repeated use

2. Is primarily and customarily used to serve a medical purpose

3. Is not useful to a person who does not have an illness or injury

4. Is appropriate for use in the patient’s home

What Are Some Examples of DME?

DME is considered to include:

¨  Equipment that can help you to get around more easily such as canes, crutches, walkers, wheelchairs or scooters.

¨  Equipment that you may need to care for yourself at home such as hospital beds, raised toilet seats, oxygen tanks, or machines that make breathing easier.

¨  Equipment that can help you to hear or see better like hearing aids or magnifiers.

DME does NOT include:

¨  Equipment that is considered “items of personal convenience” or reusable items, such as rubber gloves, catheter tubing, or irrigation kits.

¨  Equipment that is not considered to be for “medical use,” such as grab bars, lifts or shower chairs.

¨  Equipment used exclusively outside of the home is often labeled recreational or “used to pursue leisure interests” and may not be covered as DME.

WHO CAN GET DME?

People who are admitted to hospitals and skilled nursing facilities for surgeries, illnesses or injuries will get the equipment they need before being discharged. In these situations, the equipment that people receive depends on why they were in the hospital. For example, if you go to a hospital for a hip replacement, the hospital will probably send you home with a walker and a raised toilet seat.

The process for getting DME without being in the hospital is different. You can pay for any piece of durable medical equipment yourself. However, because it can be expensive, people usually use their health insurance to pay for DME. Insurance carriers have different guidelines for what equipment they will pay for. For example:

Medicare pays for DME when you:

1.  have Medicare part B;

2.  have a doctor prescribe a covered item of DME; and

3.  need the device in order to function in your home.

(The Centers for Medicare and Medicaid Services, 2005)

Medicare will pay for a person’s DME when “…beneficiaries who experience functional limitation of mobility are functionally hindered in their ability to perform mobility related aspects of daily living, such as toileting, feeding, dressing, grooming and bathing.” (Claypool, 2005)

For example, if you cannot participate in any daily activities where you need to stand for a long time, if you cannot walk to the bathroom or to the kitchen, or if you are unsteady, you may be eligible to have your insurance carrier pay for your DME.

When you request that your insurance carrier pay for your DME, there are specific things that they will want to know. Your insurance company will be looking at your physical, cognitive and emotional limitations and abilities, your willingness to use the DME on a regular basis, and whether you could use this device safely in your home. You must send this information to your insurance carrier, which will decide whether or not it will pay for the equipment.

The evaluator will consider the following issues:

1.  Physical Limitations:

¨  Do you have weakness?

¨  Do you get tired easily, have decreased range of motion, coordination or sensation?

¨  Do you have a condition that prevents you from doing everyday tasks in your home without a mobility device?

2. Mental Capacity:

¨  Can you understand how to use a mobility device safely?

3. Physical Capabilities:

¨  Are your strength, speed, endurance, range of motion, coordination, and sensation sufficient for you to use a mobility device safely?

4. Home Environment:

¨  Are there obstacles like furniture that would make it hard for you to use a wheelchair in your home?

¨  Are there stairs that would be a barrier to wheelchair use?

¨  Is the distance too far to walk with a walker, or too short for you to need a wheelchair?

5. Willingness:

¨  Would you use the device regularly, or would it sit in a corner of your home or workplace?

(The Centers for Medicare and Medicaid Services, 2005; Medicare Payment Advisory Commission, 2004)

How Do You Get The DME You Need?

Once you decide that DME is the right choice for you, there are several steps involved in getting it. If you are able to pay for the equipment yourself, you can go to any DME vendor in your area that has the equipment you would like and you can purchase it. Depending on whether it’s in stock and available, you may be able to pick up the DME immediately or usually within several weeks. However, DME is often very expensive and many people cannot afford to purchase DME on their own. Most people need to use their health insurance for financial assistance. In order for your insurance company to pay, there are specific procedures that must be followed. These steps are shown in Figure 1 and explained below.

Figure 1. Steps To Get Your DME

STEPS TO GET YOUR DME

1. Talk to your doctor

Getting DME begins with talking to your doctor about your need for equipment. Some questions to ask yourself and to discuss with your doctor, depending on your situation and needs, are:

1.  Are you able to get around in your community and into the places you need to go (work, supermarket, library, doctor’s office, etc.)?

2.  Do you feel safe while you are doing everyday activities or would you feel safer with something to support you?

3.  Do you fall? How often? What time of day? During what specific activities?

4.  Do you know of a piece of equipment that might work well for you?

5.  Could you support yourself on a walker, or are your arms too weak or do you have too much pain?

6.  Do you need a wheelchair or scooter in your house to get around?

7.  Does the wheelchair you have fit in your house?

8.  How far can you push your manual wheelchair without getting tired?

9.  Are your arms too weak to push a manual wheelchair?

10. Is your wheelchair too heavy to lift into your car? If you had a lighter wheelchair, could you lift it independently?

2. Decide what kind of DME may be best for you

Your diagnosis or disability is not clear enough for doctors and suppliers to determine what mobility device or other DME would be best for you. What is best for one person may not be good for someone else. It is important to determine which piece of equipment would be best for you based upon how it would improve your ability to participate in daily activities. Take, for example, two people who each have Multiple Sclerosis. One person may need a power wheelchair to get from one place to another. The other person may need a cane for support. Both have the same diagnosis; however, their needs for DME are very different.

Research the available equipment options and discuss your needs with your doctor. Together you can come up with the best option for you. Along with speaking with your doctor, the process of obtaining DME includes an evaluation done by a physical therapist, occupational therapist or another health care professional often in conjunction with a supplier who will know more about the different types of equipment.

The best piece of equipment for an individual is often the device that can offer the least amount of support with the greatest amount of success. For example, if you can get to the bathroom and stand and brush your teeth with a cane for support, then a power wheelchair would get in the way. However, if you are able to walk with a cane, but then get too tired from walking to brush your teeth once you get to the bathroom, then a wheelchair may be a better choice.

If you are unfamiliar with DME and how it works, you should consider:

¨  Visiting DME vendors. They will have samples and know of stores where you can look at some options (see information below on how to find a DME vendor in your area).

¨  Speaking to other DME users. Talk with friends and others to find out their experiences and recommendations.

¨  Using the Internet to learn more about DME that may be right for you.

There are three aspects to consider when deciding what equipment might be best for you:

¨  Your functional limitations and abilities;

¨  Your home environment; and

¨  Your safety.

It is important to discuss these areas with your doctor and the DME evaluator. (See also step 5, below.)

3. Your doctor will write a prescription for DME

Have your doctor write a prescription for the type of DME that the two of you decide is best. Your doctor may give you additional forms that you will need to give to the DME vendor. If your doctor does not have these forms, they will be available through the DME vendor. The doctor who provides the DME prescription will also have to sign these forms.

4. Take the prescription to a certified DME vendor

What is a DME vendor?

A DME vendor is a company that specializes in DME. DME vendors have staff who are experts in equipment. Some are physical therapists (PT), occupational therapists (OT) and certified rehabilitation technology suppliers (CRTS). The vendors work with the companies that make the equipment as well as your insurance carrier.

How do you find a DME vendor?

Your health insurance carrier may allow you to choose your own DME vendor. However, your insurance company may have a recommended DME vendor, and they may only pay for equipment you get through this vendor. Many times the DME vendor who has the contract for your insurance may not be the best qualified to handle your needs. Ask your insurance carrier what you may do if you are not satisfied with their vendor. You are the consumer!

If you have a choice of vendor:

1.  Your doctor can recommend a DME vendor.

2.  Ask your friends if they can recommend a DME vendor in your area.

3.  Telephone your local drug store, pharmacy or medical supply company and ask if they know of DME vendors in your area.

4.  Look in the yellow pages under hospital equipment and supplies, surgical appliances and surgical supplies.

5.  Look on the internet for DME. You can type “durable medical equipment” into any search engine such as “Google”.

Before you choose a DME vendor, ask questions, such as:

1.  What equipment is available that fits your needs?

Do they carry the brand of product you prefer?

2.  What equipment will your insurance carrier pay for?

§  Will your insurance cover part, or all, of the cost of the equipment? How much expense will be out of pocket for you? (Sometimes it is worth paying for what your insurance will not cover to get what you need. For example, if you really want a certain kind of seating but are only eligible for standard seating, it may be worth paying the extra cost to get what you need and want.)