No one looks forward to a hospital stay, most everyone looks forward to the day they are discharged and get to go back home. Whether you live in a private home, assisted living facility or Independent living, the day you get to go home should be met with a sense of rehabilitation after your stay. In most cases, the need for Home Medical Equipment (HME) or any times called Durable Medical Equipment (DME) is needed for the continuum of care.
In order to get the equipment from your insurance company, there is required documentation that is preset by your insurance company that is needed in order for the HME provider to get reimbursed for their services. This is many times where the discharge goes horribly wrong. Hopefully this article will help clear up some of the reasons why this becomes a problem upon discharge, some of the solutions and how you may be able to help.
First you have to understand the medical equipment provider’s role and what is required of the provider in order to be reimbursed for their services. All providers need a written prescription from the doctor for the medical equipment the doctor feels is needed.
On that prescription it must have the following:
- Name of the patient
- Date of the prescription
- What equipment is needed
- The ICD-10 codes which explains the diagnosis
- The doctors signature
- The doctors NPI Number
If these criteria are not met, sometimes the delay starts with the prescription being incorrect. Let’s suggest for this example that the prescription was perfectly executed.
Next, the provider must have the doctors notes as to why the doctor feels this equipment is needed. This also means that the doctor feels as though your prescribed equipment is “medically necessary” for your health. You may want something to help you recover, but the doctor must prove medical necessity in the notes to determine if the insurance company will pay the claim. In most cases, this is where the discharge is delayed. We will use an example of a patient who broke their hip and is now being sent home, but the family wants a hospital bed to make the recovery easier.
As we stated, the insurance companies have predetermined criteria for receiving medical equipment. If you broke your hip, or your leg, that is not necessarily the criteria requested for a hospital bed to be medically necessary. Many times, you may know that there is no way that the patient can get in and out of their ordinary bed in their condition, so if that piece of equipment is wanted, it must show medical necessity to meet the insurance guidelines. Make sure you know what the criteria for Home Medical Equipment from Medicare are. Most all insurances follow Medicare Guidelines for medical equipment.
When you are going through the discharge process, you are given a “discharge case manager” who will help you through the process and signing the papers for release. This is the time when you find out what medical equipment your doctor feels you need. Please note that this is what the doctor feels you need, however, that doesn’t mean that it’s what you qualify for according to the guidelines. Very frustrating to most.
The medical equipment the doctor feels you need will then get faxed to an HME provider of your choice, or a provider they choose for you. The notes must go to the HME provider or they will not accept the order. Sometimes the process stops here and the patient has no idea why. Did the case manager fax all the necessary paperwork to the provider? Since this alone will stall many discharges, you may want to ask who they faxed the prescriptions and call the provider to ask if they received all the paperwork, they need to make a delivery.
Another delay in discharge may be if the case manager says to you, “Your insurance will not cover that item.” Many times, that is not true. You should call the HME provider directly and ask what is needed to qualify for the medical equipment, and most will tell you, and then you can speak to your doctor again.
Just as a reminder, just because the doctor would like you to have a piece of equipment does not mean that you will get it because you must qualify according to your insurance benefits guidelines. Wanting and needing the equipment does not necessarily mean you will not get the equipment.
Here is another situation. Let’s take the hospital bed client who broke their hip, and they find out that they do not qualify for the delivery, but another client who broke their hip, does qualify and gets the hospital bed, why is that?
One reason could be the doctor’s notes being thorough, or another reason may be due to a secondary health issue or diagnosis. For example, one patient breaks their hip but they have no other health issues, whereas the other patient has COPD, a heart condition, or a neurological condition that requires their head to be elevated more than 30 degrees. Having your head raised with certain conditions, speed the recovery and medically necessary for the health of the patient.
Examples of notes providers look for are:
- Height and weight
- Complete doctor’s notes that meet the patient insurance criteria (most use Medicare as their guideline)
- Heart, Lung, Brain or spinal cord issues as a secondary condition
- Length of need
The provider makes the final determination on whether they will accept the order and set a time for delivery.
Ultimately it is the medical equipment provider who is accountable to the insurance company they are billing. The provider is allowed to bill the insurance company only after the delivery is made and all the medical papers are signed by the beneficiary. When the provider sends the claim to the insurance company, that tells them that they have all the necessary medical notes and prescriptions in their files that meet the reimbursement criteria and compliances according to their contract with the insurance company. Therefore, the provider is dispensing equipment after all this process is met, if it is not met, that may delay your discharge.
Let’s assume for this example that the provider does not accept. What do you do now? The hospital is going to release you but the doctor states the medical equipment is necessary for you to have a safe discharge but the provider states it does not meet criteria. In this instance, the hospital case manager is working hard to find a providing company who will accept the paperwork to make the delivery. The hospital is accountable to make the discharge a “safe discharge” so that you can recuperate at home. If it is not a safe discharge, and they discharge you anyway, if you end up going back to the emergency room to be readmitted, the hospital is penalized from the insurance company and their reimbursement is also in jeopardy of being paid. It’s easy to see how delays in the discharge can be complicated.
Verification of benefits
Most times, the provider does not get the request for the medical equipment until the last minute and you are waiting to go home. In that periods the provider must get all the information that was previously explained, and then must run your verification of benefits. Sometimes the beneficiary has had the equipment requested in the past and they do not qualify to get the equipment again. The normal rule of thumb is that you can only get that same piece of equipment one time within a 5-year period. For example, 1 wheelchair within 5 years no matter what type you received. Only 1 bed within the 5-year period, and so forth. You may not qualify due to that rule.
As you can see, the provider has very little time to prepare for a delivery to the hospital or home within the few hours that they are given. That in itself could delay the delivery as well since they may not be able to meet the timing of the hospital s quick discharge.
What are your options?
When a patient doesn’t meet the medical criteria to obtain the medical equipment that is needed, there are 2 options to complete the discharge.
- You can rent the medical equipment from a provider for the next month until you get the proper paperwork. If you do plan to rent, make sure you get the medical notes before you leave the hospital because the attending physician will no longer be accountable to give you anything further after discharge. The hospital will no longer be accountable or willing to help after you are released from their care, so get whatever qualifying documentation you can at the time of your discharge. You will now need to get whatever paperwork is missing from your primary care physician and they will write new prescriptions if they feel the equipment is medically necessary. Your primary care physician may or may not be willing to complete the paperwork required. Renting the equipment while you work these things out is many times imperative for the recuperation period and your only option.
- You can buy the equipment needed for your recovery. Call a local provider to see what you can do to get the proper equipment delivered to your home. This out of pocket expense can go toward your insurance deductible and medical expenses.
Lastly, it is always good to be prepared. Ask the case manager during the stay what they feel what medical equipment may be needed at discharge – it is important to know what the Medicare criteria is for the medical equipment or call Affordable Medical Supply, and they will help you through the discharge. For over 41 years the staff at Affordable Medical Supply has helped families save money and get the equipment necessary for a recovery in your own home. Call them today t see how they can bring their services to your door.