Helping someone who has trouble moving or helping themselves requires a lot of strength, flexibility, and energy. Many times, unexpected movements cause muscle strain or back injuries. Special transfer or moving equipment (often called durable medical equipment or DME) helps reduce the risk of these injuries, but the cost is high. Before buying any medical equipment, look at your insurance contracts under the durable medical equipment section to determine what is covered and what you must do to receive payment. Insurance may help cover a portion or maybe all the equipment cost if you follow their requirements and get prior approval for the purchase. However, it’s almost impossible to get paid if you buy it and ask for reimbursement later.
New caregivers have two primary challenges related to assessing equipment needs.
- What type of equipment do they need? (Brand, device, features)
- How do you obtain prior approval for the equipment from insurance?
Type of Equipment Needed
Your options for DME medical equipment range from many to one. Most medical equipment companies push their products to customers through hospital and physician office contacts. For equipment with bells and whistles used by a limited population group, purchase options are sparse and, of course, cost more.
Deciding what equipment to buy is difficult; however, it’s important to consider that many DME companies contract with healthcare providers to push their products. Each company hires a therapist who “talks the talk” and works on commission to influence hospital and physician office purchase managers to buy their products. The therapist says all the right stuff to assure the provider that their product is best so that when you come into the office, your provider hands you the therapist’s literature first. You have several options to consider most of the time, with one recommended above the rest. The DME company that promotes their product the best gets the esteemed recommendation.
So, whom should you trust? Fact is, no one is ever totally non-biased. Your doctor knows best what you need versus what’s available; however, they are not always the most knowledgeable about the equipment. That person is usually a physical medicine or rehabilitation therapist or provider for therapy equipment. Knowing your family member’s baseline, potential recovery maximum, and estimated timeframe for achievement is essential in making an educated guess. In addition, therapists know which companies sell DME equipment in your area and their customer service reputations.
Tip: Remember to buy safety equipment if the manufacturer recommends it and use it as directed. Individuals with immobility limitations may not prevent an injury from occurring to themselves. It’s up to you to put safety measures in place to protect them.
How to Establish Medical Necessity
Before purchasing any expensive equipment, always confirm with your insurance company whether you need pre-authorization to obtain reimbursement for the expense. Insurance companies only approve payment under pre-authorization if they believe the equipment is medically necessary. If pre-authorization is required and not obtained, you lose the option of financial assistance for the expense.
What does “medically necessary” mean? The equipment must treat or prevent an illness, injury, condition, disease, or symptoms and meet accepted medical standards for the use requested. When you submit a reimbursement request for review to Medicare or Medicaid, the reviewer will look for the following criteria:
- Is it Durable (can it withstand repeated use)?
- Is it used for a medical reason that the patient has as a diagnosis?
- The equipment is usually not useful to someone who is not sick or injured.
- The patient will use the equipment primarily at home, not for work.
- The lifespan of the equipment should be for at least three years or longer.
If you receive pre-authorization under Medicare for purchase, you pay 20% of the Medicare-approved amount, and the Part-B deductible applies. If you have secondary insurance, it may help pay the difference in the cost. If you are using private pay insurance, you need to look at your coverage’s durable medical equipment section before purchasing equipment to determine your co-pay and pre-authorization requirement. If you don’t, you may find out too late that you are stuck with an expense you could have avoided with advanced planning.
Medicare covers the following DME supplies:
- Blood sugar meters
- Blood sugar test strips
- Commode chairs
- Continuous passive motion devices
- Continuous Positive Airway Pressure (CPAP) devices
- Hospital beds
- Home infusion services
- Infusion pumps & supplies
- Lancet devices & lancets
- Nebulizers & nebulizer medications
- Oxygen equipment & accessories
- Patient lifts
- Pressure-reducing support surfaces
- Suction pumps
- Traction equipment
- Wheelchairs & scooters