What is Durable Medical Equipment and Will My Medicare Pay For It?
By Julia A. Keirns
I work for a durable medical equipment (DME) company and deal with patients every day. Many patients will come to us straight from their doctor office with a prescription for some type of equipment and instantly expect it to be covered by their Medicare simply because the doctor ordered it. That is not the case.
Medicare has many rules and guidelines, and as a DME company, it is our responsibility to follow those rules and guidelines. From my many years of experience, I would like to highlight some of the more common misconceptions that we deal with daily.
Number 1 — Only Medicare Part B (or a Part C Medicare Advantage Plan) will cover certain DME items. Medicare Part A is hospital coverage only. If a patient has Part C, depending on which advantage plan they have, we may not be in the network with that particular plan. Just because we are a Medicare Provider does not mean we participate in every advantage plan. We are located close to the state line and have found a few plans from the other state that will not let us in their network. They only participate with providers in their own state.
Number 2 — In order for us to give the requested item, it is our job to make sure the doctor has filled out the prescription correctly. The prescription must contain the patient name and date of birth. It must contain the doctor’s full name and NPI# and the date the doctor signed it. It is important right here to mention that a prescription is not valid if signed by a nurse. The prescription must state the item needed, left or right (if foot, leg, arm, or hip) and a diagnosis. It is not acceptable to call the doctor to ask for an item and get a prescription without physically seeing the doctor in person. If the written prescription is not correct, we cannot fill the order. Patients get so upset at this one and usually take it out on us insisting that we are the ones being difficult.
Number 3 — Medicare and Medicare Advantage Plans will only pay 80% of the fee schedule that Medicare sets. As a company, we do not set our own fees. Medicare tells us how much that item is worth and they pay 80% of that fee. The remaining 20% must, either be paid by the patient, or by their supplement plan if they have one. Yes, we bill a higher amount for an item, but I try to tell patients not to worry about the amount billed. We will only get that set fee and the rest will be adjusted off anyway.
Number 4 — Not all equipment is covered by Medicare. For example, no matter what the diagnosis is, an arm sling is never covered, and neither is a post-op or surgical shoe. These are non-covered items. Therefore, even if the patient has a broken arm and the doctor orders them to wear an arm sling, their Medicare plan will not pay for that item, and neither will a supplement in most cases. Some of the advantage plans might cover an arm sling, but none of them covers a post-op or surgical shoe.
Number 5 — Not all diagnosis codes are covered. An ankle boot is covered if the patient has a broken foot or ankle, but not if it is just foot pain for example. Medicare will determine a pain diagnosis only as not medically necessary. Additionally, knee rollabout scooters are not covered. Medicare presumes that a pair of crutches will work just fine.
Number 6 — Medicare will not pay for any bathroom safety equipment such as grab bars, safety rails, elevated toilet seats, bath chairs, or transfer benches. These are non-covered items. A commode will be covered only if it is needed by the bedside because the patient cannot get to the bathroom.
Number 7 — Many items are not purchased but are only rented as capped rental items. For example, CPAP therapy is increasing and many patients are being diagnosed with sleep apnea. A CPAP machine is a capped rental item, same as a wheelchair. Medicare pays a rental fee for 13 months and then considers the item owned by the patient. For example, patients will get set up on a CPAP machine in June and their Medicare will pay their 80% until January 1. Then the patient has a small deductible they must pay before Medicare will pick up their 80% again for the remainder of the 13 months. This year, 2020, the Medicare deductible was $198.00. It seems that every year it goes up, so it would not surprise me if the deductible were over $200 next year. Granted, some patients have a supplement plan that pays their deductible for them, but some do not.
Number 8 — There is a lot of paperwork involved in giving an item that is billed to Medicare. Many patients walk in expecting to receive an item in 5 minutes and are not happy when it takes 30 minutes to put them in the computer system, print all of the required paperwork, verify the insurance and sign everything. It takes time.
Number 9 — Oxygen is a drug and we cannot give out oxygen tanks without proper documentation. When a doctor orders oxygen for a patient, they cannot just walk in to the store to get it. We must verify documentation first. It is also important to note that the patient will never own any of their oxygen equipment. The equipment is always rented. It will remain owned by the company and maintained by the company.
Number 10 — If Medicare did not buy an item for the specific patient, such as a wheelchair or walker purchased at a garage sale, then Medicare will not pay to fix or repair the item. This one always amazes me. Another fact is that patients are only allowed to have one walking aid, such as a cane or walker, every five years.
There you have it — those are the top ten misconceptions that I seem to hear on a regular basis. There are many rules and regulations that we have to follow as a Medicare provider. One final request to all Medicare patients — please be kind and patient with DME customer service representatives. They are all just trying to do the best they can.