AS DURABLE MEDICAL EQUIPMENT (DME) becomes increasingly sophisticated, MCOs' challenges remain rooted in establishing medical
necessity. To that end, most use strategies including prior authorization and coverage limits. Meanwhile, they must also satisfy
changing state and national regulatory requirements.
MAXING OUT
At Medical Mutual of Ohio, "we've had requests for things like vacuum cleaners or air conditioners because patients feel they're
medically necessary," says Debbie Toomba, the company's director of care management. However, she says if a requested item
has any non-medical purpose, "then it's generally not a covered service," in accordance with CMS guidelines.
Virtually all of Medical Mutual's 1.6 million members have DME coverage, with prior authorization required on big-ticket items
such as power wheelchairs and specialty beds, the latter of which can cost up to $50,000, she says. Somewhat similarly, Toomba
says Medical Mutual uses maximum dollar limits per benefit-calendar year in a few categories. With items such as hospital beds and wheelchairs, Toomba says, the plan allows the patient to rent them, and then the policy
caps out once reimbursement reaches a purchase price. This way, there's no ongoing reimbursement if the patient requires the
equipment long-term.
MHE EXECUTIVE VIEW
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Medicare indicates which equipment caps to purchase or which can be paid at an ongoing rental.
"Generally CMS will allow ongoing rental to be paid on DME that may need service, such as a home ventilator, because that's
a piece of life-support equipment," she says. "This allows the DME company to come out and check the equipment monthly to
make sure that it's working properly."
Reimbursements for this type of equipment don't cap out so that patients don't have to buy a ventilator, for example, and
keep it after they no longer need it, she says.
Items most commonly requested by Medical Mutual's members include:
- wheelchairs (manual and powered);
- hospital beds;
- ventilators; and
- continuous positive airway pressure (CPAP) machines for patients with sleep apnea.
"Generally," she says, "members have a DME benefit, and if requested equipment meets medical necessity guidelines, it's a
covered benefit."
CATEGORY TWEAKING
MCOs also must adapt to changing regulatory requirements, sources say. For example, effective July 1, Blue Shield of California
established a separate benefit category for prosthetic and orthotic devices for plans offered to employer groups in order
to comply with a modification to state law, says Elise Anderson, a company spokeswoman.
In compliance with the law, she says, Blue Shield removed any annual dollar maximums being applied to prosthetic and orthotic
devices, although these devices would still be subject to any overall plan deductible applied to most covered services. Blue
Shield also modified copayment requirements in group plans so that members are responsible for office visit copayments only
if such visits are billed to fit or prescribe a device.
"Before this law was enacted prosthetic and orthotic benefits in some group plans had different benefit maximums, deductibles
and copayments than those applied to basic health services," Anderson says. "But now the benefits are on par with medical
benefits, including maximums, deductibles and copayments."
UP FOR BIDS
CMS's Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) competitive bidding program also could
impact health plans' DME benefits, according to Peter Clendenin, executive vice president of the National Association for
the Support of Long-Term Care. Last month marked the close of bid submission for the program's first round, with winning bidders
to be announced by April 2008, he says.
