DME coverage guided by medical, regulatory necessity

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.

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.

"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:

"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.