DME for quality of life: When patients need more than a hand

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1 By Nancy Lyons, BS Pharm MBA CDE, director, continuing education and clinical content, Drug Store News; and principle clinical and management consultant, NLCM Consulting Author Disclosures: Nancy Lyons and the DSN editorial and continuing education staff do not have any actual or potential conflicts of interest in relation to this lesson. Universal program number: H04-T Activity type: Knowledge-based Initial release date: July 22, 2015 Planned expiration date: July 22, 2018 This program is worth 1.0 contact hour (0.1 CEUs). This lesson is supported by an educational grant from Drive Medical DME for quality of life: When patients need more than a hand Target Audience Pharmacy technicians in community-based practice. Program Goal The goal of this lesson is to provide the community technician with a foundation of knowledge needed to be a resource for patients with durable medical equipment needs. Learning Objectives Upon completion of this program, the technician should be able to: 1. List examples of durable medical equipment. 2. Review conditions and procedures that may require devices to allow patients to return home. 3. Define DMEPOS requirements for community pharmacies. To obtain credit: Complete the learning assessment and evaluation questions online at DrugStoreNewsCE.com. A minimum test score of 70% is needed to obtain a statement of credit. Your statement of credit will be available at CPE Monitor (NABP.net). Your correct e-pid number must be included in your DSN CE profile to ensure transmission of credit to CPE Monitor. Questions: Contact the DSN customer service team at (800) Cost: There is no cost to complete this program. Drug Store News is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. INTRODUCTION The Administration on Aging, or AOA, a part of the U.S. Department of Health and Human Services has assembled a great deal of data that proves what most Americans already know. The United States population is aging. 1,2,3 To offer further support, the Centers for Disease Control and Prevention/U.S. Department of Health and Human Services report, The State of Aging and Health in America 2013, has called the projected shift in the number and proportion of older adults in America unprecedented. 2 At no other time in history will we see such a change in the population charts and the associated needs of the members of the majority demographic. In the next 25 years, the population of Americans ages 65 years or older will double to just more than 72 million. By 2030, adults 65 years and older will make up 20% of the U.S. population. The report goes on to identify the two primary factors leading to this unprecedented growth. Those are, of course, the aging of the baby boomers and the dramatic advances in health and wellness that have extended life expectancy by nearly 30 years just in the last century. 3 To illustrate the impact of medical advances, in the early 1900s our ancestors reported leading causes of death to include pneumonia, tuberculosis, diarrhea, enteritis and diphtheria. 4 Through immunization, antibiotics and general improvements in surgery and other medical interventions, these leading causes were defeated. While heart disease and cancers were on the list of leading causes of death in 1900 and remain on the list today, numerous advances have been made in these areas that have improved outcomes and lengthened lives, even if a cure isn t available. In the coming years, community pharmacy will be affected dramatically by this shift and other factors. In addition to the obvious healthrelated needs of an aging population, a great deal of data also is available pointing to earlier needs and overall demand for healthcare products and services for younger populations. While some of this demand in the younger populations is driven by a quest for prevention and wellness, the demand for healthcare products and services also is driven by medical needs resulting from unhealthy habits and sedentary lifestyles leading to conditions previously present predominantly in older populations. For example, Type 2 diabetes, a condition previously diagnosed mainly in middle age, now is a more common diagnosis in adolescents and younger adults who are overweight or obese. 5 If an individual lives with diabetes 10 to 15 years longer, the complications that uncontrolled diabetes can cause have 10 to 15 additional years to develop and present. Obesity also is being linked to other healthcare issues beyond diabetes and the common co-morbid conditions. The American Academy of Orthopaedic Surgeons published a report in 2014 linking an increase in knee replacement surgeries in younger individuals to the growing obesity epidemic that has been evident for the past several decades. 6 This report adds to the mounting evidence that the U.S. population will have significant needs for healthcare services and products over the coming decades. THE COMMUNITY PHARMACY TECHNICIAN WORKING TO HELP PATIENTS ACHIEVE HEALTHCARE GOALS With all of the population and condition changes that are predicted in the coming decades, there is another projection that will complicate care 1 JULY

2 delivery. A report prepared for the Association of American Medical Colleges projected that there will be a shortage of between 46,100 and 90,400 physicians by As healthcare needs grow and fewer physicians are available, other healthcare resources will need to be leveraged to fill in the needs and collaborate with the patient and the physician to ensure efficient and effective care delivery. As a community pharmacy technician often working closest to the patient, you are uniquely positioned to be an advocate for patients in raising awareness of healthcare services and products that are available to assist patients in meeting their healthcare goals. This is especially important when patients need solutions for acute or chronic illnesses and injuries that can limit physical and/or mental function. Assisting patients in finding the best equipment to manage their condition can be a very rewarding experience. UNDERSTANDING DURABLE MEDICAL EQUIPMENT TERMINOLOGY DME defined According to the Program Operations Manual System, or POMS, of the Social Security Administration, durable medical equipment is equipment that: Can withstand repeated use; Is primarily and customarily used to serve a medical purpose; Generally is not useful to a person in absence of an illness or injury; and Is appropriate for home use. 8 Durability is further defined by the manual as an item that could withstand repeated use, such as an item that could be rented. The manual includes descriptions of items that would not be appropriate for repeated use, thus failing the durability test, and such items as prosthetics and orthotics that, while durable, are classified differently. 7 Common examples of durable medical equipment are listed in Table 1. Additionally, CMS guidelines are present that place limits on billing for equipment that originally wasn t intended to have a medical purpose. The terms presumptively medical and presumptively nonmedical are contrasting definitions. Presumptively medical equipment examples are listed in Table 1 and are best described as products that were developed and marketed first Hospital beds Respirators Crutches Trapeze bars Inhalators Bedside commodes Wheelchairs Breathing machines (CPAP) Canes Walkers Nebulizers Suction machines Table 1 Common DME examples CATEGORY EQUIPMENT EXAMPLES PRIMARY SUGGESTED USE Mobility aids Crutches Relieving stress on leg to allow proper healing Canes Knee roller Walkers standard, metal Rollator/deluxe with seat, storage and other features Wheelchairs Powered scooters to meet a medical-related need. Presumptively nonmedical equipment examples include such devices as heaters and humidifiers, among others. These are devices that, while the effects of the device may have a positive impact on the health of the patient, originally were intended for a general, nonmedical purpose. 8,9 Prosthetics and orthotics defined CMS separates prosthetics and orthotics from standard durable equipment classifications listed above. These designations will determine coverage and authorized provider limits. In order to supply patients with prosthetics and orthotics, separate policies and procedures must be documented, including having qualified individuals on To help maintain balance and support Bath safety Bath benches To allow rest while bathing Shower sprays Bath mats Raised toilet seats Grab bars and rails Replacement solution for crutches that allows an individual with lower leg damage to keep weight off healing limb and move about more easily To provide balance and to assist with support when standing or sitting To provide balance and instill confidence when walking on longer trips To provide safe transfer from one area to another; powered options are available To allow those who may have a mobility issue freedom to move around without assistance of others To allow directed flow of water To avoid slips and falls To avoid excessive bending while going to the bathroom To provide stability Beds Adjustable support or elevation To allow comfort Breast pumps Hand-held device To allow a nursing mother to express breast milk Activities of daily living aids Respiratory devices Grabbers Dressing aids CPAP machine Nebulizer Table 3 Common types of prosthetics To allow items to be picked up with limited reach Devices to allow the patient to more easily perform dressing or simple self-care tasks As recommended by the physician For delivery of asthma medication Table 2 Presumptively medical equipment examples TYPE DESCRIPTION/PRIMARY PURPOSE Ocular Facial Somatic External breast staff who can properly fit and educate patients if products other than minimal selfadjustment equipment will be sold. Therapeutic shoes and inserts also are classified separately from durable medical equipment and have specific processes similar to orthotics guidelines that must be in place in order to provide the services to patients needing therapeutic shoes. Prosthetics The term prosthetics is defined as nondental devices that replace all or part of an internal body organ, including tissue, or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ. Common types of prosthetics are listed in Table 3. 9,10 Custom-made to replace or cover an eye after a traumatic injury, surgery, disease or malformation Custom-made to restore an area of the face disfigured by a traumatic injury, disease or malformation Custom-made to replace a non-ocular or non-facial area, such as a finger, thumb, partial/entire hand or toe, after a traumatic injury, disease or malformation Custom or prefabricated forms, bras or sleeves to replace breasts that have been removed JULY

3 Orthotics The term orthotics is defined as rigid or semi-rigid devices used for the purpose of supporting a weak or deformed body part, or for restricting or preventing motion in an injured or diseased body part. In order to provide custom-fitted orthotics, a certified orthotist or an individual who has received specialized training must work with the patient to secure the measurements for a custom-made item or adjust a customfitted item. A certified orthotist must gain certification from the American Board for Certification in Orthotics and Prosthetics Inc. or the Board for Orthotics/Prosthetist Certification. Off-the-shelf or minimal selfadjustment orthotics do not require the services of a certified orthotist or individual with specialized training. 9,10 DMEPOS COMPETITIVE BIDDING The multi-phase Medicare competitive bidding program began in January The competitive bidding process was a part of the Congress-mandated Medicare Prescription Drug, Improvement and Modernization Act of 2003, or MMA. 11 The MMA program was designed to update and improve the CMS payment structure for selected items that previously was in place for patients covered by traditional Medicare. MMA requirements are applicable only to patients covered by traditional Medicare. Medicare Advantage HMOs and PPOs and commercial insurance companies may or may not require suppliers to participate in competitive bidding as a condition of providing equipment. In the competitive bidding process, the rules were changed for suppliers of durable medical equipment, prosthetics, orthotics and medical supplies, or DMEPOS. The goals of the program were to update pricing schedules to reflect more current and competitive rates, to improve the quality of services and supplies for the patient, and to Table 4 DMEPOS initial Round 1 competitive bidding areas CBA Charlotte-Gastonia-Rock Hill Cincinnati-Middletown Cleveland-Elyria-Mentor Dallas-Fort Worth-Arlington Kansas City Miami-Fort Lauderdale-Pompano Beach Orlando-Kissimmee-Sanford Pittsburgh Riverside-San Bernardino-Ontario reduce/eliminate fraud, waste and abuse related to billed charges. With the competitive bid process, both Medicare beneficiaries and the government would pay reduced copayments and overall charges for equipment and supplies needed. Process basics Within DMEPOS competitive bidding, suppliers are divided into particular competitive bidding areas, or CBAs, to normalize differences in supplier business operating costs and other regional criteria. For example, a supplier in the rural midwest would be expected to have different costs related to rent, labor, delivery vehicles, etc., as compared with a company operating in an urban area with higher costs of living and working. When bidding, suppliers interested in becoming a CMS-contracted provider are required to submit an electronic bid for selected products using a Web-based tool. Once received, all bids are evaluated by CMS based upon the following criteria: 1. The supplier s submitted bid price; 2. The supplier s overall financial stability; 3. The supplier s ability to meet the quality standards and requirements; and 4. The supplier s agreement to accept assignment on claims for all bid items. Once the bidding process is closed and contracted providers are confirmed, the fee paid by Medicare for DMEPOS competitive bid selected products will be the median of all winning bids per item within that CBA. Medicare has contracted with an independent provider to manage the competitive bidding submission process. A number of tools, worksheets and process guides are available on the DMEPOS competitive bidding program website: DMEcompetitivebid.com. 11 STATES North Carolina and South Carolina Ohio, Kentucky and Indiana Ohio Texas Missouri and Kansas Florida Florida Pennsylvania California Competitive bidding schedule DMEPOS competitive bidding for original Medicare was phased in beginning in January 2011 with Round 1. The initial phase included suppliers serving nine CBAs. Round 2 began in July The second phase greatly expanded the number of CBAs to 91. July 2013 also marked the initiation of the national mail-order contracting process for diabetic testing supplies. This process required mailorder suppliers to complete a contracting process with Medicare in order to provide diabetic testing supplies for Medicare beneficiaries through the mail. The goals of this process were the same: to control costs for both beneficiaries and the government, to improve the quality of the services provided to members, and to reduce/eliminate fraud, waste and abuse related to claims for diabetic testing supplies. While Medicare beneficiaries are not required to use mail-order sources for diabetic testing supplies, they are required to use a contracted mail-order supplier when choosing to receive supplies by mail. 10,11,18 Recompete process As a part of the DMEPOS competitive bidding process, CMS is required to recompete contracts for providers at least once every three years. Round 2 supplier contracts and the national mail-order contracts are the next contracts to be rebid, and that process currently is under way. All current supplier contracts for these categories will expire on June 30, 2016, with new contracts effective July 1, CMS decided to shorten the next recompete process for the Round 2/mail-order supplier contracts by setting expiration dates of Dec. 31, Also new, CMS is planning to refine the competitive bidding areas, or CBAs, to prevent areas from covering more than one state. For that reason, the 91 CBAs initially identified will be expanded to 117. CMS also has begun work on the second scheduled recompete for the Round 1 CBAs. Current Round 1 contracts will expire on Dec. 31, 2016, with new contracts to become effective Jan. 1, There will be slight modifications to the defined areas to Round 1 CBAs to follow the guidance of not covering more than one state within a CBA. For that reason, the nine CBAs will be expanded to 13 CBAs for the 2017 bidding process. It is important for the technician to have a basic understanding of the terminology, timelines, requirements and the quality initiatives that are engrained within the CMS processes to assist and to help patients successfully navigate when changes occur. CMS has an online search tool called the Medicare supplier directory that allows supplier searches by zip code: Being able to explain why a patient s oxygen provider may have changed based upon the competitive bidding area in which the patient lives, or which providers in the area are contracted with Medicare and can help begin the process of seeking approval for a wheelchair 3 JULY

4 can help to keep patients on the right path to achieving or maintaining quality of life. DMEPOS in the pharmacy With the changes outlined by Congress in the Medicare Prescription Drug, Improvement and Modernization Act of 2003, pharmacy-related requirements for DME- POS also changed in Durable Medical Equipment Prosthetics, Orthotics and Supplies can be provided by pharmacies, as long as the pharmacy has received accreditation from a CMS-approved independent national accreditation organization, or AO. Alternatively, the pharmacy may be a supplier if it has received a National Supplier Clearinghouse, or NSC, exemption. 12 National Supplier Clearinghouse exemptions Some pharmacies wishing to provide DMEPOS for patients may avoid seeking accreditation by providing necessary documentation, including an attestation statement to the NSC. Requirements for receiving an exemption for accreditation include: 1. Total DMEPOS pharmacy billing amounts are less than 5% of the total pharmacy sales for the previous three years. a. Please note that total pharmacy sales include prescription and OTC department sales only. Pharmacies that are a department within a larger organization may not include total store sales in the calculation. b. Chain pharmacies with more than 25 locations are expected to have difficulty qualifying for an exemption. 2. The pharmacy has been an enrolled supplier of DMEPOS with a provider number for at least five years. 3. The pharmacy has not experienced any final adverse imposed actions in the past five years. 4. The pharmacy submits an attestation of meeting the first three criteria using the approved attestation statement found here: Palmetto/Providers.nsf/files/ WebAttestationStatement.pdf/$file/ WebAttestationStatement.pdf. 5. The pharmacy agrees to participate in annual random audits. Pharmacy accreditation Process overview Because most pharmacies will not qualify for an exemption, it is important to understand the basics of becoming an accredited supplier of DMEPOS. The DMEPOS requirements include a number of opportunities for the community pharmacy technician to support and lead the development and implementation of Table 5 Accrediting organizations DMEPOS suppliers Accreditation Commission for Health Care Inc. (ACHC) American Board for Certification in Orthotics, Prosthetics & Pedorthics Inc. (ABC) Board of Certification/Accreditation (BOC) Commission on Accreditation of Rehabilitation Facilities (CARF) Community Health Accreditation Program Inc. (CHAP Inc.) Healthcare Quality Association on Accreditation (HQAA) National Association of Boards of Pharmacy (NABP)* The Compliance Team Inc. The Joint Commission The National Board of Accreditation for Orthotic Suppliers (NBAOS)** (855) ACHC.org (703) ABCop.org (877) BOCusa.org (888) CARF.org/DMEPOS (202) CHAPinc.org (866) HQAA.org (847) NABP.net (215) TheComplianceTeam.org (630) JointCommission.org (856) NBAOS.org * NABP does not provide accreditation for DMEPOS Appendix B quality standards related to custom-fitted, fabricated or made orthoses and prosthetics. See website for specific limitations. ** NBAOS does not provide accreditation for DMEPOS Appendix A or Appendix B. See website for specific limitations. Table 6 Matching equipment solutions to identified needs PATIENT DESCRIPTION CONCERN OR NEED POSSIBLE SOLUTION A 17-year-old male patient arrives in the pharmacy following a severe sprained ankle at football practice. The team trainer and a physician evaluated him and recommended RICE (rest, ice compression and elevation), along with an NSAID pain reliever. A 39-year-old female patient arrives in the pharmacy following a hospital stay after a car accident. She has been participating in physical therapy and expects to get most of her functioning back but has definite muscle control loss that makes dressing and walking/standing for longer periods of time difficult. An 85-year-old male patient who has been diagnosed with advanced Alzheimer s dementia has begun living with his daughter s family so that she can care for him. The patient has midterms beginning tomorrow, and while he knows he could be excused from taking the tests, he would like to stay current as he is hoping for academic and athletic scholarships. Her daughter is graduating from a large high school in a few weeks and she must attend. She has been successful navigating short distances alone with a cane, but is concerned about the large building and the other people around. She also would prefer not to be a burden to her husband who has had to take on so many additional tasks. The family has a hospital bed and already has added grab bars and other bathroom safety/fall prevention equipment. The daughter is struggling with her father getting up in the middle of the night and wandering the house and the yard. She is very concerned that he will injure himself while everyone is asleep. Because the patient does not want to delay the exams for fear of falling behind, a rented mobility aid, such as a knee walker, may provide him with the ability to keep the weight off his ankle and allow him to move from class to class without assistance. He also could position the device to allow him to prop up his foot during class. The patient may benefit from a powered scooter to allow her some independence for this important event. Additionally, some aids for daily living to assist her with the dressing issues may be appropriate, especially since she undoubtedly will want to dress up for the special occasion. The daughter may want to consider adding a bed alarm to the hospital bed to alert her when her father gets up. JULY

5 necessary policies and procedures. Pharmacy accreditation is achieved by complying with the DMEPOS quality standards and successfully completing an accreditation process with one of the 10 CMS accreditation organizations, or AOs. The list of CMS-approved AOs is seen in Table 5. The accreditation process involves submitting a pre-application in which an assessment of any needed compliance-related changes is completed. This will allow the pharmacy to know deficiencies and make changes needed before officially applying. After the deficiencies have been corrected, a completed application with supporting documentation is submitted to the AO. The application then will be reviewed and an unannounced onsite survey will be completed. Once accredited, the AO will conduct additional on-site surveys at least every three years. 12 DMEPOS quality standards The DMEPOS quality standards are made up of two general sections covering supplier business services requirements and supplier product-specific service requirements, and three product category appendices. In each required section of the standard, opportunities for the pharmacy technician exist. In Section 1, titled Supplier Business Services Requirements, specific direction is given. Organizations must have policies and procedures about: 17 Organizational leadership functions where committees or department heads must be in place to oversee DMEPOS needs. o Technicians can be an integral part of committees to perform internal audits and educational sessions. Equipment quality selection processes, including FDA standards related to safety, warranties and instructions. o Technicians can research products available an ensure that all safety documentation is provided. Proper display of licenses, certificates and permits within the business location. o Technicians can play a critical role in ensuring that all documents are in date and displayed as required. Compliance with all Medicare statutes and regulations related to manuals, program instructions and contractors. o Technicians can conduct education sessions, organize paperwork for easy retrieval and conduct internal audits to ensure compliance. Evidence of policies and business practices to prevent and control fraud, waste and abuse. o Technicians can help to shape and enforce fraud, waste and abuse practices. Section 1 also sets standards needed for financial management within the organization to ensure proper accounting and billing, as well as tracking revenue and expenses; human resources management requirements, including job descriptions, training and licensure/registration needs of all staff; consumer services; performance management; product safety; and information management practices to ensure compliance with HIPAA mandates. 12 In each of these areas, opportunities for pharmacy technicians exist. Section 2 includes a number of general product-specific service requirements. In general, the supplier is expected to consult with the physician or other qualified healthcare professional to ensure that the product PATIENT SCENARIO 1 meets the billing requirements and is appropriate for the patient. With any type of DME- POS, the supplier must complete: 1. Thorough intake and assessment that includes confirming and refining the order, capturing pertinent patient-specific information and filing and documenting Certificates of Medical Necessity and other required documentation; 2. Delivery and set up that ensures timely delivery and auxiliary supplies needed to correctly operate the item as ordered by the physician, and a policy for replacement of items needing repair; 3. Complete beneficiary and/or caregiver training resources; and DR is a 73-year-old female who has been a patient of your pharmacy for several years. She is a widow with two grown children who live in other cities and she lives alone. Since retiring nearly eight years ago, she has been very active in the community with volunteer activities, including food drives that keep her on her feet for several hours each weekend. Her medical conditions include: Diabetes that is well controlled with a metformin and diet/exercise; Sleep apnea for which she uses a CPAP; Heart arrhythmias for which she had a pace maker inserted three years ago and is taking amiodarone; and Chronic pain related to arthritis treated with multiple PRN narcotic pain medications. She arrives in the pharmacy with a pre-surgery instruction list and asks for a surgical scrub the surgeon recommended. During the discussion she shares that she will be going into the hospital next week for an elective knee replacement surgery. The surgeon has estimated that she will be in the hospital for three days following the surgery and then will move to a rehab facility for not more than a couple weeks. She has agreed to complete the rehab in an assisted living facility near her children in a community approximately two hours away but is very focused on returning home as soon as possible and getting back to her volunteer work. She asks if you or the pharmacist have any recommendations for the types of products she might need when she returns home or where she might go to find items her doctor recommends during therapy, just to plan ahead. Discussion At this point, it is not possible to make complete recommendations for exactly what she will need following the surgery. Because she is planning to rehab in a facility, the nurses, therapists and other professionals working with her surgeon will be in the best position to identify her specific needs and recommend the best products. With a knee replacement surgery, it is expected that some assistance with mobility will be needed for at least a portion of time. DR also may need some bathroom accommodations for bathing and using the toilet to be sure she can move with little risk. Other things to consider are equipment to assist her in picking things up and other activities of daily life since she plans to return home and continue living alone and the surgery will limit her ability to bend for several weeks. Because your store has a small set of durable medical equipment, you show DR the various walkers and canes available, including the rollator model that has been popular with some of your patients. You also show her the shower benches and raised toilet seats that you have on display and explain why she may need to use these items for a few weeks after she comes home as she continues to heal. You could also discuss some of the other grab bars and other items that she could consider just for general safety in the bathroom. With her increasing age and associated fall risk, calling her attention to general safety is appropriate. It also may be appropriate at this point to help DR understand the basic insurance processes and encourage her to investigate with her surgeon and his staff how to secure coverage for items she may need. Explain that the Medicare coverage rules are very specific and some of the items may be covered only after she actually has the surgery and the surgeon then completes the necessary paperwork (e.g., a certificate of medical necessity and order). Other supplies her doctor recommends may not be covered by Medicare and would require cash payment. You also can educate DR about the online resources Medicare has to find local and Internet-contracted providers and information about supplies. She can try the Medicare supplier directory that allows her to find suppliers by zip code: or the Medicare coverage link: 5 JULY

6 4. Follow-up as needed. The standard also includes additional specific guidance as follows: Appendix A: Respiratory equipment, supplies and services; Appendix B: Manual wheelchairs, power mobility devices (PMDs), and complex rehabilitative wheelchairs and assistive technology; and Appendix C: Custom fabricated orthoses and prosthetic devices. The complete standard is available as a part of the Medicare Learning Network. 12 PROVIDING SELF-CARE SOLUTIONS When patients are diagnosed with a new chronic condition, such as asthma or diabetes, a first stop often is the community pharmacy. Depending on the diagnosis and the care plan developed by the prescriber, patients and caregivers arriving in the community pharmacy may have more on their minds than the dosing instructions and side effect profiles of medications prescribed. A patient with asthma may be in need of a quality nebulizer and supplies in order to avoid the frightening return to the emergency room that could happen with an asthma attack. Patients with diabetes may need blood glucose monitor device recommendations and training to ensure that the medications prescribed are having the desired effects. Patients returning home after surgery may need a number of pieces of durable medical equipment either on a temporary or permanent basis. From choosing the correct dressings for healing wounds to finding access to such accommodating equipment as crutches, canes, commodes or wheelchairs, fulfilling the patient s needs can be overwhelming, especially when combined with the stress of returning home. 13,14,15 When the need for quality medical products is driven by loss of physical and/or mental function, permanent or temporary, thoughtful recommendations are critical. Again, the pharmacy technician can screen patients for possible needs and assist in recommending products and referrals to meet their needs.pharmacy technicians also can help to raise awareness and prompt action to help prevent falls in the elderly by participating in fall awareness and prevention programs. 16 Falls are a major concern as patients age and often live alone in their homes. By getting to know your patients and understanding their living situations, discussing recommendations for adding bathroom safety grab bars and other fall prevention equipment can impact patient safety. Table 6 contains short descriptions of issues that may arise with patients visiting a community pharmacy. For each patient issue, a short discussion of a potential solution is offered. The potential solutions listed are intended only as a thought starter. As the information is reviewed, consider the patient population of your pharmacy and formulate potential solutions and your potential recommendations. Additional considerations Throughout this lesson, the focus of the discussion has been on meeting patient needs and assisting the patient in understanding healthcare coverage processes. While the patient always will be at the center of recommendations, it is important to consider the impact that the caregivers have on the decisions, especially concerning needed equipment. As caregivers are pulled in multiple directions of supporting healthcare needs for elderly parents, working and caring for families at home, well-placed solutions that allow them to balance all demands will be appreciated. Insurance coverage may be less important if simply purchasing the product will reduce anxiety or PATIENT SCENARIO 2 PRACTICE POINTS save time. Including the caregivers in education sessions, with patient permission, and providing them with resources and information concerning all options, regardless of insurance coverage, often are critical factors. CONCLUSION As health care continues to evolve, patient and caregiver needs will follow. Community pharmacy technicians can be valuable resources for patients and caregivers and the pharmacy organizations in which they are employed. By helping to ensure accreditation standards compliance, and by advocating and educating patients about all of their DMEPOS options, the pharmacy technician can take on a critical role in delivering healthcare solutions that meet patients total needs in achieving and maintaining quality of life. Several weeks later, DR s daughters arrive in the pharmacy to fill her discharge medications. You ask how she is doing and the daughters tell you that she is doing much better now but that rehab was longer than anticipated. Their mother developed an infection following the surgery and required IV antibiotics for a few weeks. The delay slowed her recovery and while they expect that she will get on track soon, she is depressed to be missing so many of her volunteer activities as she is a bit weaker from the lengthy recovery. You ask if DR has everything she needs to move around her house safely and the daughters assure you that they have worked with the rehab team to put everything in place from a walker to a number of bathroom supplies. Many of the items were covered by insurance and were sent home from rehab. A few of the smaller items weren t covered and their brother actually stopped by the pharmacy at their mother s recommendation the day before to purchase them. Their only concern is that they would really like to help get DR back to her activities but they are worried that she will tire and potentially fall if she goes before she is strong enough. They requested approval for a motorized scooter for their mother but the insurance company denied the claim. In your discussion with them you make them aware of an online medical supply company that has power scooter rentals with delivery and pick-up options in the area. Knowing how important it is to their mother to get back to her volunteer efforts, they take the information and thank you for the suggestion. When helping patients understand insurance coverage requirements, general recommendations include: 1. Many plans require evidence of the medical need of the product or supply. This may be easy or difficult to obtain based upon the issue the patient needs to overcome. Physician or other health care provider exams and documentation are a place to begin. Some plans, including Medicare, may require a Certificate of Medical Necessity. 2. A physician order for the product or supply usually is required to begin the coverage review. Even if the physician has assisted the patient in completing the Certificate of Medical Necessity, a specific order for the product with the correct diagnosis code(s) is needed. 3. Patients always should look for a qualified provider of the supply. While Medicare has an accreditation process and a contracting process in place for providers of medical supplies that are rather rigorous, it is important to advise the patient and caregivers to do thorough research when looking for a provider. Having confidence in the quality of the product and the service needed is critical to reduce stress for patients and caregivers. 15,16 Patients covered by traditional Medicare can get more information about suppliers and product coverage online. Medicare supplier directory that allows supplier searches by zip code: SupplierDirectory Medicare Coverage link that provides coverage information about supplies, tests and more: Patients covered by Medicare Advantage plans or commercial insurance should visit their plan s website for information about DME coverage. JULY

7 1. Aging Statistics. Administration on Aging. U.S. Department of Health and Human Services Administration for Community Living. aspx. Accessed July 2, Centers for Disease Control and Prevention. The State of Aging and Health in America Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; Vincent, Grayson K., and Victoria A. Velkoff, 2010, The Next Four Decades, The Older Population in the United States: 2010 to 2050, Current Population Reports, P , U.S. Census Bureau, Washington, D.C. 4. Leading Causes of Death Hyattsville, MD: National Center for Health Statistics Accessed July 3, Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and its Burden in the United States, Atlanta, GA: U.S. Department of Health and Human Services; Increase in number of total knee replacement surgeries, especially in younger adults, linked to obesity. American Academy of Orthopaedic Surgeons. June 4, Accessed July 8, IHS Inc., The Complexities of Physician Supply and Demand: Projections from 2013 to Prepared for the Association of American Medical Colleges. Washington, D.C.: Association of American Medical Colleges; Program Operations Manual System. HI Social Security Administration. May 23, Accessed July 10, Centers for Medicare and Medicaid Services. Durable Medical Equipment (DME) Center. Available at: Accessed on July 4, Medical Devices: Implants and Prosthetics. U.S. Food and Drug Administration. June 24, Accessed July 2, DMEPOS Quality Standards. Medicare Learning Network. Department of Health and Human Services Centers for Medicare and Medicaid Services. June Accessed July 3, The Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Information for Pharmacies. Medicare Learning Network. Department of Health and Human Services Centers for Medicare and Medicaid Services. June dmepos_pharm_factsheet_icn pdf. Accessed July 3, Bathroom Safety-Adults. Medline Plus. U.S. National Library of Medicine. Updated May 28, www. NLM.nih.gov/medlineplus/ency/patientinstructions/ htm. Accessed July 8, Ankle replacement discharge. Medline Plus. U.S. National Library of Medicine. Accessed June 10, After Surgery. Medline Plus. U.S. National Library of Medicine. nih.gov/medlineplus/aftersurgery.html#summary. Accessed June 30, National Center for Injury Prevention and Control. Preventing Falls: A Guide to Implementing Effective Community-based Fall Prevention Programs. 2nd ed. Atlanta, GA: Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Available at: Accessed on July 4, Competitive Bidding Program. Medicare.gov. Accessed July 1, Learning Assessment Successful completion of DME for quality of life: When patients need more than a hand ( H04-T) is worth one contact hour of credit. To submit answers, visit our website at DrugStoreNewsCE.com. Please note: Assessment questions submitted online will appear in random order. 1. From the descriptions below, choose the item(s) that best fit the CMS durable medical equipment definition. a. An air conditioner that has a built-in dehumidifier and air cleaner for a patient with asthma b. A hard-molded knee brace c. A motorized scooter d. Chair pads for a lift chair 2. The Social Security POMS system: a. Defines DME as medical equipment that is useful predominantly for people with an illness or injury and can be used repeatedly at home. b. Describes items that fail the durability test. c. Distinguishes presumptively medical from presumptively nonmedical items. d. All of the above 3. In order for a chain community pharmacy to supply DMEPOS products for traditional Medicare beneficiaries, the pharmacy must be accredited. Which of the following is/are a CMS accrediting organization, or AO? a. National Association of Boards of Pharmacy b. National Association of Chain Drug Stores c. The Joint Commission d. A & C 4. The goals of the competitive bidding process include: a. Update and lower DMEPOS costs b. Improve quality c. Eliminate fraud, waste and abuse d. All of the above 5. All community pharmacy chains are eligible to submit an affidavit to certify a National Supplier Clearinghouse Exemption and avoid DMEPOS accreditation. a. True b. False 6. CMS launched a recompete process for the National Mail Order program in April Suppliers who submit successful bids will have contract terms for what time period? a. Dec. 1, 2015 to Nov. 30, 2018 b. Jan. 1, 2016 to Jan. 1, 2017 c. July 1, 2017 to June 30, 2019 d. July 1, 2016 to Dec. 31, When making recommendations to patients for DME products they may need, always: a. Have the doctor issue a blanket order to allow billing for any item the patient chooses. b. Recommend only private-label/ store-brand items to ensure that the allowed reimbursement will cover the cost. c. Call the caregivers to see what the patient will really need. d. Complete an assessment that includes the patient and any caregivers involved, and identify options that meet the provided solutions for the issues the patient is experiencing. 7 JULY

8 Learning Assessment 8. If patients need to find a contracted provider in their area who can supply an item that is competitively bid, the best advice for the patient is: a. To access the Medicare supplier directory at SupplierDirectory b. To access the Medicare coverage link at your-medicare-coverage.html c. To ask your other patients which suppliers in the area provide the best service d. To call the Social Security Administration POMS department 9. When providing patient recommendations for needed DMEPOS products, patients should be advised to: a. Work with their physician or prescriber to access documentation of medical need and specific medical orders for the DMEPOS items. b. To fully investigate coverage requirements that may be in place prior to purchasing equipment. c. To carefully consider each selection to be sure that the product identified fulfills a need. d. All of the above 10. If a patient has a denial of coverage for a DMEPOS item that will help him or her solve a patient care issue, the patient or a family member may choose to purchase the item without billing the insurance plan. a. True b. False JULY