August 3, 2021 Workers' Comp

Peering inside the DME ‘black box’

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<p>In science and computing, a black box is defined as a device, process or system, whose inputs and outputs are known, but whose internal workings are often not well understood.</p>

In science and computing, a black box is defined as a device, process or system, whose inputs and outputs are known, but whose internal workings are often not well understood.

According to this definition, Durable Medical Equipment (DME) has traditionally operated as a black box of sorts for claims adjusters in the workers’ compensation space—and with justified reason. As a specialized area for specialty services, DME’s inner workings are complex. There is a wide range of equipment. Within each category, there are a significant number of products that vary in nuanced ways, with many offering slightly different functions. As a result, costs run the gamut, and coding gets complicated with a “miscellaneous” code used for products that aren’t easily categorized.

From an adjuster’s perspective, the DME black box has known “inputs” and “outputs,” but the “inner workings” can often be shrouded in mystery.

DME inputs

Orders: The main inputs are DME referrals sent from treating physicians. For the most part, the physicians may also be unaware of the wide variety of equipment available and what each may cost. Physicians may inadvertently write a prescription for a costly brand-name product when a cheaper generic version is available.

Timing: Often, DME is needed on complex injury claims. An injured worker may be in the hospital or another medical facility, soon to be discharged. Although adjusters may try to work with these facilities to plan for a release, adjusters often receive last-minute notice of an injured employee being discharged with urgent DME needs. As a result, it’s quite common to receive a DME request on a Friday afternoon, making it difficult to fulfill the order and ensure a smooth transition home.

Inner workings

When adjusters receive DME orders, most of the time, they simply pass them on to the specialty network provider to fulfill. However, if the inputs aren’t great to begin with and the vendor doesn’t have a stellar internal process, then the resulting outputs could vary significantly in terms of quality, patient satisfaction, cost, and other outcomes. As such, let’s consider the key factors that make up the internal workings of the DME process, so they can be more carefully tracked and monitored to ensure a better result.

Broad DME Product Expertise: A specialty network should have deep expertise across the wide variety of DME products that are available.

Adjusters want and need education on DME, but they often don’t have the time or bandwidth to research different products in the midst of an injured employee being discharged or in the middle of managing a claim. Instead, they need to rely on a specialty network to have ready knowledge to review orders on their behalf and to bring any concerns to their attention.

High-level Customer Service: A quality specialty network will offer both customer and patient-focused delivery of DME products. A small shop might not have the connections and means to facilitate a high-touch customer experience, while a large, highly siloed company may be too unwieldy, resulting in fragmented service.

Efficiency is affected by how the specialty network operations are structured. Some divide their operations by product lines, with specialty services such as diagnostics, home health care, and DME handled by separate units. As a result, adjusters might have to jump through hoops to meet all of their claimants’ specialty service needs and to obtain a comprehensive update on a file. Adjusters might end up losing precious time, which could have been used to manage their caseloads or interact with injured employees or other workers’ comp stakeholders.

Successful specialty networks will have tailored their service and delivery to help customers eliminate the burden of administrative hassles. Ideally, customers are assigned a single care coordinator to handle all specialty service needs on a single case. Whether it’s DME, home health care, or diagnostic imaging, there’s a single point of contact for all services. Adjusters appreciate this approach, as it simplifies things on their end.

Broad network: A national network of credentialed DME and supply vendors offers prompt delivery, convenience, and significant savings on fee schedules. Credentialing is also key. A specialty network must vet DME providers, ensuring they are properly licensed and insured.

A best-in-class national network should be carefully curated to include a full spectrum of specialized DME solutions. It should perform rigorous network evaluation to ensure it continues to use only the best providers. It can also customize its national network to fit a customer’s unique needs. And it can coordinate rush-, same-day, and weekend delivery at no additional charge.

Continuum of care: A specialty network should work in close collaboration with nurse case managers to ensure clinical oversight is applied when needed. Many times, injured workers require medical and specialty services together. As a result, a coordinated approach ensures better overall results, value, and savings. There have been many examples when a nurse case manager, who was helping to oversee a complex or catastrophic injury, ended up advocating on behalf of the injured employee for a critical piece of equipment, which could help in the recovery process, such as an exoskeleton to help a paraplegic walk again.

Ensuring quality outputs

The main output in this process centers around the delivery of DME to the injured employee, but that process can be divided into several key aspects. It’s also important to understand that “positive” outputs are only achieved when the inner workings of the DME box have reach a certain level of excellence.

Patient satisfaction: The specialty network typically receives an injured worker’s contact information with the original DME order. With this information, it can contact the individual to ensure he or she received the DME products, has obtained proper training (if needed), and is generally satisfied with the equipment. Likewise, patients should have received the specialty network’s contact information, so they know with whom to follow-up in case equipment doesn’t arrive or if there are issues with an item.

Efficiency: Injured employees should receive their DME products in a timely manner, so they can begin to use them when they most need it. Timeliness also ensures a prompt discharge and smooth transition home, as well as a prompt recovery and return to work, when possible.

Overall, when the inner workings of the DME box are optimized, administrative burden is significantly reduced—if not eliminated entirely. This is a tremendous benefit for busy adjusters. Specialty networks such as Apricus work hard to remove these hassles. Its care coordinators work in advance to connect the dots among physicians, DME vendors, injured workers, and billing. They also communicate directly and proactively to minimize confusion and delays, and they properly align expectations among stakeholders. For example, if a customized brace is required, it may take a lot longer to deliver than standard equipment, like a cane. The care coordinators will strive to keep adjusters and injured workers updated each step of the way.

Costs: The medical costs on a workers’ comp claim can be significant. By containing DME expenses, a specialty network contributes to medical cost containment. These networks should strive to save costs for their customers in multiple ways. For example:

• Submitting a DME plan in line with treatment guidelines to the adjuster to obtain prior authorization and a purchase order for equipment. As such, the rigmarole of unauthorized orders—which may include the filing of liens and attempted collections—may be avoided. This not only saves costs but also eliminates administrative hassles.

• Negotiating optimal rates with DME vendors to achieve costs that are below state fee schedules.

• Developing and offering cost-saving measures such as rental caps, which generate more savings. If an injured worker starts out renting equipment but needs it for a longer period than expected, there’s no risk that the payer will be overcharged through an indefinite rental period. Instead, rental costs are capped at the purchase price of the item, and when this sum is reached, the item is owned outright.

• Checking to see whether a generic substitution can be made, if and when a costly brand-name product is ordered.

• Applying retrospective savings through its bill review process, when DME claims circumvent its prospective controls.

From Black to Unlocked Box

The fact that adjusters are dealing with a full plate of responsibilities has necessitated and perpetuated the DME black-box paradigm. Claims professionals do not have the spare time to become experts in yet another area, especially since they have high caseloads, must stay up to date with legislative changes, and deal with a plethora of day-to-day interactions with injured workers, employers, and physicians.

A specialty network should strive to fulfill adjusters’ DME needs, while also turning around the traditional black-box situation. With a black box, you can’t see what’s inside, so hopefully we’ve unlocked and revealed the inner workings of the DME process, offering greater transparency—and in the end, better results.

About the author

Ted Smith is the senior vice president of national sales for Apricus. With more than 10 years of experience in the workers' compensation industry, Ted is an expert on managing specialty services, including diagnostics, durable medical equipment (DME), and home health services, and is a contributing author to The Sounding Board blog.

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