 | The examples and perspective in this article deal primarily with the United States and do not represent a worldwide view of the subject.(August 2018) |
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This article discusses the definitions and types of home medical equipment (HME), also known as durable medical equipment (DME), and durable medical equipment and prosthetics and orthotics (DMEPOS).
Home medical equipment is a category of devices used for patients whose care is being managed from a home or other private facility managed by a nonprofessional caregiver or family member. It is often referred to as "durable" medical equipment (DME) as it is intended to withstand repeated use by non-professionals or the patient, and is appropriate for use in the home.
Medical supplies of an expendable nature, such as bandages, rubber gloves and irrigating kits are not considered by Medicare to be DME.
Within the US medical and insurance industries, the following acronyms are used to describe home medical equipment:
The following are representative examples of home medical equipment [1]
For most home medical equipment to be reimbursed by insurance, a patient must have a doctor's prescription for the equipment needed. Some equipment, such as oxygen, is FDA regulated and must be prescribed by a physician before purchase whether insurance reimbursed or otherwise.
The physician may recommend a supplier for the home medical equipment, or the patient will have to research this on their own. HME / DMEPOS suppliers are located throughout the country and some specialty shops can also be found on the internet.
There is no established typical size for HME / DMEPOS suppliers. Supply companies include very large organizations such as Walgreens, Lincare, and Apria to smaller local companies operated by sole proprietors or families. A new evolution in the home medical equipment arena is the advent of internet retailers who have lower operating costs so they often sell equipment for lower prices than local "brick and mortar", but lack the ability to offer in-home setup, equipment training and customer service.[ citation needed ] In all cases, however, there are strict rules and laws governing HME / DMEPOS suppliers that participate in Medicare and Medicaid programs. In addition to rules outlined the National Supplier Clearinghouse, of division of CMS (centers for Medicare and Medicaid), all Medicare DME suppliers must obtain and maintain accreditation by one of many approved accrediting bodies.
Once a patient or caregiver selects an appropriate HME / DMEPOS supplier, he/she presents the supplier with the prescription and patient's insurance information. HME / DMEPOS suppliers maintain an inventory of products and equipment, so fulfillment of the prescription is rapid, much like a Pharmacy.
The HME / DMEPOS supplier is obligated to perform certain functions when providing home medical equipment. These include:
All HME / DMEPOS suppliers are required to comply with Health Insurance Portability and Accountability Act (HIPAA) to protect patients' confidentiality and records.[ citation needed ]
Home medical equipment is typically covered by patient's healthcare insurance, including Medicare (Part B). In order to properly code home medical equipment for billing, the Healthcare Common Procedure Coding System HCPCS is utilized. As of 2014, under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, providers of HME/DMEPOS will be required to become third-party accredited to standards regulated by the Centers for Medicare and Medicaid Services (CMS) in order to continue eligibility under Medicare Part B. This effort aims to standardize and improve the quality of service to patients provided by home medical equipment suppliers.
Medicare is a government national health insurance program in the United States, begun in 1965 under the Social Security Administration (SSA) and now administered by the Centers for Medicare and Medicaid Services (CMS). It primarily provides health insurance for Americans aged 65 and older, but also for some younger people with disability status as determined by the SSA, including people with end stage renal disease and amyotrophic lateral sclerosis.
Stark Law is a set of United States federal laws that prohibit physician self-referral, specifically a referral by a physician of a Medicare or Medicaid patient to an entity for the provision of designated health services ("DHS") if the physician has a financial relationship with that entity.
The Commission on Accreditation of Rehabilitation Facilities (CARF) is an international, non-profit organization founded in 1966 with the assistance of Mary E. Switzer, then U.S. Social and Rehabilitation Services commissioner. For some institutions, it represents an alternative to Joint Commission certification. Revenue sources include contributions from the International Advisory Council, which comprises entities being accredited.
Lift chairs, also known as lift recliners or riser armchairs, are chairs that feature a powered lifting mechanism that pushes the entire chair up from its base and so assists the user to a standing position.
QS/1 is an American software company which develops management software for pharmacies. It was founded in 1944 and is based in Spartanburg, South Carolina.
Medigap refers to various private health insurance plans sold to supplement Medicare in the United States. Medigap insurance provides coverage for many of the co-pays and some of the co-insurance related to Medicare-covered hospital, skilled nursing facility, home health care, ambulance, durable medical equipment, and doctor charges. Medigap's name is derived from the notion that it exists to cover the difference or "gap" between the expenses reimbursed to providers by Medicare Parts A and B for services and the total amount allowed to be charged for those services by the United States Centers for Medicare and Medicaid Services (CMS).
A pedorthist is a professional who has specialized training to modify footwear and employ supportive devices to address conditions which affect the feet and lower limbs. They are trained in the assessment of lower limb anatomy and biomechanics, and the appropriate use of corrective footwear – including shoes, shoe modifications and other pedorthic devices.
An independent pharmacy is a retail pharmacy that is not directly affiliated with any chain of pharmacies and is not owned by a publicly traded company. Independent pharmacies are pharmacist-owned, privately held businesses in varying practice settings. They include single-store operations, pharmacist-owned multiple store locations, franchise, compounding, long-term care (LTC), specialty, and supermarket pharmacy operation. Independent pharmacy owners generally have more flexibility to build personalized customer relationships and they strive to differentiate their services from big-chain corporations.
In the US a certificate of medical necessity is a document required by Centers for Medicare and Medicaid Services to substantiate in detail the medical necessity of an item of durable medical equipment or a service to a Medicare beneficiary. There are different types of CMN for different requirements, e.g., insulin pumps, home health and private duty nursing services, etc.
A Prosthetist and Orthotist, as defined by The World Health Organization, is a healthcare professional with overall responsibly of Prosthetics & Orthotics treatment, who can supervise and mentor the practice of other personnel. They are clinicians trained to assess the needs of the user, prescribe treatment, determine the precise technical specifications of prosthesis and Orthosis, take measurements and image of body segments, prepare model of the evaluation, fit devices and evaluate treatment outcome.
Program of All-inclusive Care for the Elderly (PACE) are programs within the United States that provide comprehensive health services for individuals age 55 and over who are sufficiently frail to be categorized as "nursing home eligible" by their state's Medicaid program. The ultimate goal of PACE programs is to keep eligible older adults out of nursing homes and within their communities for as long as possible. Services include primary and specialty medical care, nursing, nutrition, social services, therapies, pharmaceuticals, day health center services, home care, health-related transportation, minor modification to the home to accommodate disabilities, and anything else the program determines is medically necessary to maximize a member's health. If you or a loved one are eligible for nursing home level care but prefer to continue living at home, a PACE program can provide expansive health care and social opportunities during the day while you retain the comfort and familiarity of your home outside of day hours.
Durable medical equipment is any medical equipment used in the home to aid in a better quality of living. It is a benefit included in many insurance policies and in some cases covered by Medicare benefits. The item is defined by Title XIX for Medicaid:
The Accreditation Commission for Health Care (ACHC) is a United States non-profit health care accrediting organization. It represents an alternative to the Joint Commission and CHAP, The Community Health Accreditation Program.
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The Healthcare Common Procedure Coding System is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT).
HCPCS Level II codes are alphanumeric medical procedure codes, primarily for non-physician services such as ambulance services and prosthetic devices,. They represent items, supplies and non-physician services not covered by CPT-4 codes. Level II codes are composed of a single letter in the range A to V, followed by 4 digits. Level II codes are maintained by the US Centers for Medicare and Medicaid Services (CMS). There is some overlap between HCPCS codes and National Drug Code (NDC) codes, with a subset of NDC codes also in HCPCS, and vice versa. The CMS maintains a crosswalk from NDC to HCPCS in the form of an Excel file. The crosswalk is updated quarterly.
Credentialing is the process of establishing the qualifications of licensed medical professionals and assessing their background and legitimacy.