Arizona Disability Post

Improving the Delivery of
Durable Medical Equipment and Services
in Arizona

Let’s improve the delivery, repair and maintenance of durable medical equipment in Arizona! A Task Force of consumers, suppliers, health plans and state agencies has developed recommendations to improve communication, timely delivery and repair, and access to DME suppliers. We need your help to make sure these recommendations reflect appropriate solutions to the problem. Please take a few minutes to review this Executive Summary of draft recommendations and send us your comments and suggestions for strengthening the recommendations. Comments may be submitted until July 7th, 2008. Following review of the comments, the Task Force will finalize their recommendations and plan the implementation strategies.

General comments can be submitted by completing the first section. If you have specific comments about a recommendation, you may add those in the blocks following each recommendation.

Please click here to download and read the complete Executive Summary, RECOMMENDATIONS TO ACHIEVE, “Superior Customer Service” by the Durable Medical Equipment Task Force

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General Comments:

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Goal I: Communication: To provide direct, specific, and timely communication that is responsive to consumers, suppliers, health plans, program contractors, medical personnel and insurers across the DME service system.

Recommendation 1: Implement methods to ensure consumers have information about the steps in the process of obtaining durable medical equipment and who to contact about DME questions at each of the Arizona State Agencies administering programs and services for people with disabilities.

Recommendation 2: Designate customer service representatives at health plans, program contractors and suppliers and provide consumers with the name and contact information of their customer service representative. Ensure customer service representatives have clear responsibility for responding in a timely manner to consumer inquiries on the status of new orders or repairs and have the ability to track delays and notify consumers of possible delays.

Recommendation 3: Develop a web-based forum for consumers to have easy access to information about available DME suppliers, performance of DME suppliers, and specialty DME suppliers and to communicate with each other about their “good DME experiences” as well as their “bad experiences”. Include in the web site the following information:

educational material about the process of obtaining durable medical equipment,
information about when and how to file a grievance or appeal,
an advocacy protocol that can be duplicated and used by all consumers and advocacy organizations,
the steps for acquiring durable medical equipment – including but not limited to specialized custom equipment to allow consumers to be able to track their equipment delivery process and advocate on their own behalf,
who is responsible for what activities and within what timeframes at each step in the process including physicians, health plans, program contractors, DME suppliers, DME manufacturers, and consumers, and
supplier standards for service delivery.

Recommendation 4: Provide consumers with information at the time of delivery of wheel chairs about the warranty, how to register the warranty, equipment specific preventative maintenance needed, what will invalidate a warranty, and the consumers’ responsibility regarding maintenance.

Provide a template for consumers to record specifics about their equipment, the maintenance history and the repair history.
Include information about who to contact when a repair is needed.

Recommendation 5: Implement at the DME supplier level a system to track orders and repairs with the capacity to pin point where there are delays, to issue alerts internally within the supplier organization and to notify consumers regarding delays. Additionally, the system should be able to provide aggregate reports on the status of meeting pre-determined expected timelines.

Recommendation 6: Ensure communication occurs between seating evaluation therapists and supplier representatives before equipment is ordered when the recommendations of the therapist and supplier representative are different. Use a feature match approach when determining the right equipment to be provided.

Goal II: Standards and Practice Protocols: To improve the effectiveness of DME suppliers, health plans, program contractors and insurers through a system of uniform standards, reasonable expectations, and streamlined processes.

Recommendation 7: Clarify the rules and requirements that apply when a consumer has the ability and desires to pay, at their own expense, for equipment and disseminate the clarification and information about the process system wide.

Clarify the possible implications, if any, from the standpoint of Medicare, Medicaid, private insurers, etc.
Provide a standard form and process to be used by all DME suppliers for informing consumers of these implications and obtaining, if needed, their signature indicating their desire to purchase supplies and / or equipment on their own.
Make this information available to consumers through web sites, newsletters, public forums.

Recommendation 8: Develop and adopt specific standards and performance indicators in quality, timeliness, and staff qualifications that will improve the effectiveness of DME service delivery.

Establish uniform standards for “reasonable” timelines for each step in the DME process.
Distinguish between routine durable medical equipment and specialized durable medical equipment.

Recommendation 9: Require that DME suppliers be accredited and include their accreditation status in a published list of DME suppliers. (Note: DME suppliers that plan to do business with Medicare must be accredited by December 2009.)

Recommendation 10: Require that all DME suppliers have a Certified Rehabilitation Technology Specialist on staff, as appropriate to the DME services they provide.

Recommendation 11: Analyze existing data and establish across health plans, program contractors and suppliers a higher, consistent dollar threshold before a repair event requires prior authorization and establish a prior authorization “fast track” for repairs that are estimated to be above the newly established threshold. For example, only repairs in excess of $1,000 require prior authorization.

Recommendation 12: Establish a standard protocol regarding seating evaluations and seating clinics to include when seating evaluations are to be completed prior to ordering a wheel chair, what follow-up is to occur after delivery of the wheel chair and on an ongoing basis, what monitoring is recommended. The protocol should address, but not be limited to, the following issues:

involvement of the consumer’s current therapist in the evaluation such as the therapists who work with students in schools,
identification of therapy organizations with qualified therapists who are able to provide the evaluations,
ensure an RTS is participating in the evaluation with the therapist,
the content of key elements of formal seating evaluations such as: range of motion, equilibrium reactions, fine and gross motor skills, ability to self propel and transfer, self care issues, transportation requirements, and visual skills including depth perception, and
minimum qualifications for people who conduct seating evaluations.

Recommendation 13: Establish a practice protocol for provision of “loaner” equipment and accessing alternative transportation when loaner equipment is not appropriate or not available.

When a repair requires that a wheel chair be taken to the repair facility, DME suppliers should provide the best possible match in loaner equipment or consumers, working with their case managers and the DME supplier should identify appropriate alternative transportation arrangements.
Provide specific training and education to ensure that case managers, in all the systems, have information about transportation alternatives, the potential need for increased authorization of attendant care hours and the potential for health and safety issues to arise while a consumer’s equipment is being repaired.
Consider authorization by the health plan for consumer owned back-up equipment to be repaired for use while the consumer’s current equipment is being repaired and / or new equipment is being ordered.

Recommendation 14: Develop and implement a practice protocol and a system of quality assurance for follow-up after delivery of equipment to ensure fitting of the wheelchair to the consumer, and accuracy of the piece of DME ordered to that delivered, prior to requesting the consumer’s signature accepting the wheelchair or other piece of DME.

Require DME suppliers to provide customer satisfaction cards at the time of delivery and six months after delivery. Make results accessible to the health plans, program contractors, insurers, and consumers.
Provide consumers with a check list of – what to expect and what to “watch for” as they begin to use the equipment (similar to when we get a prescription – possible side effects – if x happens, stop and call the doctor.) For example, if you feel unstable, not centered using the equipment, call the supplier – NAME at XXXX number. If you have questions, call NAME at XXX number.
Ensure therapists conducting the assessment specifically consider and distinguish “need” versus “want” with regard to wheel chairs. Provide consumers with information about why their desired piece of equipment may not fit with what the functional assessment result indicates is needed.

Goal III: Consumer Choice and Advocacy: To empower consumers of DME to be informed advocates through choice, education, and knowledge of standards, practice, and policies of their insurer and DME supplier.

Recommendation 15: Require AHCCCS Health Plans, ALTCS Program Contractors and Department of Health Services, Office of Children’s Rehabilitation Services contracted Clinics to provide multiple choices of DME suppliers – at least two or more; if providers are available in the geographic area.

Recommendation 16: Provide more consumer choices of suppliers / places to go for repair service to enhance access including choices that may be geographically closer to the consumer and/ or more timely in completing the repair.

Recommendation 17: Provide more consumer choices regarding accessing seating evaluations and seating clinics.

Recommendation 18: Provide easily accessible information about DME suppliers; i.e. create a list of accredited DME suppliers, where they are located geographically, what DME services and equipment do they provide, and whether or not they have a Certified Rehab Specialist on staff. Provide the information through multiple web sites. (Possible web sites: AzDisabilityPost.org, Az Association of Law Libraries (AzAll), AzLinks, Disability Resource, Assistive Technology Arizona (ATAZ), and NAU – Az Technology Access Program (AzTAP), health plans, and relevant state agencies.)

Recommendation 19: Implement a standardized consumer / advocate guide and checklist to enhance understanding of the process, the roles of each party, and reasonable expectations of timelines.

A common check list will assist providers, consumers and advocates in understanding the steps in the DME process, what the reasonable timelines are for each step, and who to contact if a request is delayed.
The guide must include what action to take in the case of delays.
Include advocacy tips - the top 10 things consumers can do to make the process more accountable and timely. For example, consumers need information about why DME suppliers must be able to see the old equipment when a replacement is being requested – consumers are reluctant to let them see it.

Goal IV: Quality Assurance and Timeliness: To provide quality durable medical equipment within acceptable timeframes.

Recommendation 20: Implement formal quality assurance plans at the insurer, health plan, program contractor and DME supplier levels that include:

performance improvement indicators for customer satisfaction,
consumer satisfaction surveys with questions specific to DME and to wheelchairs,
standardized questions regarding DME services in all customer satisfaction surveys,
a rating system developed based on customer satisfaction and tracking of delivery; i.e. quality and timeliness,
sharing of the results of customer satisfaction surveys with consumers, insurers, health plans/program contractors and suppliers,
monitoring of grievance and appeals issues raised, resolutions, and timelines for response, and
mechanisms for seeking consumer advice on how to improve the quality and timeliness of the delivery of durable medical equipment.

Recommendation 21: Implement clear and consistent grievance and appeals processes among all health plans, program contractors and DME suppliers and as part of quality assurance monitor and publish the results.

Develop standardize grievance and appeals timelines for response across the system, such as, consumers will receive a response to a written appeal within 10 days regardless of insurer source or consumers will have contact from the organization with which they filed a grievance within 48 hours – may be not an answer, but acknowledgment that the grievance has been received.
Provide consumer friendly information about grievances and appeals, when to use the grievance process versus the appeal process, how to file a grievance or an appeal, and what are the reasonable timelines for receiving a response.
Publish grievance / appeals processes in newsletters and / or circulate to other organizations on how the process works.
Monitor the number of grievance and appeals and provide information regarding the results to consumers and advocates.
When feasible, appoint a DME specialist to handle DME grievances at the state agency level.

Recommendation 22: Establish consistent guidelines for all DME suppliers regarding repairs and customer service including consistent processes and documentation requirements.

Recommendation 23: Discontinue at all levels of the DME service system (insurer, health plan, program contractor and DME supplier) the practice of paying for specialized, customized DME under a capitated rate system and implement fee for service rates for all specialized, customized DME including wheel chairs.

Recommendation 24: Reassess the durable medical equipment fee for service schedule specifically addressing the following issues:

the adequacy of rates to cover costs,
reimbursement for loaner equipment, seating evaluations, seating clinics, repairs for the life of the product, etc.,
reimbursement for the costs related to maintenance and management of a “fleet” of loaner equipment, and
reimbursement for the costs of repairing “back-up” equipment belonging to the consumer that can be used while the consumer’s current equipment is repaired.

Recommendation 25: Define and implement health plan, program contractor and DME supplier incentives for exceeding service standards and consequences for non-compliance with standard guidelines such as consistent delays, lack of or delay in resolution of grievances, and lack of responsiveness to consumer inquiries.

Recommendation 26: Implement new and/or review and modify existing processes to ensure requests for equipment and supplies are specifically based on the needs of the individual consumers and not just the “typical” service / equipment. For Example – A shower chair must take into consideration the weight of the consumer – any standard shower chair may not be appropriate.

Recommendation 27: Implement at the state agency and health plan/program contractor and DME supplier levels specific network capacity assessment methods to document DME supplier capacity and be alerted to the need for capacity expansion.

Recommendation 28: Develop partnership opportunities with employment organizations, advocacy groups and Rehabilitation Service Administration to recruit and train technicians to fill the work force gap in wheel chair repair technicians.

Goal V: Training and Education: To provide clear and consistent training and education throughout the DME delivery system.

Recommendation 29: Provide specific information to primary care physicians regarding needed documentation.

Provide information about what the primary care physician should expect to see in reviewing a quality seating evaluation / assessment.
Develop standard language or a template for a prescription for complex requests such as wheel chairs, so that prescriptions include the necessary information for Medical Director’s to determine medical necessity.
Ensure physicians have information about the need for both a prescription for the seating evaluation AND a prescription for the wheel chair itself.

Recommendation 30: Increase awareness within the system about the potentially critical nature of delays in obtaining and/or repairing DME equipment.

Provide specific training and education for health plans/program contractors, insurers, DME supplier and state agency customer service representatives about durable medical equipment, the health and safety issues surrounding receipt of the wrong equipment and/or delays in getting equipment.

Provide medical directors, case managers and prior authorization staff with specific information and education about DME issues and the potential health and safety implications of a lack of quality or timeliness in providing DME.

Goal VI: Repairs and Maintenance: To complete durable medical equipment repairs timely and accurately and in settings which are respectful of and responsive to the needs of consumers.

Recommendation 31: Discontinue at the health plan, program contractor and DME supplier level the requirement that a prescription be provided before repairs can be made.

Recommendation 32: Maintain an inventory in stock of standard wear and tear items; batteries, wheels, castors, safety related devices, arm pads. If needed items are not in stock, allow consideration for expedited shipping based on the needs of the consumer.

Recommendation 33: Offer a variety of options for repairs and preventative maintenance such as appointments, group maintenance work shop days; mobile and / or same day repair or walk-in repairs, in home repairs. For example, every Saturday hold a workshop specific to batteries, tires, etc. Conduct a pilot clinic to see if the response warrants this type of service.

Recommendation 34: Inform, on an ongoing basis, case managers about the availability of repair clinics so they can communicate with their consumers, and provide information about clinics on web site or in various organizational newsletters.

Recommendation 35: Preventative Maintenance – Implement a focus on preventative maintenance including, but not limited to:

increasing inventories of common preventative maintenance parts,
establishing a consistent process and documentation for consumers to have original paperwork of equipment needing repair; i.e. original date of receiving the equipment, PCP’s name and a copy of the prescription,
educating consumers regarding up keep of the equipment and maintenance/repair requirements, and
providing, on an ongoing basis, information to consumers (alerts) about preventive maintenance and repair clinics.

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