Avoiding Product Substitution with your DME Provider



With new rules and regulations, product substitution has been of utmost importance. This is added with new reimbursements plans that quite often lead to a loss of revenue. It ends up affecting all – physicians, patients, DME provider, healthcare staff etc.

Every now and then, product substitution occurs because many physicians and/or patients are unaware of the DME products (e.g. dressing supplies) that are covered by medical insurance. Hence, practitioners end up using inferior or inappropriate products for patients. In most cases, Medicare and other insurance providers cover wound care dressing supplies under general policies. But Medicare ensures that the size of the dressing be matched to the size of the wound for reimbursements. Other reasons why DME products get substituted or understood as DME provider not stocking the product is mainly due to the deficiency of the apt product receipt wherein in actuality, the requested product is not covered as per the patient’s policy/LCD (local coverage determination).

Often, the DME provider does not inform this to the patient/healthcare provider (product is not covered), hence ends up sending an inferior/dissimilar quality and lesser number of products as well. Sometimes, this is due to a simple reason that the DME provider believes that since HCPCS codes are the same for two different products, he can send the substitute to the patient and not the same make as the one directed by the health care provider. Occasionally, DME providers carry out this activity due to the substantial price difference in the same product categories and retain a profit margin whilst DME billing.

To avoid these substitutions, a couple of aspects must be looked into:

1. DME representative: It is important to know that DME providers do not work with all insurance payers. Hence, creating multiple relationships with varied DME providers is an added advantage.

2. Products: Ensure that the products frequently ordered are available at all times with the concerned DME provider.

2. Cheat Sheets: Creating these sheets can be handy for the healthcare providers/staff to check if the prescribed product is available with the specific DME and covered/not-covered by the insurance.

3. Supply Ordering: To send and receive orders in the most time effective manner, review the ordering methods regularly (Email, fax, direct EHR gateway submission, etc.).

4. Supply Order Form: Ensure there is a ‘DO NOT SUBSTITUTE’ tagline on all orders and that the orders are relatively easy and simple to understand (e.g. include tick boxes for various selections). Streamline the form and upgrade it at regular intervals to best fit the needs of the health care provider and DME ordering and regulating procedures.

5. Contact Person: It is beneficial to have a contact person who directly liaisons with the DME representative at all times.

All these issues can contribute to a well established and corrective patient care.

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