E16 Mastering Medicare DME interview with Steve Ackerman
[00:00:00] Amy: No, no, it basically becomes this dialogue, like, Hey, is this okay? That no, that's not okay. But we can't tell you what to really write. Yeah. So try again. Okay. No, it's illegal for us to tell you how to frame this conversation. So we're going to basically put you in a restaurant and be like order what you want.
I want chicken chow fun. Nope, Nope. Nope. I'm not telling you what kind of restaurant we're in. Yeah. It's not
like this 
Alex: is the, is it a wonder that physician suicide rate? 
Amy: I mean, this is crazy. 
  Hey buddy. Welcome back to another mastering Medicare podcast. I am your cohost, Amy Schiffman, [00:01:00] and I am here with my cohost, Alex, Mohseni. 
Alex: Hello everybody. 
Amy: Hello? And we are so excited about today's podcast. We are interviewing Steve Ackerman, who is I'm going to call you the president CEO, owner of spectrum, durable medical equipment.
And he is going to, and I probably just botched the name of the company. It's probably spectrum medical, I think anyways, and now the dog is barking. So we're doing a great intro so far. And, uh, we are going to talk today about durable medical equipment and it is possibly one of the most complicated things that I used to try to figure out when I was a house call, doctor.
I mean, it is impossible to figure out how Medicare pays for how people get, what does Medicare pay for? All of this has been a giant mystery and I encountered every day in my current position. And so we're so lucky to have Steve here and he is, is going to open our eyes. I am going to let Steve introduce himself a little bit since I've done such a great job and tell us a little bit about his [00:02:00] company, what he's been up to for the past many, many years.
And we are so excited to have your expertise here today. 
Guest: Oh, thank you very much, Amy and Alex, it's wonderful to be here. Uh, uh, the company is spectrum medical. Uh, you were pretty close on that. Um, we've been in the, uh, in the DC area since 1983. Um, so we've seen the highs and lows and rides of Medicare, uh, change over the years.
And, um, the interesting thing is the environment at home has stayed the same for those 38 years. You know, you typically have families in a crisis situation or in a rehabilitation situation that you're dealing with and, um, uh, assistive devices and equipment, uh, are a big part of both of those things where you, whether you're getting better or whether you're dying in peace.
Um, having a hospital bed, a wheelchair oxygen, Bathroom equipment and those sorts of things make a big deal in, uh, how that process goes. I think if you're, [00:03:00] you're a, I don't know if you want me to just dive into the background of what Medicare covers and durable medical equipment or, uh, how would you like this to go?
Amy: So why don't we do this? Why don't we first talk about what is durable medical equipment? Let's start off with some really good definitions. We'd like definitions. 
Guest: Okay, well, durable medical equipment that has come out of actually Medicare's, uh, vernacular. They, they have divided equipment. Um, and this is a good thing for people who are ordering equipment or getting questions, asked to them, uh, they said, well, what kind of equipment does Medicare cover?
Well, the first thing is it has to be able to sustain repeated use. It's nothing disposable diapers. Underpads they're not covered by Medicare or anything. You can throw away. Um, now that I'm not going to get into wound care and some of the other things where they do have coverage, but, uh, basically any, any equipment has to be durable.
It can't be used in the absence of illness or injury. So you can't get an exercise bike, for instance, uh, covered through Medicare. [00:04:00] Uh, it has to be a, it can't be an environmental improvement. So you can't, uh, A stair glide in the house is not covered. That's an environmental improvement, hand controls in an automobile are not covered.
It's an environmental improvement. And then the last thing, and probably the most controversial is a, can't be a safety item. So once you go right through the bathroom door, anything in the bathroom is considered a safety item. The only piece of equipment that's accepted in that as a, uh, over toilet commode, which can be, you know, it has to be prescribed as a bedside commode and then it can be used over toilet.
But, uh, um, so anything that's a safety, a lot of lobbying up on Capitol Hill. So over the years that have, um, You know, kind of explored that because it makes no sense to pay 40, $50,000 for a fractured hip, uh, when you can pay $50 to have a grand bar put into somebody's bathroom. But, uh, um, yeah, Medicare follows these, [00:05:00] those four items, you know, it has to be durable.
It can't be used in the absence of illness or injury. Uh, can't be an environmental improvement and can't be primarily a safety item. Uh, so it has to be really something that's clean necessary, and that's acting on improving whatever that underlying chronic condition is. Probably the most controversial item right now is the hospital bed, because the, for instance, the high, low function on a hospital bed, meaning that the part of the bed that goes up and down, uh, about 10 years ago, was excluded from the Medicare program.
So Medicare will pay for a semi electric bed where your head comes up in your feet, come up. But they didn't, they decided that the high, low function was more of a, uh, help to the caregiver as opposed to something that's medically necessary. And, you know, again, if you, if you've cared for anybody in a bed and you need to get them in and out of the bed, you realize very quickly that raising the bed and lowering the bed, uh, goes a long way to getting them in and out safely.
But again, there's the word [00:06:00] safety that comes into it. That, uh, again is not primarily medical. So I kind of went off the, off the rails there on, on 
Amy: durable. That's literally, I can't actually believe that in the past 10 years, I never looked up what the definition of durable medical equipment it was. That was amazing.
So that explains a lot. I didn't realize that the safety component, because, and I don't want to sort of jump too far ahead, but that the high, low function that you're talking about, we often would see that ordered in assisted livings. And they would want that because they would want to put the bed low.
So that PO folks who might be getting out of bed in the middle of the night would sort of roll out of bed as opposed to fall out of bed. And it would reduce the chances of them breaking a hip or injuring themselves in some other way. So we were actually using it sort of off label to some extent, like they needed a hospital bed, but they didn't really need the high, low function for what we thought they were using it for.
Guest: Exactly. [00:07:00] And a lot of times it's ordered for caregivers, you know, if you've ever. Change somebody in a bed or done a wound dressing or, or, uh, giving somebody a bath in bed, um, you know, getting the bed up to a 25 or 30 inches high as, uh, you know, a decent thing in terms of people's backs, leaning over. And, and, uh, but again, it's not addressing the underlying medical condition of the patient, so 
Amy: medical condition, right.
So we're going to play a fun game. Steve, I'm going to name something and you're going to tell me if it is durable medical equipment covered by Medicare. Are you ready? Are you excited? I'm so excited for this game. Okay. All time go. Right. This is like your regular job, but this is like fun game time for Amy.
Okay. Uh, a hospital bed. Is that DME? 
Guest: Yeah, that's a little bit is DMA. Uh, you know, again, it meets the definition that can stand repeated use. It can be used. Um, to improve somebody's underlying medical condition. Now within that [00:08:00] hospital bed, we just described the, the various functions. So there's levels of hospital beds and the, uh, uh, the high, low function, which is something that most folks do want to have is the only part of the bed that is not covered.
Amy: Got it. So I'm gonna, I'm going to come to you as sort of like Joe blow doctor. And I'm going to tell you what I know about hospital beds, and then you, as part of this fun game are going to tell me if I'm right. So there's Medicare pays for standards, something called the semi electric bed, which means the head goes up the feet go up, but there's a crank function that actually controls the high, low function.
That's the standard hospital bed, correct? 
Guest: Yeah. And it doesn't actually have to have the crank function on it. Oh, Again, the crank function is something that, uh, is an additional expense when you're acquiring the bed. Um, most people providing hospital beds, put it on as a, as a matter of civility, because then you can raise and lower the height of the bed, but that's absolutely not required.
And they do make some electric hospital beds that you can set in [00:09:00] three different settings. Um, you know, by adjusting the head and the foot board, uh, those are the less expensive ones, but again, they, they meet Medicare's criteria. Um, and so you can set the bet either low, medium, or high, but then it's 
Amy: right.
Why is it called semi electric will plug into the wall? 
Guest: Well, now full electric is, um, a, a six function, hand control. You have, the head goes up, the feet goes up and the overall height of the bed goes up and down. A semi electric bed has a four function, hand control where just the head comes up electrically and the feet comes up.
Electrically. The medical criteria for a hospital. The underlying thing is that you need to have frequent and immediate change in body position, you know, to alleviate pain or to alleviate some kind of respiratory a problem, or to alleviate, you know, a choking problem. You need to be able to change the head or the feet quickly.
Uh, to correct a medical condition that can get out of hand very quickly. So that's, that's the 
Amy: right, [00:10:00] right. Alex, we're going to have an entire podcast on hospital beds only. I've decided like, literally this is it's just gonna keep going. All right. So we've decided there's hospital beds. So there's semi electric, there's full electric and then there's high, low.
What is the distinction between high, low and full electric? 
Guest: Well, high, high, low is kind of a misnomer there. You've forgotten that there's also a manual vent. 
Amy: Of course there's a manual bed. Right. 
Guest: Does 
Amy: Medicare actually pay you to use one of those? Cause it seems like 
Guest: again, the, this gets back to the frequent immediate change in body position.
Um, I haven't seen a manual bed ordered and probably 20 years on the fee schedule. You know, it's on all of the, uh, things that we contract for with them. Um, but it, a manual bed basically has three cranks at the end of it. So you have to crank the head up, you have to crank the feet up. Um, but it, it doesn't give you that immediate change and the patient can't control it to himself, so him or herself.
[00:11:00] And so that is very, it's not ordered very often. High, low is the, the, uh, it's kind of an out of date term, but it really refers to the bed being able to go up and down on its own. 
Amy: It's a type of full electric bed 
Guest: though. Well, no, a full electric bed implies high, low, 
Amy: it implies high, low. So basically we say high, low bed.
It is a full electric bed and that is an additional cost over and above what Medicare will pay for Medicare doesn't pay for the full electric. It pays for the semi electric. And then when you want to kind of like spice it up a little bit, it, you have to pay extra 
Guest: well start. Yeah. Several years ago, Medicare did realize that there was deluxe equipment out there.
And that there was an underlying, um, you know, that they pay for the basic types of equipment, you know, again, the semi electric bed versus the fully electric bed. So they did allow for an option for people to be able to upgrade equipment provided. They were given. Um, real good advanced [00:12:00] or they call it advanced beneficiary.
Notice that it's a non-covered item. They didn't want to see suppliers or doctors or anybody, um, loading stuff onto people that they didn't need, or they didn't really have the choice in doing so. We have, you have to do a lot of full disclosure, you know, if somebody wants to get a rollator as opposed to a rolling Walker, That that's a whole nother rabbit hole.
We can run down. 
Amy: You just walked right into the next thing. So we've established as part of our fun game where I pepper you with questions. So a, a hospital bed is durable. Medical equipment is a wheelchair. A is a wheelchair DME. 
Guest: Yes, it is. 
Amy: Okay. And, and wheelchairs, um, come in, I don't know, 4,000 shapes and sizes.
And will Medicare just pay for any old wheelchair or like, how does, how does Medicare sort of see wheelchairs in terms of its variety? 
Guest: That's a, this a, this is a, a real kind of complex area and you can stop me 
Amy: other podcast on wheelchairs too noted. Okay. Keep going. Well, I'll stop you in the middle if we need to kind of keep moving, but yeah.
[00:13:00] Give me the basics 
Guest: know there are a couple of cuts that you need to make when you're talking about wheelchairs. Um, the first thing is, are you talking about a power wheelchair or are you talking about a manual wheelchair? And then when you're talking about manual wheelchairs, you need to make the cut of, are you talking about a basic, uh, Wheelchair that would be appropriate for a geriatric patient.
Um, or are you talking about a complex rehab wheelchair that would be appropriate for somebody with a spinal cord injury or, or advanced multiple sclerosis or, or something that would require complex rehab fitting complex world, um, broke off from the DME world. Solidly. I want to say about 20 years ago, it used to be, every company did everything and we've seen, you know, respiratory has kind of moved into its own specialty.
Um, and sleep is its own specialty and complex rehab. Wheelchairs are their own specialties and people would call up here looking for, you know, I, I want to tilt and space for my mother with, you know, electric tilt and, and head support and all of the things that you would see [00:14:00] typically on say a. A child with cerebral palsy.
Um, there's a whole different area of fitting that goes on with that. And we will refer them to seating clinics. There are a number of good ones in the area at one down at Mount Vernon hospital when it NRH. And I, you know, I think Adventist rehab has a seating clinic, but basically for those more complex things, there is you have a higher level of reimbursement that you can get from Medicare and higher level of quality of cushions.
And. And things by going through a seating clinic and having an evaluation done, um, getting a power chair, um, you know, through a regular process, uh, with dealing with a medical equipment company and having a doctor, right. It is almost like an act of God. I mean, that is so 
Amy: that's why Medicare actually reimburses physicians for spending the time to fill out the 12 to 17,000 page document in order to get a power wheelchair, like Medicare pays for you to fill that paperwork 
Guest: out.
That's correct. 
Amy: Yeah. Not only the pain [00:15:00] for you to provide it, but it pays for the doctorate. It's crazy. Yeah. 
Alex: Wait, can I interrupt? What is a seating clinic? I've never heard that term before. 
Guest: Uh, I see it in clinic as a, um, uh, it's actually a physical place that you go to and it's usually attached to a rehabilitation, um, uh, hospital or, or it books in our area it's attached to a real rehabilitation hospitals.
And they have a, um, a certified people there in the DME business, that's called an ATP, which is an assisted device professional. Um, that brings in equipment, works with the OTs and PTs and the, and the patient they're, uh, trying out different things. They use pressure mapping for their, their seating to determine cushions.
There's all of those, probably a two or three hour evaluation that goes on. It could be multiple evaluations to get the right piece of equipment. For somebody. Um, and again, you're dealing with much more involved kinds of cases. Um, so, so the, the [00:16:00] idea is, is that there's a collaboration between equipment provider, doctor, and, and, uh, occupational therapist to come up with the optimum piece of equipment.
And in the case of children, it's, it's critically important because you're going to, you're buying a tool thousand dollars piece of equipment and. The child is going to grow out of it in a year. So you have to have, uh, the ability to stand the chair they're in to growth. You have to have so much more complicated thing than, than, um, Sitting an 85 year old, a geriatric patient.
Right? 
Amy: So if I was a doctor, speaking of that, so if I, sorry to interrupt, cause you told me I could interrupt you. So I'm interrupting you to ask you if I am a geriatrician, an internist, uh, a physical therapist, who's going to be guiding a physician who might be ordering a wheelchair for an 85 year old dementia patient.
What are my choices for, for wheelchairs? 
Guest: Okay, well, Nick, your choices there and, and we're, we're. The vernacular has kind of been driven by the, uh, Medicare pricing model, which is the K codes. Um, you have a K [00:17:00] one K two K three K four, you know, pay five and six. Um, you're, you're starting to get into the, the bariatric equipment and, and the, the higher end equipment.
But 80% of the time you're going to be ordering a, a, probably a K three wheelchair. And to describe them, K one is a standard wheelchair. K two is a Hemi wheelchair, which is a low seat model. The term Hemi wheelchair comes from a hemiparesis. They were designed originally for people with a stroke, um, that needed to get good foot contact on the floor to be able to propel the chair on their own because they only had one foot and one arm.
So you use the arm as the gas and the foot is the steering wheel. So the Hemi chair was a typical wheelchair, has a, uh, a 17 inch, uh, or 18 inch seat to floor. A height and then a Hemi wheelchair will have a 16 inch seat to floor. So it drops you down two inches. Um, and we'll typically look for that being ordered if anybody's five, four and [00:18:00] below and their, and their foot propelling, meaning that, you know, part of their getting around is using their feet to, uh, move the chair.
Um, and then, so K three that's K two K three is a light, a standard lightweight chair. Uh, which is probably the most ordered chair because it presumes that a heavier chair. K one is not, um, a lot of things you can't propel it. They're too heavy. We're talking about a 40 pound chair at a K one, and then you get to a K three and you're back into the low thirties.
Um, the interesting thing is that the Hemi chair is really a K2 with just the lowered seat. So you're the way the wheelchairs are made. Right now you can take a K three and switch it into Hemi height. Um, you know, almost at will. It takes about 15 minutes to do it. 
Amy: Steve, quick question. I am just like the dumb doctor.
Who's just out in the community. How in the world? Is a [00:19:00] doctor supposed to know any of this. I'm not going to lie. I do know about the K's and the, this and the, that. And at one time I really understood this stuff, but like, I feel as though things have gotten so complicated, you, you can't know all of this, how do doctors order wheelchairs?
Guest: Like how, like, how would 
Amy: any doctor know what to do? 
Guest: Yeah, well, there, there are a couple of ways that they're being ordered right now. We're we're um, we're using a, an ordering portal. That shit. Yeah. Parachute that, uh, I think Alex, I saw that, you know, Dave, Gelbard, he's a good friend of ours, uh, started parachute, which is an ordering portal.
Again, the ordering portal is you have to be very careful with because, um, one of the things that Medicare has had fraud and abuse problems with his, his, uh, Orders that are just stamped out without any thought to them. And, uh, and, uh, so anything that looks like it's a template or anything that looks like it's just me, uh, Uh, put in front of a doctor [00:20:00] for a stamp and a signature, um, is no longer being accepted under audit by Medicare.
You've got to get, when I talk about, uh, with therapists and their clinics, I mean, it is literally easier to get, hold on than it is to get a Walker. Uh, as far as justification from a doctor's standpoint, um, notes, we 
Amy: have Pete that I would like to, to repeat that statement. It's so profound. 
Guest: It is easier to get a prescription filled for oxycodone than it is for Medicare 
Amy: from 
Guest: a doctor's standpoint.
I mean, as far as not required, can you, 
Amy: I was waiting for him to kick in. I was waiting for Alex is like mind the finally blow. 
Alex: I'm just astounded by what you just said, which is that any order that looks like a template? Uh, could or should be, or would be rejected. So if you [00:21:00] make it a standardized process for the doctors to order these, then that's going to get rejected.
Like what do they want? Like an 
Guest: essay from the doctor, that's it? Well that, you know, it's true. The actual detailed written order can be in. And this is Amy getting back to your question of how does the doctor order it? We have a, we have a template. Detailed written order where you check off, Hey, it's an 18 inch by 16 and see to it's a K three wheelchair.
I want, Hey, I want to a back and a cushion with it. And so those items can be checked off and signed on, but the kicker comes in is that the norm I have to reflect, um, that you've had a discussion with the patient about those items and, or, or, or has to show medical necessity, um, for those items, um, In, in your, uh, chart notes.
And we need a copy of that. We don't need a copy of the entire chart note. We needed a copy of the notes that say that, that this has gone on. And so this 
Amy: is a new thing, right? To have a copy of the chart notes used to be, you would [00:22:00] just sort of like randomly get a prescription pad. You'd be like one wheelchair sign.
Dr. Schiffman, here you go. Right? Like that used to be how it went now. It's it's. 
Guest: I don't want electric wheelchair. You have to rule out the fact that you can propel a standard wheel or you can't propel a standard wheelchair.
Amy: So how is this factor 
Alex: supposed to know what to write in there? 
Amy: No, no, it basically becomes this dialogue, like, Hey, is this okay? That no, that's not okay. But we can't tell you what to really write. Yeah. So try again. Okay. No, it's illegal for us to tell you how to frame this conversation. So we're going to basically put you in a restaurant and be like order what you want.
I want chicken chow fun. Nope, Nope. Nope. I'm not telling you what kind of restaurant we're in. Yeah. It's not
like this 
Alex: is the, is it a wonder that physician suicide rate? 
Amy: I mean, this is crazy. 
Guest: No, no. And, and, and the, [00:23:00] uh, you know, 
Amy: women, we digress, 
Guest: you know, in the industry, uh, uh, and I've done a lot of work on, on Capitol Hill. I was the chairman of the American association for home care for the last three years. And we're constantly trying to get this revised.
And, and when we've agreed in the past as an industry to have certain things come into play, um, it's always with the understanding that Medicare is going to be doing extensive training to the physician community, and that somehow never happens. So, 
Alex: you know, what they consider extensive training is, well, yeah, they create a webpage or a PDF document with 55,000 pages of details about some new thing that doctors have a lot of time to search for and read.
Right. I mean, that's crazy. It's insane. 
Amy: It's insane. There is mild insanity to every single topic that has to do with Medicare. 
Guest: Yeah. 
Amy: The amount of that, the thing that blows my mind, um, [00:24:00] is, uh, the thing that blows my mind is that we, how could a doctor know that neutropenia? K one K two seat race. And by the way, I remember I had this distinct memory, Steve, of like trying to order a wheelchair and they'd be like, do you want armrest?
Well, yeah, it'd be want those, you know, like you have to order it like piece by piece. It's like ordering cars, steering wheel. Yeah. Front seat. Yep. Also assigned seat. Yeah. Like a backseat also. Like it's sort of like, they make you order this thing and like pieces and it's kind of cool. It's just like a Lego.
Thing that they just don't give you well, some of the, I mean, I just don't get it. Like, how are doctors supposed to know this? I mean, Steve, can I get a little bit of like kudos? Like I did kind of figure a lot of this out. And it was really important in my training of my providers. 
Guest: You're one of the only people that took the time to come over here and actually kick the tires and see what was going on on our end to better understand the.
But you were ordering and, and, uh, I think, you know, taking a walk [00:25:00] through the warehouse, uh, it explains a lot and you know, I've got to say in defense of Medicare, you know, again, they get, get a bad rap on all, a lot of this. They have had to police a, uh, a crazy industry. I mean, our industry, uh, because of the ease of getting provider numbers, um, you know, we, whenever we went down to Capitol Hill, we were always fighting the, uh, The guys that are on channel nine and 11, o'clock slamming things down people's throats.
And then, you know, and there's well publicized, you know, power chair sales from companies that are on the tarmac at Dade County, in Miami, you know, with people that have no business being in the, uh, in the industry. So they've done a lot with accreditation. They've done a lot with, with, uh, pricing, but they've also, um, you know, done a lot.
I think the over complication of this as a defense against, uh, People just jumping in and, and, you know, it's, they're, they're kind of vain attempt to trying to keep the industry clean. And personally, in a lot of cases, they throw the baby out with the bath water because it, uh, over-complicating, it [00:26:00] just, you know, makes either equipment unavailable to people or, uh, it certainly puts extra stress on the time that position tab, which has limited.
And this is yeah, your, your, your commodity is time. And if you've got to spend an hour. Putting together a wheelchair, um, prescription there. There's something wrong with the system for sure. Up yet. 
Alex: Yeah. It seems like every week there's a new story about some sort of DME fraud, uh, you know, uh, in Florida or Texas, it always seems like 
Guest: large 
Amy: Florida and Texas.
Guest: Yeah. It's like, it's like the bank robber that said I Rob banks, because that's where the money is. 
Alex: That's right. That's right. 
Guest: So, 
Alex: um, 
Amy: we're not done, but we're not done. We're not done with our fun game. Oh, you have more questions. Okay. So we've got, okay. So we've got hospital beds and we've got wheelchairs.
We could have like four podcasts on each of those then walkers. Yes. That's considerable. 
Guest: And, and, and, uh, [00:27:00] the industry we got, you know, we, we call this stuff, bent metal. I'm like, excuse me. Are you still there? 
Amy: Yeah, we're here. We're here. 
Alex: Did you lose your audio, Steve? 
Amy: Oh, no, he actually dropped completely.
Okay. We'll edit this out. Okay. 
Alex: Well, we can keep recording, uh, while he logs back in. So it's Amy, while we wait for Steve to lock back in. Um, so. What was the most common, uh, DME that you would order in your house call practice? 
Amy: Oh, always a hospital bed. We would get to people's homes and it would be kind of amazing.
We didn't order a lot of wheelchairs because you have to be able to, and Steve will get back on and talk about this. Wheelchairs are actually intended for indoor use. It's not really, there are transport. Wheelchairs, but I don't think Medicare pays for a transport wheelchair. They only pay for wheelchairs that can be used in someone's home.
So in, when we went to [00:28:00] people's houses, the first to say is where do you sleep the bed a recliner? You know, I can't breathe 19 pillows, like whatever it is. And the very first thing we would do is get a wheel, is get a, excuse me, a hospital bed into their home. So that became my, like, we were really good at ordering hospital.
Beds. And we had a dropdown list template in our EMR. That would say, cause you need, I think needed three reasons why the person would need a hospital bed. Like a, it wouldn't be like, it needs to be at this degree so that they can breathe. Cause they've got COPD or. To assuage pain or there was all sorts of different things.
So we could get those different reasons into the chart note by temp, we did template it, but it was still a dropdown. So it, Lou in the dialogue came out, it looked, you know, it looked like a real, like, I believe this patient needs a hospital, but because they have this, this, this, this, and this, and we would be able to, you know, put in their medical problems.
And that would be the, sort of the, the written [00:29:00] part of that order that they needed. And it would be in 
Guest: our chart note. 
Alex: What was the process in terms of like, Uh, w w what, if you hadn't ordered it correctly, who would find out first was with the DME company? So 
Amy: the DME, the D so first off, they're not even going to submit to Medicare for payment, or even attempt to deliver without about 25 different steps.
They, number one had to make sure you had Medicare part B. So we, whenever we sent over an order, They would also do a Medicare check. So we would do a Medicare check and then they would do a Medicare check, make sure that they were going to get paid. And then if they knew they would get paid, then they would say, okay, do we have all the pieces of this puzzle?
Number one, do we have permission to deliver it? Do we have the chart note that supports it? Do we have an order that supports it? Um, if the patient is going to want to have something more than just a standard electric bed, do we have a. Proof of payment that we can Jack up the price. So I think we've talked about this, but Medicare [00:30:00] is basically a rent to own lease to own system.
And so basically, because it's a lease to own system, it's a 13 months of Medicare paying about $99 a month for a semi electric bed. So Medicare will pay up to $1,300 for that 70 electric bed. And after that, the patient owns it outright. It's a life it's basically, I think you own it for us. For the rest of your life.
And, but you can't get another bed for five more years. So we knew that when we were starting this process, we said, we want for Medicare to pay for as much of the stuff as possible for this person. So we would make sure that they understood that they're getting a semi electric bed. Medicare's going to pay for it completely for them except for their copay, because it's a part B.
So it's 80 20. So they're gonna have to pay 20% on the cost unless they're. They're you know, secondary insurance will sort of kick in for the rest. And for 13 months, Medicare will pay $99 per month. Now, if they wanted a full electric bed, [00:31:00] they would have to pay an additional, you know, between, I don't know when Steve comes back, he'll tells us between 70 and a hundred extra dollars per month on top of their part B copay, unless they had a good secondary insurance, but the semi electric was the standard.
And then if you wanted to sort of get more stuff. You would have to pay and that included, um, you know, if you want, I'm not really sure about the standard, um, of the mattresses because the mattresses themselves. Yeah. There's also standardized. So you get a standard bed and a standard mattress with every standard hospital bed.
That's what we call a semi electric. So for $99 a month, you get that whole package. There is a difference. You could get different types of side rails. Like if you're in assisted living, you can only certain get certain types of side rails. You can get a half rail or a full rail or whatever the case may be.
You could not have all of the bells and whistles and have Medicare pay for it. But if you have. An American express card. Like I always say you can get all of that stuff, so they would need to know I have [00:32:00] that in order. Okay. Did the doctor want for the person to have a semi electric or full electric? Oh, they want a full electric.
Great. Not only do we need to, hi Steve. Not only do we need, not only do we need to have all of the. Um, records that prove the patient actually needs the hospital bed, but we have to probably have proof of payment. So Steve, I'm going to catch you up just briefly and, and, and tell you where we landed. We took a brief interlude and we're discussing how.
Does, how does it the back and forth sometimes, yeah. Between a physician and a durable medical equipment company like yourself. So I, and I always used spectrum. So, um, when I would send an order over and this was before parachute, so I'm going prepare. She, because I think most people are not on parachute.
So I kinda like to talk about it in a non parachute world because that's really very, um, it, it helps. The provider, the geriatric care manager, whoever's going to be helping or participating in the ordering of DME to kind of really understand the nuts and bolts. So what I said was I [00:33:00] have a dropdown menu in my electronic medical record that would basically say they had certain medical problems and we knew what they would be in order for Medicare to pay for the standard semi electric bed.
And then. What I said was, is I would then send over the order and my chart note, and then you guys would make sure that a, the patient has had part B Medicare, that we had the right stuff in the chart note that the order looked correct. And that if we wanted to Jack it up and do a full electric, that you would have to call and verify that the patient's family member representative or patient themselves would be willing to then pay for that extra cost.
We then talked a little bit about the fact that this is a lease. From Medicare that you end up owning it at the end of 13 months. So that, and I, and I was remembering, and Steve, this is where we're going to sort of have a little fun with my fun game of peppering you with, is this DME in standard, semi electric hospital bed, Medicare reimburses, you guys X amount of dollars like 99 [00:34:00] bucks per month kind of thing.
Is that basically what it is? 
Guest: More it's more like 60 now. 
Amy: Sweet. It went down. That's even better. So 60 bucks a month for 12 months. So $720. Does it pay for itself? 
Guest: Right? Barely. Barely. I mean, this is, we can go down a whole, another rabbit hole with talking about competitive bidding and how the pricing has a.
Come down on all this equipment, but I think let's get back to your question about the interaction between the doctor and the Dean. Yeah. What we typically do is it has to be good, a little bit of a collaborative effort, and generally what'll happen is a care manager or a physician's assistant will call us and say, Hey, dr.
So-and-so wants to order a wheelchair. Um, we'll go through some of the specifications with them. The first thing we ask anybody that calls in here is their height and weight. Because you have to, you have to determine very quickly if you're dealing with somebody it's in a bariatric world or somebody who's particularly small and wheelchairs, again, the three [00:35:00] flavors that are pretty interchangeable or the, the narrow adult, the standard adult, and then the, uh, heavier adults.
So it's a 16 inch seat, an 18 inch seat or a 20 and seat and all of those fall within Medicare's. Um, Yeah, coverage criteria. So you want to, you want to get the proper seat for somebody right away. So we'll have that discussion. And then, uh, frequently what we do if, if the office doesn't order or the person doesn't order a lot of equipment, we'll send over, um, a copy of our detailed written order that has all of the boxes checked on it.
And then a copy of what the, the, uh, notes need to refer to. And again, they can't just sign the notes and send them back to us. They have to be incorporated personally into the, uh, Uh, the chart notes that shows that there was discussion and thought about ordering these particular things. It sounds a lot more complicated than it is, but, you know, again, if people are ordering things quickly, it, um, you know, it's a couple of sentences that need to just meet, uh, [00:36:00] what's called Medicare's local coverage.
Determination. LCD is kind of what drives all of this. And, uh, every piece of equipment has its own LCD. And, um, you know, some of them are, are antiquated, you know, to get a reclining wheelchair, you either have to be highly susceptible to decubitus ulcers and unable to do a functional weight shift, or you have to be self catheterizing.
You know, it has nothing to do with the fact that you spend eight hours a day or 10 hours a day sitting in a nursing home in the wheelchair, and you need to go back and forth a little bit. Um, so if those two things are not in the, the, uh, Order or one of those two things is not in the order for a reclining wheelchair.
It will be denied on, uh, uh, on review or on audit. And, um, again, the industry we've been arguing for years about clinical inference, as opposed to, you know, a lot of time, you know, if somebody has had ms for 30 years and they're on their third wheelchair, you're wondering why am I having to even prescribe this or [00:37:00] discuss this?
I mean, it seems a little ridiculous, but Medicare has not made the leap into a. Except in clinical inference at, at the audit level. And, um, we've made 
Amy: good, the term clinical inference in my life. It's kind of profound. Like it's part of the expected course of that illness that somebody with ms. ALS, blah, blah, blah, blah, blah, is gonna have this 
Guest: cord injury.
I mean, why, why are you justifying a spinal cord injury for the third time 
Amy: in France? Brilliant. Yeah, we should all use a little bit more of that. 
Guest: Well, it is. And then if you're thinking and looking at the whole patient and that sort of a situation, uh, you know, for years, the guy 30 years old is going to school or going to work with a spinal cord injury was getting the same LCD as an 85 year old with prostate cancer, you know?
So the, the, uh, it's taken a lot to kind of unglue. You know, what, what they're looking at in terms of the individual patients, but, uh, and it's [00:38:00] an ongoing fight. Sure. 
Amy: I mean, I want to just reflect for a moment. I think I may have said in a previous podcast, in as part of my house calls practice, we would go into, you know, lots of different people's homes.
And I would go in and be like, Oh, that's where a quarter of a million dollars is. I was looking for that. Right. We would see three bariatric beds, three bariatric wheelchairs, three, this three of that. You know, because over time people collect DME thousands and thousands of dollars of DME was I went into one house.
I was like, Oh my God. 
Guest: Yeah, well, 
Amy: Medicare, hi, this is a hundred thousand dollars just sitting right here in this person's 
Guest: room. Yeah. 
Alex: They're a secondary market. 
Guest: Uh, it's pretty limited. Um, in terms of, um, particularly the power stuff because of how individual it is. Medicare, you know, kind of attack that problem Amy, a few years ago and they, they limited it actually several years ago.
Um, they limited the amount of equipment [00:39:00] they'll buy for somebody in a five year period. For instance, you can't get a second wheelchair in five years. You can't get a second bed in five years, you know, pretty much any standard DME unless it's been stolen or damaged beyond control. And, and, uh, in those cases, proving that as you know, sometimes I just want to give it away.
It's easier to give them the patient. The equipment than it is to prove that, uh, something was stolen in terms of what Medicare looks for. But the, the, the bottom line is yes, there there's been, uh, a lot of waste, a lot of accumulation. And then there's technology changes. I'm sure if you go in that same house, you're going to see three or four different generations of power chairs.
So it's, you know, it's like automobiles, they get better. People want to have the, the latest model. 
Amy: Oh, sorry. I just wanted to interrupt really quick. Just the, the issue that I did bring up with wheelchairs is wheelchairs are not intended for outdoor use a wheelchair that is ordered is supposed to be able to be used indoors.
Correct. 
Guest: This is [00:40:00] another, uh, big thing. Durable medical equipment is ordered principally to, um, accommodate activities of daily living that are limited by whatever the disease process is. And that the inference on that is that it's in the home. Um, so if something is being ordered specifically to get somebody out of the home, uh, and it's ordered that way, it's not a covered item.
Um, 
Amy: as an example, a transport wheelchair not covered by Medicare. 
Guest: Well, a transport wheelchair. It's interesting that they have those on the, on the peace schedule, but they, they kind of also defeat the LCD because in order to get a wheelchair covered, uh, you have to be able to propel it on your own. You have to be willing and able to propel it.
And there's no way to put a transport wheelchair propose don't know what that is, is a, is a wheelchair with, with, uh, four, eight inch castors, as opposed to a standard wheelchair that has two, eight inch castors in the front. Okay. Then it has a 24 inch wheel on the back that everybody's familiar with and it has [00:41:00] the, uh, The, the tremoring that you grab onto to propel the chair.
Right? So the transport chair is more designed to be able to push somebody to the movies, or I guess we don't go to movies anymore, 
Amy: pre pandemic stuff. Yeah. 
Guest: Um, and it's easy, you know, the back folds down on it and you can throw it in the car real easily. So it's, it's very, very, um, friendly to the person who, or the caregiver.
And not necessarily primarily medical in nature. Now, if you call Medicare, they're going to tell you that transport chairs covered. And, you know, we go back and forth on all of this, but, but, uh, again, it doesn't, it doesn't meet the criteria of being able to sell propel. 
Amy: Okay. So we've got, okay, Alex, you go, I'm going to keep peppering 
Alex: that I've been accumulating here.
Um, so what are the most common reasons that a DME order gets rejected and. W, you know, if you have an audience of physicians here, what do you, and you, you have a billboard, like what would you put on that billboard in terms [00:42:00] of teaching them, how to order DME better, 
Guest: the number one thing. And the key thing is the notes, you know, and, um, you know, having the office understand that those notes have to be in the, uh, The physician's record.
You know, again, we can, we can tell you, we can send a piece of paper over that says, Hey, you need frequent, immediate change in body position to alleviate pain, to get a bed. But that, that actual note, and we're looking for it pretty much verbatim because when we go to an audit, if we're audited, that's what the auditors are looking for.
And they're not looking for clinical inference, you know, they don't want to, you know, just because. You have a diagnosis. That's obviously got you in pain. It needs to be stated in the notes that that was the case. 
Alex: So Steve, has anybody created or do you provide, or do others provide a cheat sheet that says.
Here are the 10 or 20 most common conditions. Uh, here is an example [00:43:00] of what the note should say or what the key elements are. That should be in your note. 
Guest: Yes, yes. Now again, we, we, we, we walk a tight rope there because we're not allowed to coach. And, um, you know, this had, when we were doing a lot of work with power chairs, it became a real tricky thing because it was back and forth three or four times to get notes.
Um, correct. Stop. And, you know, at some point we have to say, Hey, we've coached too much. You've got to take this to another, uh, another vendor because they're not looking for us to write the stuff that is essentially going to get us paid. I mean, this is where the fraud and abuse problem, uh, 
Alex: so crazy. So can you unpack that a little bit about what does that mean?
You're not allowed to coach and what could happen to you or the physician? 
Guest: Uh, well, they, they, they, I guess the abuse problem stems, you know, if you go back a few years, there were some very well publicized [00:44:00] cases, particularly, uh, with the scooter store, for instance, where, um, they were hammering out template notes and template, uh, orders that meant every point on the local coverage, determination the LCD.
And then, um, and then actually they were leaning on physicians, hard, uh, part of the, the, uh, Indictment against the scooter store involved the fact that they were bullying physicians into signing things that they didn't necessarily agree to, uh, in order to get people, you know, Hooters that were not really medically necessary.
And so that it becomes a, uh, uh, tipping point right there where we, you know, we're hoping that that folks in our industry, but you know, again, you've got new people, you've got, uh, people that are unscrupulous that you have to be careful of. Yeah. The idea is, is that the physician was. The, the, uh, kind of watch, you know, the gatekeeper of the Medicare program as far as durable medical equipment and what happened [00:45:00] back in actually, you know, to digress for a second, the, when the Medicare program was, was developed, you know, back in the sixties, it was a perfect model because you have the 20% that was paid by the patient.
And 80% was paid by the government. And when that model was enforced through the seventies, It worked beautifully because the patient paid attention to the bill and the patient ordered what they needed. As soon as you know, in the early eighties, when co-insurance came into existence and you were able to purchase the coverage for the 20%, it became an entitlement program.
I mean, everybody took their eye off the ball and there was no gate. Okay. 
Alex: That is a really interesting observation that the patient used to be the check on fraud and abuse because they carried 20% of the expense on part B services. And when you take that had a way, all of a sudden the, the opportunity for fraud is.
Too. It's just too tempting. Um, that's really, really good. Just 
Amy: like an all you can eat [00:46:00] buffet. 
Alex: It makes me think like it's, it's a real shame that, that we've ended up in this situation that we are in because we've made it so difficult for physicians that the patient is the patients who need these aren't, aren't getting them or getting them fast enough.
And that's a real, real shame. It makes me think of other possible solutions. You know, what, if you could just order, uh, you know, a wheelchair by just writing wheelchair, uh, but, uh, and not have to know all this complexity as a physician. Uh, but maybe, I don't know. Maybe if there were a third party auditor who has a, you know, a trusted entity.
Who would access the medical record review it, use the, kind of the, the clinical inference that you mentioned to say, yeah, this is obvious. This patient, he's a wheelchair. I put my stamp of approval and I am like, you know, KPMG or some other third party auditor that the government trusts. And so make it easy for the doctor, but still use [00:47:00] this as a stop against fraud.
I don't know. Is there anything like 
Amy: that? Oh, wow. Can we hold on before you, Steve, you go on Alex. Can I just ask. Is your idea. And this thing that you just said, kind of like saying the ROI on having DME in the home is actually very high. If you give somebody these certain things, they will have a much less chance.
So maybe going back to the hospital falling, um, you were somebody who had a ton of medical records and you said, wow, this is potentially an underused resource with a huge ROI. You can sort of in bulk sort of suite people's medical records and be like, why don't Bob, Sam, Shannon, and Fred who work in your company or work, or in your insurance company or in your sort of, or, you know, beneficiaries of your insurance company.
Why don't they have these things? Why aren't you supplying them with DME and that, and like, look for stuff in chart notes that would sort of cue you up to think, Oh my gosh, why don't we have DME for these people? Kind of like, you might do it for why don't they have home health? Why aren't they getting house calls?
Why aren't they getting physical therapy? [00:48:00] So you could be sweeping people's documents for under utilized high ROI thing. 
Alex: Well, that's an interesting concept. Do I? That's not really what I was saying. I was saying. It's four. How about instead of Medicare putting the burden on the physician to, you know, throw the dart and hit the documentation blindly like without any coaching or guidance, like clearly that is leaving a lot of patients without the equipment that they need.
Right. That must be the end result of that. Uh, and they've done that because it's their only defense against the rampant, fraud and abuse. Uh, and it is good to stop proud of you. So let's come up with a better system. You, you can't keep putting more money, more burden and complexity on the physician and expect that you're not going to have bad outcomes for patients.
Guest: That's the second, the product use has gotten much, much better in recent times. I mean, the industry is policing itself. Um, accreditation came into play back in the, uh, I think it's around 2009. [00:49:00] Mandatory accreditation became part of our industry. So, uh, uh, and the, and the, and the accreditation is actually very, very, um, it's a strenuous process to go through it, you know, Jayco and.
Chap and all of those have a DME component now that, uh, uh, you have to do that so that the fraud and abuse, um, the thread of it is always there, right. And providers are gonna are gonna be there. And there's always, you know, four or five times a year. Now there's a huge, you know, million billion dollar case that is broken right there.
You know, there's, there's something going on. DME is an it's an interesting component because I talked to a lot of people about it. And my recommendation generally always is get home and see if you need it. You know, some, some people view it, um, as a, a, um, a negative in their life. You know, this is holding me back, you know, I can't get around.
Um, and so when I'm talking to people, you know, a lot of people will come in [00:50:00] and want to buy things. Uh, in advance of their surgery and, and my answer is always get home. You know, first of all, you're going to go through, uh, therapy at the hospital. They're going to order a few things. If you need it, that's appropriate.
It's usually all typical stuff. Um, and then get home and, and don't, don't solve a problem until you have it. Um, and then again, getting back to your point with the doctors, the, the, the one, uh, group of people that don't get enough credit or the, uh, or the home health, OTs, and PTs that are out there. And they're generally making the recommendations back to the doctors on, uh, what equipment is appropriate for people in the home.
Amy: Yeah. So Steve, I just want to interject just really quickly. I agree. I need to sort of pile on and say that PTs and OTs are the most important partners in DME ordering that you could possibly have. The one thing I would say to my providers. So I said, listen, you can figure out K one, two, three, blah, blah, blah, and all the different pieces, but do not.
Do not [00:51:00] hesitate to put a physical therapist in there immediately. When you think there's going to be, you know, a durable medical equipment order that will be required. Why guess why, why do we, why are we getting, this is what they are trained to do. So. What it used to be was is that if somebody went into the home and I was like, Oh my gosh, they need a hospital bed.
Some of that was really easy. But as soon as it came to wheelchairs and walkers and recommendations for other types of stuff, I would put parties, home health in place immediately, immediately. Why not? Or part B actually support yeah. Part a or part B physical therapy in the home. Come in, let someone do a home safety assessment.
Let somebody look at what the person's functional limitations really are. And tell me how to order this very complex thing, because. Wheelchairs are not just hard walkers or hard beds, they would come up with other different ideas. And it's like, not again, not knowing what kind of restaurant you're sitting in and they know the restaurant that they're sitting in.
So, sorry. Yeah. They're just amazing, um, adjuncts to this [00:52:00] process. 
Guest: That's also a smorgasbord of what's covered and what's not, you know, again, a lot of times you need bathroom equipment and that's not covered, but you need a bath seat or do you need a transfer bench? Or if you need a transfer bench, do you have a shower extension?
You know, those kinds of things, they're all very good at kind of pulling that together. And if you, you know, if you need a shower extension, should you get it from the DME company or get it from Costco where it might be 20 bucks less? You know? So the, the PTs and OTs have a really good command of that.
And, um, you know, can kind of go a long way. We also act as a backstop at, at least in our office because, um, we're the ones that are saddled with a problem. If the wrong stuff's ordered, cause we're running back out again, getting stuff corrected. So if an order comes in for somebody who's 220 the pounds for a narrow adult wheelchair, you know, we've got bells that go off here and we'll go back back to the doctor's office and say, Hey, um, Is there a reason that somebody who's 220 is being put in a 16 inch chair and usually it's a mistake or an oversight, or, or maybe that they're there, you know, [00:53:00] seven feet tall and thin, you know, that thin.
But, uh, you know, we, we generally will use body mass index to kind of make sure that they're getting the right size chair because, uh, we deliver the wrong one. We're out the next day with the right one in variably. Steve. Talk to me 
Alex: a little bit about the nightmare of walking into a patient's house, where there are a hoarder or maybe there's bed bugs and it's full of garbage and you need to now pull in a hospital bed.
There's no space for it, like w w I'm just, 
Amy: I love that granular question. It's a great question. It's really reality. 
Alex: I think that's the reality. Sometimes 
Guest: I've got a couple of drivers that could probably answer it better than I do, but the, the, uh, um, we're, we're very, um, uh, I guess investigative on the phone, uh, with any equipment we're setting up, I mean, we're our, our customer service people would call you in the morning are gonna say, is there a space cleared [00:54:00] for this bed to come in?
You know, if we need a single outlet for it, we don't want to see it plugged into a surge protector. Um, and our guys have got to pay attention to that. We had an incident out at, um, the Washingtonian where, uh, we advised a guy, you know, to not plug into a, you know, it was a situation where there was a hoarder and everything was plugged into one surge protector.
And, uh, we, we, uh, told him in no uncertain terms that we weren't delivering oxygen because they were still smoking. Yeah. So we have to make the whole environmental judgment. Anyway, that place went up in smoke. Uh, because of the electrical problem, that wasn't my gosh. Yeah. So we, we have to be, be real careful on that, but, but getting our equipment in, um, you know, we, we just definitely demand that there's space for it when we show up.
Um, and then if there is an obvious problem, if we're putting oxygen in some place and we go into a basement and it's full of mold, Uh, we'll get right on the phone with the doctor's office and say, Hey, this, you know, you, you've got pneumonia, a [00:55:00] case coming in about five minutes. It's if this person is not moved to a better, uh, living circumstance, and usually we're going in with home health and we're going in with hospice that has social work attached to it, that will address that.
But, uh, in the case of individual patients that are ordering things through a primary care physician or something, um, uh, we'll make the call. If we see something that's out of line. Is it 
Alex: your responsibility at all to remove any old stuff, whether all DME or old beds, or is that completely up to the patient?
Guest: That's completely up to the patient. In fact, we don't move equipment anymore. We did back in the old days, but, uh, it became a zero sum game for us where if something got broken, we were buying it. If, uh, our guy got hurt, we were paying worker's comp for it. So we were basically now insisting that people, uh, You don't have the space clear and rely on family, friends, or other professionals to move things that they might need move 
Amy: just [00:56:00] quickly.
Um, just to go back to the secondary market. I remember you guys were looking at what that secondary market could look like and doing a cleaning. I don't know if you cleaned for the secondary market, are you doing equipment cleaning for people who own their equipment and just want to clean? 
Guest: Oh, you're talking about the wheelchair maintenance, the 
Amy: wheelchair maintenance program.
Yeah. 
Guest: Yeah. That's, that's, um, that's kind of exclusive to us as far as I know, but yeah, if somebody's wheelchair and, uh, needs to put back into shape, um, we, they can either bring it by or we can pick it up. They're two different price points on it, where we'll power wash it and disinfect it and, uh, adjusted lubricated change.
Any parts that need to be, you know, to basically give it life again. Okay, 
Alex: Steve, if the patient has, or is on an ma plan, a Medicare advantage plan instead of original Medicare, does that change anything better or worse for 
Guest: you? Yeah. And the same thing is true with, um, some of the commercial payers there. A lot of those are contracted with [00:57:00] specific companies.
Um, you know, for instance, we're contracted with, with blue cross, we don't work with Aetna or United healthcare, but what happened when, and Kaiser is a good example as well, they, they have a direct contract with a Priya on a national basis. And, um, the problem is, is that these contracts were all written with percentages off Medicare pricing.
And with this competitive bidding program came in, um, six or seven years ago, pricing dropped about 45%. And the number of, uh, suppliers in the, in the business dropped about 45%. I mean, this is a whole nother discussion we can have about where that's gone, but, uh, all of those, uh, contracts dropped down to what I thought was below sustainable levels.
I mean, Medicare is barely sustainable and if you're taking another 25% off, there's really no amount of volume. Um, A company my size can pick up that would, would, would, uh, make that work. So if you have an advantage plan, you need to get in touch with them and find out who they're [00:58:00] contracted with. And, um, again, most of the people that are ordering equipment on a regular basis, you know, hospital-based discharge planners or, or, uh, uh, discharge planners at rehab facilities, deal with it enough that they know who the players are for the different insurance companies.
And we'll direct orders to them that way. 
Alex: Got it. And what are the mechanics of that? So if I'm a doctor and my patient has an ma plan and they need, I think they need a wheelchair, do I give the prescription to the patient and it's up to them to then go figure it out? Or, or does my office staff try to figure it out?
Like who does that? 
Guest: I would say that that's kind of based on the, um, Uh, I don't want to say it quality of the patient, but the, you know, the mental, mental, and physical capability of the patient, you know, if somebody is going to be able to fend for themselves, all they have to do is flip their card over and call customer service and find out who that supplier is.
And then, um, Have them get in touch with you to get the prescriptions, or again, you're when you're dealing with an ma plan, you're still dealing with the same Medicare [00:59:00] criteria that you need to follow. So there is going to be probably need from no a person in your office to coordinate getting the paperwork.
Right. But at least you can get the name of the supplier right off the back of the card. And, um, you know, so again, that's probably something that you could rely on the patient to do, and then to get the forms to you. It depends on how quickly you want the equipment is the other thing, you know, if somebody is de saturated down to 82%, uh, and they need oxygen, um, it's probably gonna take more involvement from your office to get that moving quickly, to keep them out of the hospital.
Amy: Can we just, um, what I want to do is because I know that everybody's time is valuable. I want to just make sure that we get through what DME is and then sort of have some thoughts about this. Cause honestly, Steve, we could have you back six more times. Um, so we've got hospital beds, we've got wheelchairs, we've got walkers.
How about for the bed tables? 
Guest: That's a convenience. So 
Amy: that Medicare doesn't pay for that. 
Guest: Not going to be covered. Let's [01:00:00] jump back to walkers for one second. Cause we over one that people have a big question on laters. The world of rollators exploded about five or six years ago. And the difference between a Walker and a rollator, a rollator is kind of a deluxe, a four wheel item that has handbrakes on it and a seat you can lock the handbrake so you can turn around and sit on it.
They're used all over assisted living and, and, uh, Nursing facilities to get people around. And they're, they're a wonderful item. They are not, they're not a Medicare covered item because all of the features on them are, are, uh, you know, from the color to the basket are all convenience items that make up the price of them.
Medicare will cover a basic rolling Walker. Um, and some of them, you can get a cloth seat on if you, if you, if you need it there, they're not really particularly safe, but the, um, Uh, so we get a lot of questions where people have ordered a Walker or a rolling Walker, and they're expecting a rollator delivered to the house.
[01:01:00] And, um, uh, it becomes, uh, again, one of those upgrade situations where we have to have a long discussion with them about what's covered, what's not covered. And then when you get into the role leaders, there's a whole variety that you can get them for $75 online, up to $225. Actually. There's. There's there's a thousand dollar rule later, if you can believe it, I'm like, 
Amy: gosh, I want that one.
Guest: It is nice. 
Amy: That's the one I'm going to have. Just tell me what the name and make and model is. Maybe we'll just have it in the house, you know, just to sit on and move around when I'm cooking 
Guest: really nice. The point is that you can see the variety of questions that will come in on that. I'm sure it's covered or not.
And it's basically the. You know, the metal frame rollator with the two wheels on the front is what you're going to get through the Medicare program. And then anything above that is going to be out of pocket. Got it. 
Amy: So you just have to pay the difference between what Medicare would have covered and the full cost of the item.
Guest: They will 
Amy: give you a [01:02:00] little something. Some, 
Guest: yeah, that, again involves a lot of, again, the advanced beneficiary notice and a lot of paperwork right. Doing that for awhile, but the discussion time and, and, uh, Filing time and all that, uh, again became problematic. So we're right now, we're either doing a role later.
You know, through a private situation or a Walker through Medicare. 
Amy: Okay. You're not in between the two. They do not mix. Alright, let me, I'm going to sort of like continue to kind of reiterate what we've talked about and I'm going to ask a few, like maybe three or four more questions. And I think we're going to wrap because we need to have you back.
It's like such an incredible amount of information. We've got beds. Wheelchairs walkers. And we've got a three in one commodes. Um, did I leave anything off? That's like the major things that Medicare does cover, they cover a seat lift, but not the seat 
Guest: burden thing is like an alternating pressure pad, 
Amy: all the things that go on top of that.
Okay. I feel like we need to wait on that. [01:03:00] That is like the 2.0, so we're going to wait on the bed discussion. Cause I do think we might have you back literally just to talk about beds. That would kind of be an amazing story. Cause then we can talk about overlays and all that other kind of stuff. And it could just go on and on and on.
And I really do want to hear more about some of the, so some of the adventures that you've had over the years and talk a little bit about contracting and you know, all the nutty stuff that's going on in the industry. Cause I think you're just an amazing fountain of information, but what are the main things that would you say, um, consumer would know, we need to know.
Number one is. How long between the time a doctor sends an order to when they might receive their equipment. Usually what's the average turnaround time. 
Guest: Let's say if the paperwork is, is done correctly, um, most companies can still do it in 24 hours. Oh, wow. Hours. Yeah. Um, but the, the, the watch word in there is the paperwork being done correctly.
Um, And then we have to go through, it takes us [01:04:00] about a day of processing time to check and see if they've had the equipment before and make sure that the Medicare is all 
Amy: same and similar. Right. You do a same and similar evaluation to make sure they haven't had a wheelchair. Cause you can't have a wheelchair and Walker in the same five-year period or something crazy like that.
Guest: Yeah. That's that's frequently mistaken. Um, You can't order a wheelchair and a Walker together because you're either going to be ambulatory or not ambulatory a lot of disease progressions, have you ambulatory? And then you become name, not ambulatory. A lot of rehabilitation has you non-ambulatory and then you become ambulatory.
So as long as the sequence of it makes sense, and they're not ordered on the same day. You can usually get one of those two covered. If it, if the whole situation makes sense. Um, but again, it takes eyes on, on watching all of this, but the turnaround time should not be astronomical where we're seeing problems.
Uh, and the industry has just been screaming, bloody murder is when people get hung up in the hospital, [01:05:00] uh, waiting for stuff, you know, particularly oxygen, you know, to get home, you know, an extra day in the hospital, uh, is worth six months at DME, you know, in terms of costs. Oh my God. 
Amy: Oh my God. Alex, did you hear that?
Okay. I need a little smile, nod a little 
Alex: and it's, it's just, it's just crazy. 
Amy: It's just crazy. I mean, no, I mean, I used to say you can do 13 house call visits for one emergency department visit. That was my little like weird nugget like that. Like, yeah, it's just crazy. 
Guest: I mean, aging in place, um, is here to stay, you know, it's 30 years.
It's gotta be focused around the house or the, or the whole system's going to break. And, um, you know, whether that is, you know, communities coming together to help people out, whether it's realizing that durable medical equipment, similar types of home things, uh, make sense. Cause it keeps people out of the hospital.
Um, there's going to be a combination of all of that going on and we're going to see if we can solve the social interaction [01:06:00] issue with keeping people at home, which is the biggest problem. You know, we're poor people, I'm isolated, but, uh, I think we've all learned how to deal with that in the last five or five months.
Um, yeah. Um, we're going to see a lot more activity going on at home than we had in the past. Well, 
Amy: I'm really, I'm gonna, I'm going to give us all a break because this is definitely like the one that like part, one of what is likely to be Steve, hopefully you'll accommodate us and come back because you are an amazing, um, fountain of information.
And I guess I should give you a chance to say. How can someone reach you? And if I was a, uh, a patient and I wanted to get DME, I could reach out to you and you would tell me how to get it from my doctor. So how, how would I reach you? What is the best way for our listeners to reach you? 
Guest: We're old fashioned.
You can, you can call (301) 587-2992. And, uh, uh, if you, you can negotiate your way through, uh, uh, it's a small phone tree, but we had to, I fought that for years, but, [01:07:00] uh, of course. We had to do that, but we're, we're pretty easy to get ahold of, uh, yeah, you can also, we're a spectrum. medical.net is our website and you can, you can drop a note in there and we'll pick it up and call you back.
But, uh, um, we spend the day talking to people and, and we're happy to take calls. If people have questions. 
Alex: Thank you, Steve, Steve Ackerman from spectrum medical, but this has been totally amazing and wonderful. We really appreciate it. 
Amy: Yeah. Like literally, we're going to have you back like next Friday, next Friday, Saturday, Sunday, a little bit more DME.
Alright. Thank you so much. And um, it's been a pleasure. You can reach us@wwwdotmasteringmedicare.net. And that's a wrap, huh? All 
Guest: right. I got it very much.