Business Briefs: Ten Self-Audit Questions: Coordination of Care with Suppliers of Medical Products

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  Today’s wound care clinics are being held to higher levels of accountability than ever before: eg, accountability for assessing the patient’s underlying problems; for selecting the most appropriate management protocol, drugs, dressings, medical equipment, off-loading devices; for assuring that the physicians, podiatrists, and non-physician practitioners write complete orders and sign the orders in the medical record (as well as the order forms required by the medical suppliers); and for coordinating care with other entities that are providing services to the patient such as home health agencies, skilled nursing facilities, and medical suppliers. In keeping with last month’s column on self-audits and the medical supplier theme of this month’s journal, this Business Briefs column will review 10 self-audit questions that you can use to rate your coordination of care with medical suppliers. Take a few minutes to read and answer each of the self-audit questions in Exhibit 1 before reading the remainder of this article.

Self-Audit Question 1:

  Most wound clinics are receiving pressure from materials managers and hospital administration to control the costs of the medical supplies and equipment that they are using. Therefore, if you answered “yes” to questions #1, do not feel alone. However, you must not be “penny-wise and pound-foolish” when selecting wound care supplies and equipment. If you are receiving pressure to convert to products that are not contributing to closing wounds in the least amount of time and with the least complications, you must take the time to educate the materials manager or administrator “why” a lower cost product may not always produce the lowest cost-of-care. Remind them that the most expensive product is the one that does not support optimum clinical outcomes. Also remind materials managers and administrators when products are separately payable and/or have separately payable procedures attached to them.

  I recently had the opportunity to speak with a group of materials managers who purchased products for multiple wound clinics. To my surprise, many of them did not know which products were separately payable and had separately payable procedures attached to them. In fact, many of them said, “I do not care about the wound clinic’s revenue. I just want to purchase the lowest cost products.” I then spoke with the hospital administrators and asked them whether they were more interested in using the lowest cost products, the products that produced the best outcomes with the lowest cost-of-care to the system, or the products and procedures that generated revenue. Their responses were totally different than the materials managers: they selected the best outcomes with the lowest cost of care and the products/procedures that generated revenue. Therefore, wound care professionals must educate materials managers and ask for assistance from hospital administration to run interference with the materials managers if they are acting “penny-wise and pound-foolish”.

Self-Audit Question 2:

  Unfortunately, many wound clinics are still answering, “yes” to question 2. Wound clinics are required and have the responsibility to cover the wound with the appropriate dressings during the clinic visit. However, they are neither reimbursed nor required to supply dressings for home use. Most Medicare patients purchase the Medicare Part B supplement that covers 80% of the Medicare allowable for dressings used by the patients at home. Most private insurance and Medicare supplement plans cover dressings for home use. Many Medicaid plans also cover dressings for home use. Therefore, wound clinics should coordinate care with the medical suppliers for dressings; negative pressure wound therapy pumps, wound suction pumps, off-loading devices, etc. By not supplying products that are not your responsibility, you can help control your expenditures, which should please your materials manager and administration.

Self-Audit Question 3:

  If you answered “no” to this question, I hope you will go back and read the May 2011 issue of Today’s Wound Clinic that was dedicated to the topic of payer coverage. Wound care professionals must monitor the Medicare LCDs that pertain to the products they provide; the services and procedures that they perform; and the products, procedures, and equipment that they order from other health care providers. Each month when you monitor your Medicare contractor’s LCDs, you should also monitor the pertinent LCDs of the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) that processes the claims for the medical suppliers in your area. If you do not know the DME MAC that services your geography, please go back and read the December 2010 Business Briefs column. There you will find the names and Web Sites of the 4 DME MACs that service medical suppliers throughout the country. Some of the DME MAC LCDs that wound care professionals should monitor are:

    • Hospital Beds and Accessories
    • Manual Wheelchair Bases
    • Negative Pressure Wound Therapy Pumps
    • Orthopedic Footwear
    • Pneumatic Compression Devices
    • Power Mobility Devices
    • Pressure Reducing Support Surfaces Group 1, 2 and 3
    • Seat Lift Mechanisms
    • Surgical Dressings
    •Therapeutic Shoes for Persons with Diabetes
    • Walkers
    • Wheelchair Options/Accessories
    • Wheelchair Seating

Self-Audit Question 4:

  The correct answer to question 4 should be “yes”. As discussed numerous times in this column, wound clinics should verify the patient’s insurance benefits (private insurance, Medicaid, Worker’s Compensation, etc.) and obtain prior authorization requirements prior to caring for the patient. That is a great time to learn if specific medical suppliers are approved to supply the typical supplies and equipment needed by a wound care patient in between visits to the wound clinic. If the patient has a preference of one of the medical suppliers, you will then be able to communicate with that supplier about documentation and order forms that they require to justify medical necessity for the product(s) needed by the patient. While the physician is completing and signing orders in the medical record, he/she can also complete and sign the required medical supply order form(s).

Self-Audit Question 5:

  The answer to question 5 should be “no”. Wound care providers should read their Medicare contractor’s LCDs and other payers’ medical policies to determine the utilization guidelines for the medical supplies and equipment that will be used by the patient at home. These guidelines frequently describe services that are a pre-requisite for the supplies/equipment; the frequency of use that is deemed medically necessary; the maximum amount of supplies that will be covered in a given time period; etc. For example: The DME MACs LCD for Negative Pressure Wound Therapy Pumps state:

    • Coverage is provided up to a maximum of 15 dressing kits (A6550) per wound per month unless there is documentation that the wound size requires more than one dressing kit for each dressing change.
    • Coverage is provided up to a maximum of 10 canister sets (A7000) per month unless there is documentation evidencing a large volume of drainage (greater than 90 ml of exudate per day). For high volume exudative wounds, a stationary pump with the largest capacity canister must be used.
    • Suppliers must not dispense a quantity of supplies exceeding a beneficiary’s expected utilization. Suppliers may dispense a maximum of one month’s supply of dressing kits or canisters at any one time.
    • The supplier must not automatically dispense a quantity of supplies on a predetermined regular basis, even if the beneficiary has “authorized” this in advance. As referenced in the Program Integrity Manual (Internet-Only Manual, CMS Pub. 100-8, Chapter 4.26.1) “Contact with the beneficiary or designee regarding refills should take place no sooner than approximately 7 days prior to the delivery/shipping date. For subsequent deliveries of refills, the supplier should deliver the DMEPOS product no sooner than approximately 5 days prior to the end of usage for the current product.”

  If you follow the LCD and medical policy utilization guidelines, the patients will only be required to pay their annual deductible and their co-payment for the supplies/equipment. If you exceed the utilization guidelines, the patients will have to pay the entire cost of the supplies/equipment deemed not medically necessary.

  Many of today’s advanced wound care products have “extended wear times” which may require less product than is covered by the payer. Physicians should be sure to order only the amount of product that is needed to care for a specific patient. Medical suppliers should only supply the amount of supplies/equipment that is ordered by the physicians: they should not routinely supply the maximum allowed by the payer.

  Physicians should try to write orders by the category of product rather than by the brand name, unless a particular brand is medically necessary for a specific patient. With thousands of wound care products available in the market, physicians cannot expect a medical supplier to stock every brand. However, a reputable medical supplier will do their best to acquire a non-stocked brand that is medically necessary for a particular patient. Communication between the wound clinic, physician, and medical supplier is the key to coordination for at-home wound care products.

Self-Audit Question 6:

  Hopefully, your answer to this question was “no”. If it was “yes”, you should ask yourself if you contacted the medical supplier to learn their side of the story. You may find that the patient could not afford the co-payment for the product(s) and refused the items ordered. You may find that the physician order may not have justified the medical necessity for the product(s) ordered and/or the amount of product(s) ordered. You may find that the medical supplier did not carry the exact brand ordered, but supplied a very comparable brand. Actually you will be surprised at the number of reasons the patient did not acquire the product(s) ordered; most of the reasons are usually patient-centered rather than medical supplier-centered.

  Most medical suppliers are very responsible and care about providing the patients with supplies and equipment that meet their medical needs. If wound care providers are tempted to criticize the medical suppliers, they should first contact the suppliers to learn about the situations surrounding specific issues.

Self-Audit Question 7:

  Congratulations if you answered, “yes” to this question! Prior to opening a wound clinic, and annually thereafter, wound care professionals should invite the medical suppliers, who offer wound care supplies and equipment in their area, to a meeting at their wound clinic. Give the medical suppliers a tour of the wound clinic, explain the types of patients that you typically service, introduce them to the wound care professionals who write the orders for wound care products used at home, review the categories of products that are typically used in your wound care protocols and learn if the medical supplier stocks those product categories, review the volume of each category of product that you expect to order on a weekly, monthly, quarterly, and/or annual basis, and discuss the possibility of the medical suppliers acquiring a particular brand that you feel cannot be substituted. The medical suppliers should share their documentation and order forms with you and review the process for completing and signing the forms before the product(s) can be shipped/delivered. The medical suppliers should also describe their method of delivery and tell you how to handle patients who are seen on Friday and need product on Saturday, Sunday, and Monday. I have personally facilitated many of these meetings between wound care clinic professionals and medical suppliers. At the end of each meeting, both parties always have a better understanding of how they can work together to meet the needs of their mutual patients/customers.

Self-Audit Question 8:

  I would not be surprised if most wound care professionals answered “no” to this question because the Medicare competitive bidding program has not included wound care supplies and equipment in Round One of the program. Section 302 of the Medicare Modernization Act of 2003 (MMA) established requirements for a new Competitive Bidding Program for certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). Under the program, DMEPOS suppliers compete to become Medicare contract suppliers by submitting bids to furnish certain items in competitive bidding areas, and the Centers for Medicare & Medicaid Services (CMS) awards contracts to enough suppliers to meet beneficiary demand for the bid items. The new, lower payment amounts resulting from the competition replace the Medicare DMEPOS fee schedule amounts for the bid items in these areas. All contract suppliers must comply with Medicare enrollment rules, be licensed and accredited, and meet financial standards. The program sets more appropriate payment amounts for DMEPOS items while ensuring continued access to quality items and services, which will result in reduced beneficiary out-of-pocket expenses and savings to taxpayers and the Medicare program.

  On January 1, 2011, CMS launched Round One of Medicare’s competitive bidding program in nine different areas of the country for nine product categories; none of the categories were wound care related. Round Two was announced this summer. This should give medical suppliers, in 91 different areas of the country, ample time to prepare for the competitive bidding, which will actually take place in the winter of 2012. Round Two covers the following eight categories, some of which are wound care related:
    • Oxygen, oxygen equipment, and supplies
    • Standard (Power and Manual) wheelchairs, scooters, and related accessories
    • Enteral nutrients, equipment, and supplies
    • Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs) and related supplies and accessories
    • Hospital beds and related accessories
    • Walkers and related accessories
    • Negative Pressure Wound Therapy pumps and related supplies and accessories
    • Support surfaces (Group 2 mattresses and overlays)

  Once the names of the medical suppliers that won the competitive bidding are announced for your geographical area, you should invite them to visit your wound clinic as discussed above in question 7.

Self-Audit Question 9:

  The correct answer to this question should be “yes”. To conduct the self-audit, you should obtain the documentation and ordering guidelines that can be found in the DME MACs’ LCDs, in the other payers’ policies, and that can be obtained from the medical suppliers who service your patients. These guidelines are usually very specific. CAUTION: Medical suppliers usually go out of their way to provide you with documentation and order forms that must be completed before they can supply products to your patients. Those forms are great and should be completed. However, that exact information should also be included in the physician’s progress notes and order section of the patient’s medical record (no matter if it is a paper record or an electronic record). Remember, if the medical supplier is audited, the auditors can and usually do request the patient’s medical records, which the wound clinic and physician are obligated to supply.

Self-Audit Question 10:

  I hope everyone answered, “yes” to this question. Currently, coordination of care is a very important component of a wound care center for excellence. In the future, the new payment models (that Medicare, Medicaid, and many private payers are promoting) will require even more coordination between all entities that provide services to all patients, including patients with chronic wounds. This coordination must be “second nature” to all professionals in your wound clinic. Do not force new wound clinic professionals to learn about the medical supply documentation and ordering process by trial and error. Take time to share the pertinent LCDs and medical policies and to train them how to coordinate the documentation and ordering process with the medical suppliers in your area.

Summary:

  Hopefully this self-audit has shown you the strengths and weaknesses of your coordination of care with medical suppliers. Wound clinics should conduct this self-audit at least annually. If the wound clinic coordination processes cause you to answer all the self-audit questions correctly, you will improve your revenue, improve the medical suppliers’ revenue, and most importantly – manage your patients’ out-of-pocket expenses.

Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her email address: kathleendschaum@bellsouth.net.