Is Retail the Answer?

When you are fed up with the burden of working with Medicare, Medicaid and other third party payers, where do you turn?

For many home medical equipment companies, retail is the answer. The idea of collecting cash up front is wonderful compared to completing the documentation required for third-party billing. For some, cash collections may mean meeting payroll. Moreover, it is far easier to train a retail clerk than to train a biller and a collector. So, why doesn’t everyone add retail to the business mix?

From a practical perspective, many people do not turn to retail because the retail business is more difficult to operate than it appears. Why? Not only must retail salespeople have professional and courteous appearances, they also must be able to think on their feet and quickly provide third-party requirements — while still abiding by the same rules and regulations as everyone else.

For instance, front-end retail sales staff must understand Medicare documentation guidelines, how and when to use the Advance Beneficiary Notice, other third-party payer matters, and Health Insurance Portability and Accountability Act privacy protocol.

Retail and Medicare

If the retail department is busy at all, it usually is flooded with customers, each of whom requires patience and time. Explaining to the customer how to properly use the equipment is only one responsibility of the retail sales clerk. The clerk also must inform the customer of Medicare requirements. For example, if the patient is a Medicare Part B recipient, has a doctor ordered or prescribed the item in which he or she is interested? Does the item require a written order prior to delivery? If there is more than one item, are they contraindicated (e.g., a commode and a walker)? Are they two ambulation aids? If so, Medicare will pay only for the least expensive item.

Answers to these questions will vary based on the your decision to accept or not accept assignment. These are just a few of the myriad of complexities that often arise during the intake process, retail or otherwise.

Take another example, experienced by Velma Goertzen of Health-E-Quip in Hutchinson, Kan.: A Medicare patient entered the store with a doctor’s order to buy a manual wheelchair. The customer insisted on paying cash and refused to deal with Medicare.

Additionally, the customer wanted to spend down assets to qualify for Medicaid. The salesperson explained that Medicare only pays for the rental of the manual wheelchair and that, because the customer was a Medicare recipient, Health-E-Quip was obligated to file the claim.

Furthermore, Health-E-Quip would need to issue an ABN for the wheelchair because Medicare would not reimburse for the purchase of the item. This visibly upset the customer, and Health-E-Quip almost lost the sale. Fortunately, the customer finally relented and allowed the store to issue the ABN.

Retail and the ABN

Now that ABNs are required on both assigned and non-assigned claims, the front-end staff must thoroughly evaluate each patient’s medical need to determine if the patient’s condition warrants the item or if an ABN should be issued. This includes seat lift chairs, scooters and other items for which most providers don’t accept assignment.

Additionally, even non-Medicare providers are responsible for obtaining an ABN, as well as for notifying patients that they will not be reimbursed because the retail store is not a Medicare provider.

This presents a new set of problems: How does the store know that it is violating a regulation when it is not a Medicare provider and, therefore, not privy to such information?

Retail and Upgrades

Just as critical to retail is the recently revised and clarified upgrade option. Although the option is beneficial to customers, employing this provision is very complicated for your staff. Explaining it to the patient or the patient’s family is even more burdensome. And, wait until the patient receives the Medicare Summary Notice, showing two line items billed for the one item they received. If Medicare doesn’t get patient complaints about this, I will be surprised.

Retail and Patient Privacy

As you can see, retail job requirements include a keen understanding of Medicare regulations. Now, more than ever, it is time to train retail staff about another impending Medicare provision — the HIPAA privacy rules.

During a recent visit to an HME store, I watched a retail clerk answer the telephone at the front counter — while customers were waiting to pay — and blurt out to her co-worker: “Have you seen Mrs. Jones’ (name changed, of course) file? She wants to get a four-wheeled walker for her arthritis and I need to see her file.”

For several minutes, the two staff members discussed Mrs. Jones’ medical history in front of the other customers. They never “got it”: This sort of behavior violates HIPAA’s privacy rule.

You must be cognizant of privacy issues when dealing directly with the public. Goertzen, for example, has added screen savers to her computers to keep patients’ information out of sight of customers. Additionally, she has added a secluded soundproof area to her store for retail customers to discuss patient information privately. Finally, her billing area is locked to prevent unauthorized personnel from entering it.

At Wishing Well Medical in Santa Monica, Calif., employees have stopped tagging equipment for specific patients on the showroom floor. This is doubly important for Wishing Well because the company services many celebrity patients. Additionally, Donny Albrecht, the company’s vice president, is reluctant to give other HME companies patient information without an authorization or release form.

Retail and Other Payers

Along with Medicare-related information, retail staff must be knowledgeable about other payers. For example, they must know how to routinely check Medicaid patients for current program eligibility.

Further, they must verify benefits and eligibility for walk-in patients who have neither Medicare nor Medicaid, but are insured by another third-party payer. All this in addition to the authorization and documentation requirements that must be arranged while the patient is waiting. In a busy store, there are likely other customers who are waiting to be helped while insurance information is gathered.

Retail and Staffing

Although, at first glance, it may appear that retail sales personnel do not need the same skill sets as other intake and billing staff, the truth is that they may need more training and knowledge.

The retail sales staff must be well versed enough in industry regulations to ask the right questions while a patient awaits his or her goods. This type of pressure is not easy to handle, and requires special people — people who are not easily flustered by stress, for one.

Further, retail staff must be well-trained, knowledgeable and strong communicators. With proper training and experience, retail salespeople can mean the difference between payment and denial, and between a successful and unsuccessful audit outcome. And ultimately, retail sales staff remain the first people customers meet.

Miriam Lieber is president of Sherman Oaks, Calif.-based Lieber Consulting, specializing in operations management and reimbursement for the HME industry. She can be reached via e-mail at [email protected] or via phone at 818/789-0670.