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
by Miriam Lieber
March 1, 2003

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
mllieber@pacbell.net or via phone at
818/789-0670.