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Durable Medical Equipment is a challenging piece of case management. The outcome of a case can be manipulated by failure to provide or use DME for too little or too long.

Here are some guidelines to help you determine what your Injured Worker (IW) needs.

The goal is to have the right equipment at the right time to allow for maximum recovery.

  • What DME will the injured worker need after a surgery or multiple trauma events? The physician should be asked about DME as soon as a surgery is planned. With cases of multiple trauma, as soon as the IW is admitted to the hospital. Early intervention is “key” and allows the system to process the DME needs in a timely fashion. When the IW is discharged home, the DME will be there and ready to go without any delay.
  • Clarify who will be ordering the DME- the hospital? Some physicians write orders for DME prior to the surgery or while in the hospital. The hospital may provide the equipment and the patient will go home with the DME, such as an ice machine post surgery. Confusion can result when you and the hospital duplicate the effort to provide this service and can result in loss of control of DME purchases for quality and cost containment. The hospital and all medical providers should be informed when the carrier has specific requirements for DME providers and any monetary limits. When dealing with the hospital, ask if this item is coming from their supplies or being ordered from an outside provider they choose? Will it be billed by the outside vendor or will it be on the hospital bill?
  • Is the patient’s weight over 300 pounds or taller than 6 feet? The IW that meets either of these criteria need specialty DME. Weighing over 300lbs, requires heavier constructed DME such as: bariatric- beds, bedside commodes and wheelchairs. Regular DME could result in potential injury due to collapse or non-use of the item because they cannot fit into it. A large IW in a non-bariatric bed will be fatigued because he cannot sleep and may cause delay in healing or increase anxiety. Feet hanging over the end of the bed may cause blood clots or bedsores on the lower extremities.
  • The IW who is over 6 ft tall will not fit on a regular hospital bed because it will not adjust or extend to accommodate this height. Research to find a company that has a bed that will extend may be time consuming. There seems to be only one hospital bed maker that has beds that fit unusual sized patients, Hill Rohm.
  • Will the IW need a hospital bed at home and how long? Most patients need (on average) the hospital bed for 30 days. Monitoring for continued necessity of the bed should be done.
  • Can the IW purchase the DME at any department or pharmacy store? If the answer is yes, that is not considered DME under most plans. You may risk pre-cert denial. Purchase of these items should be authorized by the adjuster according to the workers compensation plan.
  • What about the hospital bed mattress or pads? The potential for formation of bedsores is the key issue to consider for use of bariatric mattresses and mattress pads. If the IW meets the need for bariatric equipment or has multiple fractures/spinal cord damage/trauma which result in a long period of time in bed, a special mattress or mattress pad (egg crate, water mattress, etc.) should be considered. Note: obese IWs need a thicker 6 inch egg crate.
  • Does the DME need precertification? How long will take? Getting DME approved on time will expedite surgical and post-operative recovery. Finding out at the last minute that a DME must be approved due to type or cost will cause delay in surgery scheduling, or prevent IW from having the DME available upon arrival at home. Sleepless nights due to feet hanging over the too-short bed; no Ice machine for shoulder surgery after being discharged home, etc. only impedes healing. Both IW and physician are not happy with this situation and benefits will be extended due to the delayed healing process.
  • Does the carrier have a preferred provider list of DME companies? If yes, then policy should be followed. All providers- MD, PT/OT, and hospital should be notified to prevent delay of obtaining the equipment.
  • Does the carrier/case manager need to request discount? If there is no network DME provider, especially for large dollar items-ask for a discount.
  • Will the DME need to be attached to the home permanently? If a Hoyer lift needs to have a “track” installed in the wall, this may not fall into the DME category. Most DME do not require reconstruction of the home. In this situation, another product should be obtained. If this is the only type DME that can be used, inform the carrier who needs to be involved in any permanent installation of any equipment. Some of these items are: hand rails in bathroom, chair for stairs, ramp for wheelchair, etc.

Your case manager’s role will be to coordinate the medical providers, Injured Worker, and carrier through the management of the Durable Medical Equipment process. The goal of the case manager is to expedite the needed DME based on knowledge of the DME policy of the Non-Subscriber and Subscriber programs and medical facts of the case.

August 2010
Author: Deborah Goza, MS, RN, CCM, COHNS
Editor: D. Perry