Overview
Our Training Goals
1. To establish knowledge in DME
2. To have a healthy working environment
3. To have a fun while learning
4. To pass the Basiics Training
Two Stages of Training
Basics Training
6 months probation period
What is dme and why do you need it?
Example:
wheelchairs- mwc, reclining mwc, commode, pwc,
power scooter
hospital beds
cane- single point cane/ quad cane -narrow and wide base
crutches
walkers- fww front wheeled walker
oxygen tanks/ machine
biliblanket- bili light
lift with style
nebulizer
hoyer lift or patient lift
cpap machine - continuous positive
airway pressure / those who have
sleep apnea
DME- Aid better quality living
Medicare-federally funded-same program across USA
federal health insurance
Qualifications:
65 yo and older
65 yo below- w/ disabilities
all ages with end stages Renal Disease and ALS
parts a,b c and d
Purpose of DME?
Aid better quality of living.
To qualify for Medicare:
1. Must be 65 years old and higher.
2. Younger than 65 y/o but with disability
3. All ages with ESRD and ALS.
(Dialysis patient and liver transplant candidate)
ALS: Amyotrophic lateral sclerosis
what do the diff part of medicare
PART OF MEDICARE
A-ORIGINAL MEDICARE- MEDICALLY NECESSARY INPATIENT CARE
- hospital insurance/ NO MONTHY PREMIUM
B-ORIGINAL MEDICARE
PART A + PART B = Original Medicare / Traditional Medicare
PART A OR HOSPITAL INSURANCE (HOSPITAL/FACILITIES – IN PATIENT CARE IN HOSPITALS,
SKILLED NURSING FACILITY & HOSPICE CARE
-----------------------------------------------
Part B or Medical Insurance helps cover medical services, such as doctor visits, outpatient care,
medical supplies and more.- HOC
DOCTOR VISIT
OUTPATIENT- PART B
Part A and Part B can exist at the same time.
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THREE INTERCHANGEABLE PART C
ADVANTAGE PLAN OR ALL INCLUSIVE PLAN OR MEDICARE REPLACEMENT PLAN
- RUN BY MEDICARE APPROVED PRIVATE INSURANCE COMPANIES
- THEY COVER ALL YOUR PART A & B BENEFITS
- ADDITIONAL BENEFITS: VISION/DENTAL/HEARING/GYM OR FITNESS COVERAGE
THEY NEED TO HAVE ACTIVE PART A AND B
PART A AND B SHOULD BE ACTIVE TO AVAIL PART C.
PART C - HAS EXTRA BENEFIT : DENTAL, VISION/HEARING, FITNESS OR WELLNESS
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PART D - PDP
PRESCRIPTION DRUG PLAN
IT COVERS ANY PRESCRIPTION DRUG
MEDICATION GIVEN TO THE PATIENT
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MEDICAID - is joint federal and state funded
health program for individuals
each state creates its own Medicaid program
*******
MEDICAID
Medicaid is a joint federal and state health program for individuals, families, and children with limited
income and resources.
Each state creates its own Medicaid program
Eligibility
Covered health benefits
Costs
--------------------
*Mandatory benefits:
Hospital services
Doctor services
Home healthcare
-------------------
*Optional Benefits:
Prescription Drugs
Routine dental and Vision Care
--------------------------
HOC- its located in California
Medicaid in California -- Medi-Cal
Dual Eligible - eligible/ qualified
for both medicare and medicaid they
qualified as dsnp (dual special need plan)
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Medicaid- they must belong to a
low income family
-it could cover 100%
Qualification for Medicaid:
-Belong in a low-income Family
----------------------------
Medicare Supplement Insurance- Medigap policy- 3rd insurance
- paired w/ original or tradition medicare- part A and B
-can never be paired w/part C
80% coverage- 20% patient covers
MEDIGAP IS ALSO OFFERED BY PRIVATE INSURANCE.
MEDIGAP CAN ONLY BE PARTNERED WITH
ORIGINAL MEDICARE EITHER (PART A + B) AND
CANNOT BE A PRIMARY INSURANCE.
**Patients cannot avail themselves of medigap if patients have Part C coverage.
Medicare Supplemental Plan or Medicare Supplement
Reducing OOP cost of the traditional Medicare
------------------------------------
Medicare Advantage plan- 2 TYPES OF PLAN -- HMO AND PPO is applicable
Medigap covers the 20% for the patient
Medicare: 80%
Medigap or Medicare Supplement Plan: 20% (IT MAY)
MCR- MEDICARE
MCD- MEDICAID
---------------------------------
HMO PLAN - Medicare Advantage Plan - Part C Plan
Health Maintenance Organization
-you must have a pcp- primary care doctor / physician
-low monthly premium
-need to coordinate first w/pcp for referral
-covers limited option - INN providers only / contracted MD or participating MD
PROVIDER NETWORK
Health Maintenance Organization = HMO
Type of medical plan that has a lower premium compared to other plan but has limited options in
choosing your doctor
A PT MUST SEE HIS PCP BEFORE GOING TO ANOTHER DR (SPECIALIZED DR). PCP WILL MANAGE ALL
YOUR CARE PRIMARY CARE DR OR PRIMARY CARE PHYSICIAN
PCP:
Primary Care Physician
a.k.a. Primary Care Doctor
a.k.a. Primary Care Provider
IN NETWORK:
A health care provider that has a contract with a patient’s health insurance plan to provide health care
services to its members at a pre-negotiated rate.
Other Terms: Contracted / Participating
-----------------------------------
Medicare Supplement Plan
- Medigap is secondary to MCR
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What is PPO plan
PPO PLAN- Preferred Provider Organization Plan
-small co-pay
-referral is not required
-can see both INN and ONN provider
Preferred Provider Organization = PPO
A type of medical insurance provides freedom for the members to choose specialized doctor without
going or asking for referral from primary care doctors.
Coverage is much more larger compared to HMO because they can see DR who are in and out of
network
PPO plan does not mean patient have an OON. It must be confirmed
means that the doctor or facility providing patient care does not have a contract with the health
insurance company.
PPO DOES HAVE AN Out of Network Providers (OON) or Non-Contracted Provider/Non-Participating
Physician BUT NOT ALL THE TIME IT IS AUTOMATIC SO OON MUST BE CONFIRMED.
-------------------------------
COINSURANCE, COPAY, DEDUCTIBLE
- DEDUCTIBLE IS THE AMOUNT YOU MUST PAY BEFORE INSURANCE STARTS COVERING SOME OF THE
COST
** Deductible
Amount that a patient needs to settle before insurance take effect
replenished per calendar year or anniversary year
HIGH DEDUCTIBLES- LOWER PRICE FOR INSURANCE PLAN
DEDUCTIBLE RESET YEARLY - CALENDAR YEAR/ PLAN YEAR ANY MONTH (ANNIVERSARY)
*Calendar Year - January to December
Plan Year - Anniversary Date
-PAID TO THE HOSPITAL OR DOCTOR
-------------------------------------
COINSURANCE
- WHERE THE PAYMENT IS SPLIT INTO TWO
- IF THE DEDUCTIBLE HAS BEEN MET
- Common Examples for Coinsurance Percentage:
80/20
90/10
50/50
- is not fixed amount
-it varies and paid per service
**
Coinsurance
Coinsurance is the percent of what PT and insurance provider pays together.
It is applied after you fulfill your deductible.
Coinsurance is not a fixed amount varies and is paid per service
-------------------------
COPAY
- FIXED PAYMENT
Copay
Fixed amount patient pays each time insurance is being used or pay whenever they visit a doctor
It is a fixed payment even when a patient has deductible
-------------------------------------
STAGES OF PAYMENT:
1ST STAGE: DEDUCTIBLE
ONLY THE PT'S RESPONSIBILITY
NOT ALL PLAN HAVE A DEDUCTIBLE
DEDUCTIBLE AMOUNT VARIES DEPENDING ON THE INSURANCE OF PT AND TYPE OF PLAN OF THE PT
2ND STAGE: COINSURANCE
JOINT RESPONSIBILITY BETWEEN PT AND INSURANCE
COINSURANCE IS NOT ALWAYS PT'S RESPONSIBILITY BECAUSE SOMETIMES THERE IS A SECONDARY INS.
3RD STAGE: OUT OF POCKET MAXIMUM )OOPM)
LIMIT THAT WAS SET BY THE INSURANCE
-------------------------------------------
HERE ARE SOME SAMPLE FOR YOUR REFERENCE, TEAM
PT - PATIENT
DR - DOCTOR
ER - EMERGENCY CONTACT
HT - HEIGHT
WT - WEIGHT
RX - PRESCRIPTION
DX - DIAGNOSIS
---------------------------------------
As DME provider means we are under Part B, coinsurance is only applicable to us because copayment
applies with Part A.
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PREMIUM- MONTHLY PAYMENT- membership
ex: netflix-monthly payment/cost of plan
to keep the insurance active
DEDUCTIBLE - PT's responsibilty
OOPM- if the deductible and coinsurance has filled insurance covers 100%
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MEDICAL GROUP/ IPA- INDEPENDENT PHYSICIAN ASSOCIATION
-OPERATES THEIR OWN PRACTICES
-DETERMINE THEIR OWN POLICY
IPA (INDEPENDENT PHYSICIAN/PRACTICE ASSOCIATION) A.K.A. MEDICAL GROUP
●Group of physicians
●Determine their own policies.
●IPA help in:
a. Admin support
b. Access to network of specialist and hospitals
c. Help them provide better patient care.
SUTHER GOLD
ALL CARE
Sept 18 – NOTES
Todd Usher is the Husband of Andrea Ewert
-----------------------------------------
healthcare.gov
Healthcare Insurance
Copay does not apply to HOC
Copay does apply to pdp and Dr's visit
Coinsurance- PT and ins shared cost
OOPM- the limit of money
Affordable Care Act - essential services shall be
given to pt
---------------------------------------
Medicare- federal health insurance across US
Parts of Medicare
*part a, b - original / tradition
part A- inpatient stay/ hospital insurance
part B- outpatient/ medical insurance
*part c- medicare advantage plan
*part d- pdp (Rx)- medication
---------------------------------------
Provider Network
INN
ONN
PPO - Prefferd Provider Organization
HMO- Health Maintenance Organization
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OOPM - OUT OF POCKET MAXIMUM
------------------------------
ICD- 10 3-7 alpanumeric codes
- diseases
CPT Code- Item Ordered
Internation Classification of Diseases 10th Edition
CPT Code
HCPCS Code
PROCEDURE CODES
ICD-10 = INTERNATIONAL CLASSIFICATION OF DISEASE 10th edition
Clinical Modification (CM)
Procedure Coding System (PCS)
69,000 codes- icd-10
14,000 codes -icd-9
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Documents and Faxes
-understanding the types of docs received through DME
HOC- supplier of medical equipment
Fax Cover Sheet
Demographics
Insurance Card Copy
Physician Written Order
Chart Notes
Sleep Study
1.*** Fax Cover Sheet
look for key items
topics covered
key words
company logo
- will always have "fax" on cover sheet
- will include "to" section
-will include "from" section
Fax Cover Sheet
Will always have "fax" on the cover sheets
Will include "to" section
Will include "from" section
Other term for fax is "fascimile"
2. *** Demographics
-full name
-address
-email add
-dob
-marital status
-ssn
-insurance info
-emergency contact
-SDM
Demographics
Full name
Address
Email address
Date of birth
Marital status
Social Security Number (SSN)
Insurance info / Health Insurance List (note to contact patient if secondary insurance is not avail)
Emergency contact
PCP
NOTE:
NOT ALL DEMOGRAPHICS HAVE SSN
3. *** Prescriptions
-PT's name, add, dob
-dx
-rx
-cpt code/ item ordered
-length of need
-item ordered
-Dr's name
-Dr's NPI
-list of supplies
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OSA Obstructive Sleep Apnea / Obstructive Sleep Apnea (OSA)
Prescription
Sometimes referred to as :
RX
Referral form
Order form
Physician Written Order (PWO)
Written Order
-------------------------
DX CODE FOR OSA: G47.33
Physician Written Order - PWO
PWC- G35
4.*** Insurance Card Copy
- very easy to identify as it will look
like card photocopies
-will include policy number
- will sometimes include drivers license
-front and back portion
Insurance Card Copy
Very easy to identify as it will look like card photocopies
Will include policy number
Will sometimes include driver's license
will sometimes include PCP - Primary care physician/doctor
NOTE: If the insurance card copy is not included, you may utilize demographics to see the member ID. No
need to ask PT to send insurance card copy
5. *** Chart Notes
sometimes referred to as:
- progress notes
-office visit notes
-face to face chart notes f2f / ftf
Key items:
- reason for visit
-chief complaint
-active problem list
- allergies
-surgical history
- family history
-social history
-vitals (height/weight)
-physical exam
-assessment
-medication list
-examination
-diagnosis list
**
Chart Notes
Reason for visit
Progress note
Chief complaint
Active problem list
Allergies
Surgical history (History = Hx)
Family history (History = Hx)
Social history (History = Hx)
Vitals (height/weights)
Assessment
Physical exam
Medication list
Diagnosis list
Examination
PCP
Pages
Encountered dates (upper right corner)
-------------------------------------
6.*** Sleep Study - sleep cycle
order:
CPAP
BIPAP
AUTOBIPAP
- study date
-titles such polysomnograph report, titration report
home sleep test (hst)
Sleep study
Study date
Titles such as polysomnography report, titration report, home sleep test (HST)
Sleep study summary
Graphs
PCP
Vitals
Sleep Analysis
Respiratory Analyis
different types:
-baseline sleep study/diagnostic-natural observation without treatment
-cpap titration/ split night study - combination of baseline and titration study
*titration study- they conduct different pressure to the patient
-home sleep study (HST) - done at home, they use accusom device
manufacturer- Novasom
NOVASOM is the company and AccuSom is the machine itself.
“Snap diagnosis” means it is a home sleep test.
----------------
NOTES:
NOVASOM / AccuSom – signifies that it is a home sleep test.
NOVASOM is the company and AccuSom is the machine itself.
“Snap diagnosis” means it is a home sleep test.
------------------
1. BASELINE SLEEP STUDY / DIAGNOSTIC
> PATIENT IS OBSERVED SLEEPING NATURALLY WITHOUT ANY TREATMENT
> INITIAL SLEEP STUDY USED TO DIAGNOSE OSA
2. CPAP TITRATION / SPLIT NIGHT STUDY
>COMBINTAION OF DIAGNOSTIC STUDY AND A TITRATION STUDY
>> TITRATION STUDY -THEY USE PRESSURE SETTING TO SEE WHAT WILL WORK BEST FOR THE PT TO
TREAT OSA.
3.HOME SLEEP STUDY
> INITIAL SLEEP STUDY DONE IN THE PT'S HOME.
>DEVICE: AccuSom
>MANUFACTURER OF THE DEVICE: NOVASOM
>SNAP DIAGNOSIS = HOME SLEEP STUDY
SDM- Substitute Decision Maker
SDM - SUBSTITUTE DECISION MAKER - power of attorney where this person will be in charge of
decisions
Brightree
Alt+Enter
Format in Labelling:
1.PWO
if the signed date is different we need to call
the Dr's ofc to ask if when did they signed the docs
and asked for a revised copy of the docs.
Supplement Plans can never be a primary ins
*for f2f - we must follow the encounter date
if there is an electronically signed date
1. Fax Cover Sheet
2. PWO
CPAP | SIGNED | 6/24/2020
3.DEMOGRAPHICS
4-6 INS CARD COPY
7-17 F2F NOTES
FOLLOW-UP HST RESULTS | SIGNED | 6/24/2020
18-21 SLEEP STUDY
ACCUSOM STUDY INTERPRETATION AND RECOMMENDATION | SIGNED | 5/19/2020
22-34 F2F NOTES
CONSULT NPT-SLEEP APNEA EVAL | SIGNED | 4/27/2020
*** DOCUMENTS
- CONTACT DR'S OFFICE TO CONFIRM THE CORRECT DATE SIGNED OF PWO
*** INSURANCE
- CONTACT PT TO CONFIRM IF THERE IS 2NDARY INS
THE PROCESS THAT WE ARE FOLLOWING DURING TRAINING HOC'S PROCESS
PERSONAL TAB
- HOC PROCESS/ TRAINING
IF WE INPUT INFO IT SHOULD BE IN CAPITAL LETTERS
ACTION FOR THE MIDDLE NAME IF IT IS NOT INDICATED ON THE DOCUMENT.
NO NEED TO CREATE ACTION PLAN IF THERES NO SSN
- ADDRESS
MAKE SURE IT IS NOT A PO BOX ADDRESS BECAUSE IT IS NOT DELIVERABLE
IF PO BOX IS LISTED, LEAVE IT BLANK AND CREATE AN ACTION PLAN.
- if phone and mobile is the same we prioritize phone #
-contact pt to obtain alt contact #
- we need 2 numbers - phone/home and mobile number
-there must be an email address
- contact pt to obtain email address
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tax zone = pt's city
Select the nearest branch near the pt's city
Modesto Branch
Sacramento Branch
2 or more equipment - choose DME
ACCOUNT GROUP is where we select the item being ordered.
Choose DME if the main item being ordered is not available on the list ACCOUNT GROUP.
If there is MORE THAN 1 ITEM being ordered, also select DME.
KINDLY UTILIZE ALL CAPS OR UPPERCASE LETTER FOR UNIFORMITY.
USER 1 FORMAT: USE THE NAME SHOWING HERE ON TEAMS
LAST NAME, FIRST NAME
ex. ALMARIO, DYLENE MILD
REASONS ON WHY A P.O BOX ADDRESS BE USED AS A
DELIVERY ADDRESS:
WHY P.O BOX ADDRESS IS NOT ACCEPTED?
MOST OF THE DME ITEMS WON'T FIT
THEFT IS VERY COMMON IN THE US.
SIGNATURE FROM THE RECEIVER IS REQUIRED
COMMON ABBREVIATIONS YOU'LL ENCOUNTER DURING OUR BASICS TRAINING:
PT - PATIENT
DR - DOCTOR
ER - EMERGENCY CONTACT
HT - HEIGHT
WT - WEIGHT
RX - PRESCRIPTION
DX - DIAGNOSIS
HEIGHT AND WEIGHT
IF THERE ARE 2 DIFFERENT NUMBER ON THE VITALS, CHOOSE THE ONE THAT HAS THE RECENT DATE
IF THERE IS NO HT AND/OR WT ON THE DOCUMENT, CREATE AN ACTION PLAN.
NPPES NPI Registry
OSA G47.33 - we follow what is listed in PWO
CALIFORNIA - INS - NORIDIAN MEDICARE JD
THE MEDICARE CONTRACTOR IN CA IS CALLED NORIDIAN. WE MUST ENTER MEDICARE IN THE PT’S
ACCOUNT AS NORIDIAN MEDICARE JD
ZERO = 0
LETTER 'O' - O
IF THE PRIMARY INSURANCE IS MEDICARE, USE THE CODE: NORIDIAN /MEDICARE JD
START DATE OF INSURANCE
POLICY NUMBER/MEMBERSHIP ID/ID NUMBER
IF POLICY NUMBER IS BLURRY, YOU CAN GO BACK TO DEMOGRAPHICS AND CHECK THE POLICY NUMBER
THERE
IF PT ONLY HAS ONE INSURANCE, CREATE AN ACTION PLAN
-------------------------------------
IF THE PRIMARY INSURANCE IS MEDICARE, USE THE NAME: NORIDIAN /MEDICARE JD
START DATE OF INSURANCE
POLICY NUMBER/MEMBERSHIP ID/ID NUMBER
IF POLICY NUMBER IS BLURRY, YOU CAN GO BACK TO DEMOGRAPHICS AND CHECK THE POLICY NUMBER
THERE
IF PT ONLY HAS ONE INSURANCE, CREATE AN ACTION PLAN
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FORMAT IN LABELLING DOCUMENTS
1. PWO ( PHYSICIAN WRITTEN ORDER)
FORMAT IN LABELLING:
MAIN ITEM BEING ORDERED | SIGNED OR UNSIGNED | DATE SIGNED
2. F2F NOTES
FORMAT IN LABELLING:
REASON FOR VISIT | SIGNED OR UNSIGNED | DATE OF VISIT OR ENCOUNTER DATE
3. SLEEP STUDY
FORMAT IN LABELLING:
TITLE OF THE DOCUMENT | SIGNED OR UNSIGNED | DATE OF STUDY
4. OTHERS
FORMAT IN LABELLING:
TITLE OF DOCUMENT
