Self-insured employers who are trying to control the cost of medical care within their workers’ compensation program will often use medical triage, nurse case managers and pharmacy benefit managers, but overlook durable medical equipment (DME). Durable medical equipment is reusable medical gear or reusable medical products necessary for the injured employee to function at home or away from a medical facility. Durable medical equipment must be prescribed by a doctor and most DME will have no benefit to a person who does not have an injury or occupational illness. The need for durable medical equipment is closely related to the severity level of an injury — the higher the level of severity of an injury, the greater the probability that an injured employee will need DME.
Can Be Expensive, However Cheaper Than Hospital
Depending on the nature of the DME, it can be very expensive adding considerable medical cost to the workers’ compensation claim. Examples of DME that can add substantially to the claim cost include:
- Oxygen tents
- Hospital beds
- Motorized wheelchairs
- Power operated vehicles
- Lift chairs
- Continuous positive airway pressure (CPAP) machine
- Iron Lungs
- Traction equipment
- Prosthetic limbs
- Transcutaneous electronic nerve stimulators (TENS units)
- Air beds or fluid beds
While some DME can be expensive, it is always much cheaper for the injured employee to be at home using DME than it is for the injured employee to be in a hospital room, nursing home or other type of convalescent facility. The cost of medical care supplied away from the home can range from 100% to 1000% higher than the cost of medical care at the injured employee’s home with DME.
In some liberal jurisdictions, the range of DME has been expanded to include such items as:
- In-home spas
- Hot tubs
- Orthopedic/specialty mattresses
- Air conditioners
- Hearing aids
Prescription Written by Doctors Should be Verified
Prescriptions for these types of items are normally only written by doctors chosen by the employee’s attorney. If the employer is confronted with a prescription for specialized DME of this type, an independent medical examination of the injured employee can be completed to verify the need for the specialized DME. An alternative is to have a utilization review or a peer review of the prescription to verify the medical necessity. A different approach is to have the request for specialized DME reviewed by the workers’ compensation board or industrial commission for their concurrence or denial.
Claims Adjuster Should Arrange for Purchases
If it is determined the specialized DME is necessary, the claims adjuster or the nurse case manager should arrange the purchase of the specialize DME. This will allow the adjuster or nurse case manager to obtain the necessary equipment, but restrict the purchase to what meets the doctor’s prescription, but does not exceed it. For example – the doctor writes a prescription for a Tempurpedic mattress and the industrial commission rules it must be provided. If the claimant is left to select and order the mattress, the claimant will select the $6,000 version, while if the adjuster is responsible for obtaining the mattress, the adjuster will select the $3,000 version that meets the requirements of the doctor’s prescription.
Some DME is not expensive and is commonly provided to injured employees. Examples of less expensive DME includes:
- Commode chairs
- Non-motorized wheelchairs
Hold Durable Medical Equipment Costs Accountable
If the state medical fee schedule includes DME (some state fee schedules do include DME while others do not), and if there is no question in regards to the medical necessity of the DME, it should be submitted to the medical fee bill review service for control of the cost of the DME.
In the states where the state fee schedule does not address DME, the self-insured employer should make arrangements with a company that specializes in DME to provide all necessary DME. A pre-arranged pricing agreement for the DME items listed above will reduce the cost of DME.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center.
Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.