OBJECTIVE:

  • To know the basics of healthcare policies in the US.
  • To get familiarized with the different insurance processes.
  • To understand the Revenue Cycle Management.
  • To know the different stages of RCM.
  • To learn the basics of HIPAA (Health Insurance Portability and Accountability Act of 1996).

US HEALTHCARE

  • Costs of health care are higher in the United States than in other countries and put a strain in the overall economy. Health care is paid by the government programs (such as Medicare and Medicaid), private health insurance plans (usually through employers), and the person’s own funds (out-of-pocket).
  • The US government funds two kinds of health plans. This is through Medicare and Medicaid. They are especially designed for the elderly, disabled, poor and young. However, many Americans have their healthcare paid for by their employers. It’s often included as a fringe benefit in job packages.

WHAT IS DME? (DURABLE MEDICAL EQUIPMENT)

  • Any equipment that provides therapeutic benefits to a member because of certain medical conditions and/or illnesses that can withstand repeated use, is primarily and customarily used to serve a medical purpose, and is appropriate for use in the home.
  • Includes, but not limited to, wheelchairs (manual and electric), hospital beds, traction equipment, canes, crutches, walkers, kidney machines, ventilators, oxygen, monitors, pressure mattresses, lifts, nebulizers, incontinence supplies, wound care products, etc.

WHAT DME IS COVERED BY MEDICARE?

  • Medicare Part B covers DMEs your doctor prescribes for use in your home. Only your doctor can prescribe medical equipment for you. DME meets this criteria:
    • Durable (can withstand repeated use)
    • Not usually useful to someone who isn’t sick or injured
    • Has an expected lifetime of at least 3 years
    • Used for a medical reason
    • Used in your home
  • DME that Medicare covers includes, but isn’t limited to:
    • Air-liquidized beds and other support surfaces (only rented)
    • Blood sugar (glucose) test strips
    • Commode chairs
    • Crutches
    • Infusion pumps and supplies
    • Nebulizers and nebulizer medications
    • Sleep apnea devices (CPAP) devices and accessories
    • Canes (however, white canes for the blind aren’t covered)
    • Continuous passive motion (CPM) machine
    • Hospital beds
    • Wheelchairs
    • Oxygen equipment
    • Suction pumps
    • Walkers
    • Traction equipment
    • Blood sugar monitors

WHAT DME IS COVERED BY MEDICAID?

  • Medicaid is a State and Federal partnership, which provides coverage for low income, elderly, disabled and families with children. Medicaid will cover Durable Medical Equipment (DME) that is medically necessary. Medicaid has multiple coverage plans, therefore copay amounts may vary.
  • It can be provided outside of nursing homes, when this occurs it is referred to as Home and Community Based Services or Waivers. Individuals participating in a Medicaid Waiver program typically have a higher degree of personal involvement in the acquisition of DME than Medicaid Nursing Home residents.
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