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

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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

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*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

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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

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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.

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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

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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

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As DME provider means we are under Part B, coinsurance is only applicable to us because copayment
applies with Part A.
--------------------------------------

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

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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

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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)

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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