The Ins and Outs of OSA Supply Replacement

1
The Ins and Outs of OSA Supply Replacement

• Laurie Scott
• US Marketing Manager

2
Learning Objectives

• Review multi-faceted benefits of a proactive
  re-supply program
• Understand the financial opportunity that a
  replacement strategy offers
• Discuss ways to boost the effectiveness of your
  Supply Replacement program
• Share participants 'best practices' for Supply
  Replacement, if time permits

3
Agenda

• Comprehensive Patient Care
• Financial Considerations
• Getting Organized
• Contacting Patients
• Delivering Products
• Summary

4
Supply Replacement - Part of a Comprehensive
Patient Care Model

• Who needs OSA Replacement Supplies?
• ONLY Adherent, Compliant Patients
• How do your current set up and follow up
  processes support short-term and long-term
  compliance?
• Are you picking products for the right reasons?

5
Better Patient Care Drives Compliance

• Proper mask fit at set up
• Mask Choices delicate balance
• Vendor-supplied Mask Fitting Workshops CEUs
• Vendor 30 Day Guarantee programs
• Several follow-up calls in first critical weeks
• New LCD requirements
• Psychological Issues Desensitize, Perception
• Reinforce benefits of compliance, improved daily
  functions
• Engage Educate their social support system
• Refittings, other clinical interventions as
  needed issues occur over time

6
Product Selection

• Provide the best opportunity for success
• Weigh upfront product cost vs. long term
  success
• Profit today
• Mask Choice a few options, delicate balance
• Consider comfort technologies
• Humidification, flexible comfort settings for
  exhalation or pressure relief
• Patients using flex technology had a significant
  improvement in adherence over a 3 month period
  (vs. traditional CPAP) and demonstrated an
  increased confidence in their ability to adhere
  to treatment (1)

1. Aloia, MS et. al. Chest 2005 1262085-93
7
Why Patients Need Fresh Supplies

• Equipment has a limited lifespan
• Reduced risk of infection
• Keeps the mask fitting comfortably, without leaks
  
• Facial oils interact with cushion, deteriorate
• Pin hole leaks are irritating, patient tightens
  straps
• Result Soreness, redness, irritation
• Keeps CPAP machine functioning correctly
• Clogged filters reduce the LT life and
  effectiveness of the device

8
Benefits of A Better Care Model

• Improved Patient Compliance
• Lifetime need for supplies
• Patients turn to you vs. internet
• Patient refers other patients to you
• Patients turn to you for their / their familys
  future home health needs
• Differentiation vs your Competition
• Ask about and DOCUMENT patient compliance!
• Market Compliance Program to Referral Sources

9
Agenda

• Comprehensive Patient Care
• Financial Considerations
• Getting Organized
• Contacting Patients
• Delivering Products
• Summary

10
NOTE

• This information is for illustrative purposes
  only.  
• You should not consider this to be either legal
  or reimbursement advice.
• Given the rapid and constant change in public and
  private reimbursement, Philips Healthcare cannot
  guarantee its comprehensiveness, accuracy, or
  timeliness. 
• Philips urges you to seek your own counsel and
  experts for guidance related to reimbursement,
  including coverage, coding, and payment.

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Can I Afford to Enhance Pt Care?

• 2007 Study 100 Home Care Providers
• 71 of their payer contracts have favorable
  reimbursement rates
• 68 of those with a Proactive SR Program were
  motivated by favorable reimbursement, among
  other reasons
• Medicare examples as of today

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2009 Medicare Guidelines for CPAPMask and
Accessory Replacement
Product Examples HCPCS Code Medicare Allowable Maximum Frequency
Nasal Mask Swift, Opus, FP Zest, OptiLife, ComfortGel A7034 106.46 1 per 3 months
Nasal Mask Cushion - replacement Cushions for Mirage Micro, ComfortGel, FP Zest A7032 36.68 2 per month
Nasal Pillows - replacement Pillows for OptiLife, Swift, Opus A7033 25.71 2 per month
Full Face Mask Quattro, ComfortGel Full A7030 170.72 1 per 3 months
Full Face Mask Cushion - replacement Quattro, FP Forma, ComfortGel Full A7031 63.14 1 per month
Headgear A7035 30.57 - 35.97 1 per 6 months
Chinstrap A7036 14.00 - 16.47 1 per 6 months
Tubing A7037 31.55 - 37.12 1 per 3 months
Filter, Disposable A7038 4.15 - 4.88 2 per month
Filter, Non-disposable A7039 11.79 - 13.87 1 per 6 months
Humidifier Water Chamber - replacement A7046 17.66 1 per 6 months
Based on 2009 Medicare national average
allowables.  All states are at the Medicare
Allowable Ceiling for masks, replacement cushions
and water chambers. (Puerto Rico rates are
higher.) Frequencies listed represent the
usual maximum amount of accessories expected to
be medically necessary per Medicare policy.
Coverage and payment determined by Medicare.
13
2009 Medicare Guidelines for CPAPMask and
Accessory Replacement
Example Annual (13 mo.) allowables for a
Medicare patient with a nasal CPAP mask and
chinstrap _at_ maximum frequency
1,825.61 (Actual allowable and frequency will be
based on individual patient medical necessity)
At initial setup / first month 251.41 A7034,
A7035, A7036, A7037, A7038(2), A7032, A7039
Month 2 82.34 A7032(2), A7038(2) Month 3 82.34 A7032(2), A7038(2) Month 4 188.67 A7034, A7032, A7037, A7038(2) Month 5 82.34 A7032(2), A7038(2) Month 6 82.34 A7032(2), A7038(2) Month 7 269.07 A7034, A7035, A7032, A7039 A7037, A7038(2), A7036, A7046
Month 8 82.34 A7032(2), A7038(2) Month 9 82.34 A7032(2), A7038(2) Month 10 188.67 A7034, A7032, A7037, A7038(2) Month 11 82.34 A7032(2), A7038(2) Month 12 82.34 A7032(2), A7038(2) Month 13 269.07 A7034, A7035, A7032, A7039 A7037, A7038(2), A7036, A7046
Based on 2009 Medicare national average
allowables (except where 50 states are at same
level). 
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Medicare OSA Supply Shipments

• Can you ship and bill quarterly supplies at one
  time?
• YES

15
Getting Paid for Quarterly Supplies

• April 2008 RAD
• Lunch and Learn

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Earlier Proof Sources

• December 2006 CMS Bulletins
• Maximum of 90 days of supplies
• 2004 DMERC Clarification Letter ComfortLite
• Mask with 2 types of cushions in one package

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December 2006 Bulletins
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ComfortLite Questions
19
ComfortLite Questions
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Financial Scenario Tool

• Demonstration

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Summary

• A Patient Care Model that includes regular OSA
  supply replacement
• Is good for the patient
• Is financially viable (for many payers)
• Is good for your business

22
Agenda

• Comprehensive Patient Care
• Financial Considerations
• Getting Organized
• Contacting Patients
• Delivering Products
• Summary

23
Now What Do We Do?

• Simple in Theory

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Reality

• 2007 Study
• 100 Home Care Providers
• 37 Strong Proactive program
• 16 had Reactive-Only SR programs
• Most never attempted
• 47 Mixed

Why are they even despite setting up patients for
years?
25
Talk About Sleep and ResMed Survey

• How frequently are you in contact with your
  equipment provider?
• More than once a month 5
• Once a month 10
• Every 2- 5 months 21
• Every 6-9 months 25
• Once a year or less 40
• 54 of patients 10 months or more without
  replacing their masks

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Constraints

• Reasons for Never implementing a program (14)
• 71 Labor Constraints
• 36 Difficulty billing Insurers or Patients
• 29 Difficulty determining which patients are
  eligible for supplies at any given time
• Dont expect current staff to add to their plate!
• Will need additional personnel

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Obstacles Encountered When Implementing
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Supply Replacement

• A structured set of processes and procedures
• designed to better setup, manage, track and
  proactively follow-up with patients
• to improve patient acceptance, comfort and
  results
• while growing your business
• and capturing the ongoing revenue associated with
  regular CPAP mask and accessory replacement.
• Better Outcomes Through Better Patient Care

and bill too!
29
Getting Organized for Supply Replacement

• How can the next steps be easier to do?
• Be ready to Bill Insurance
• Know when to Contact Pts
• Decide how to Contact Pts
• Consider how youll purchase and deliver products
• The more you plan, the smoother your efforts will
  be!

and bill too!
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Getting Organized

• 1. Bill Insurance
• Best Practices
• Document and maintain for each insurance contract
• Schedules
• Allowables
• Specific filing needs
• Document and maintain Patient-specific insurance
  coverage
• Ask each time if coverage has changed
• Inform patient of their coverage rights

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Getting Organized

• 2. Plan When to and How to Contact Pts
• When
• When is the patient eligible?
• How
• What method(s) will you use?
• When will you contact the patient?
• Key
• Good Patient Data Files

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Getting Organized

• 2. Plan When to Contact Pts
• Decide how to track replacement cycles.
  Investigate options.
• Does your billing software help track follow-up
  and future supplies?
• Are upgrades available? Separate modules?
• Other billing software choices?

33
Getting Organized How to Track

• 3rd Party compliance and supply program mgt
  options
• VGM HOMELINK, VGM Pro total solution, many
  options
• medSage voice response system, integrates w/
  your system to extract eligible patients
• iAssist, vendor-offered Assist-like programs
• Jaysec
• Call Centers (Part B specialists)
• Vendor-Supplied compliance supply replacement
  tools
• ResTraxx, Boomerang
• EncoreAnywhere, Encore Pro compliance,
  reminders, aging reports

34
Getting Organized

• 2. Plan When to Contact Pts
• Think through when to contact OSA patients at
  home
• Plan staffing for those times

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Whats Wrong with this Picture?
Difficulties in Implementing

• Are OSA patients different
• from respiratory patients?
• When are OSA patients
• home?

36
Getting Organized

• 2. Plan When to Contact Pts
• Best Practices
• Establish procedures to help better track patient
  replacement cycles beginning TOMORROW
• Add to set up checklists, integrate into every Pt
  contact
• Gather and Update often
• Complete addresses
• Phone numbers (multiple)
• Email (need permission - HIPAA!)
• Preferred method to contact, preferred time to
  call
• Consider 3rd Party options!

37
Getting Organized

• 2. Plan How to Contact Pts
• Mail
• Phone
• E-mail
• Retail Store walk-ins
• Clinics - mass mailings to all, or more targeted
• Patients proactively involved
• Plant the Seed at Set Up!
• 3rd Party providers
• Often multiple methods used

38
Getting Organized

• 2. Consider 3rd Party solutions to manage both
  When and How.
• VGM HOMELINK, VGM Pro
• medSage
• iAssist, vendor-offered Assist programs
• Jaysec
• Call Centers (Part B specialists)
• Others?

39
Getting Organized

• 3. Consider how youll purchase and deliver
  products
• Supply Replacement requires more stock
• Older styles, multiple sizes
• Assess Warehouse capacity
• Investment in inventory
• Place for OSA supplies in Retail space?
• Contacting patients will drive more walk-ins
• Determine how CPAP Clinics can compliment your
  patient care model and supply replacement.
• Assess 3rd party delivery options, i.e.
  drop-shipping

40
Getting Organized

• 3. Consider how youll deliver products
• Best Practices
• Do Clinics / Go Retail
• Encourage Clinic Pre-registrations
• Know who is eligible for supplies before they
  come
• Know who is eligible within weeks
• Clean up records of your install base of patients
  as you go
• Display out of pocket accessories!

41
Getting Organized for Supply Replacement

• The more you plan, the smoother your efforts will
  be!

and bill too!
42
Agenda

• Comprehensive Patient Care
• Financial Considerations
• Getting Organized
• Contacting Patients
• Delivering Products
• Summary

43
Contacting Patients - Dos and Donts

• Do
• Inform patients why they may need regular
  replacement supplies
• Ask about therapy compliance, issues offer
  clinical intervention and support
• Review your OSA replacement process at initial
  set up
• Explain their insurance eligibility, rights
• Let them know about their co-pays
• Tell them what accessories may be of interest,
  may enhance their therapy experience (PAP
  pillows, hose covers, cleaners)
• Inform re which items are not covered out of
  pocket

44
Contacting Patients - Dos and Donts

• Dont
• Tell the patient what they need
• Imply that their insurance says they need
  supplies
• Ship supplies not authorized by patient
• Ask patient if it is OK to ship monthly /
  quarterly supplies automatically unless OK with
  their payer
• Auto-ship supplies

45
Contacting Patients - Dos and Donts

• What are the regs related to calling Medicare
  patients?
• 424.57 Special payment rules ..
• (c) Application certification standards. .The
  supplier
• (11) Must agree not to contact a beneficiary
  by telephone when supplying a Medicare-covered
  item unless one of the following applies
• (i) The individual has given written permission
  to the supplier to contact them by telephone
  concerning the furnishing of a Medicare-covered
  item that is to be rented or purchased.
• (ii) The supplier has furnished a
  Medicare-covered item to the individual and the
  supplier is contacting the individual to
  coordinate the delivery of the item.
• (iii) If the contact concerns the furnishing of a
  Medicare-covered item other than a covered item
  already furnished to the individual, the supplier
  has furnished at least one covered item to the
  individual during the 15-month period preceding
  the date on which the supplier makes such
  contact.

46
Contacting Patients - Dos and Donts

• CMS Automatic Shipments
• Up to a 3 months supply of appropriate
  accessories may be dispensed and billed, provided
  these steps are completed for each re-supply
  transaction
• Patient is contacted
• Patient acknowledges their need for supplies, and
  
• Patient approves the re-supply and quantity
  desired of each of their CPAP accessories. (Given
  that Medicare patients have a co-pay, the
  quantity of each item to be supplied should be
  approved by the patient.)
• (Assumes coverage criteria for E0601 are met)

47
Issued by all four DME MACs
48
Contacting Patients - Dos and Donts

• E-Mail
• HIPAA Security need patients permission (or
  encryption)
• Must be clearly identified as a solicitation or
  advertisement for products or services and must
  not contain a misleading subject line
• Must contain an easily usable opt-out option
• Must have a return e-mail address, the
  provider's postal address

49
Contacting Patients

• Multi-pronged approach
• Patients Proactive Involvement
• Your Proactive Efforts
• 3rd Party Options

50
Patients Proactive Involvement

• Inform at set-up, set the tone re supply
  replacement
• Provide info re why they should replace supplies
  regularly
• Provide reference tool re their insurance, their
  rights, normal replacement cycles
• Custom tools, reminders for patient to carry or
  take
• Manufacturers package inserts, tools wallet
  cards w/ sticker

51
Patients Proactive Involvement

• Inform at set-up, set the tone re supply
  replacement ..
• Refer them to manufacturer reference materials
  and replacement tools
• FP Vigor8
• MyResMed.com Pt resources and e-mail reminders
• Respironics SleepApnea.com reference materials
  and e-mail ReminderZzz
• New How long does a mask last? brochure for pts
• Packaging alternatives that plant the seed re
  replacements
• Respironics DuoPacks mask first replacement
  cushion

52
Contacting Patients Your Efforts

• Follow through with your plan!
• Additional Staffing
• Work Hours
• Avoid assigning the emergency of the month to
  this team
• Consider staff skill levels
• Clinical background to make compliance and supply
  replacement calls?
• Reward staff for improving/maintaining patient
  data, compliance levels, replacement sales

53
Contacting Patients Your Efforts

• Mail
• Phone
• E-mail
• Retail Store walk-ins
• Clinics - mass mailings to all, or more targeted
• Patients proactively involved
• Plant the Seed at Set Up!
• 3rd Party providers
• Often multiple methods

54
Contacting Patients Your Efforts

• Assess success of contact methods used
• Why did they succeed? Why did they fail?
• Tune up the process repeatedly
• Mix it up! Calls, direct mail, clinics
• Segregate patients based on preference, your
  success
• Use manufacturer materials where provided
  postcard mailers, reminder cards

55
Contacting Patients 3rd Party Options

• medSage Voice Response System
• Integrates with billing system
• Regularly runs queries to pull out patients that
  qualify for supplies
• Contacts Pts telephone VR system
• HOMELINK, VGM Pro calls, email, mail options
• Jaysec
• I-Assist - call center
• Medicare B Call Centers
• Others?

56
Summary

• Ensure compliance with federal and local
  regulations
• Set the tone at patient set up with info, tools
• and in every contact afterward
• Involve and inform the patient - every step of
  the way
• Vary your contact methods
• Use 3rd party solutions to organize, manage and
  implement your patient care-based supply
  replacement program

57
Agenda

• Comprehensive Patient Care
• Financial Considerations
• Getting Organized
• Contacting Patients
• Delivering Products
• Summary

58
Delivering Products

• Options
• Ship from stock
• Ensure available warehouse space, staffing and
  higher inventory carrying COSTS
• Sell and deliver at CPAP Clinics
• Captive audience, interested in their therapy
  success
• Enhance the retail walk-in experience
• Offer choice, visibility
• Use Vendor-supplied materials
• More contact more walk-ins
• Consider 3rd party Drop Ship

59
Benefits of Drop Shipping

• Reduced inventory carrying costs
• Cash available for other purposes
• Carry only what is needed for new set ups
• Reduced need to carry older products
• Positive cash flow
• Sell a mask today, buy it today, pay for it 30
  days after the sale
• Reduced labor
• Ordering, receiving, monitoring of inventory
• Processing patient orders
• Eliminates shipping packaging costs (box, label,
  filler)

60
Drop Shipping Options

• Large Fulfillment Houses
• McKesson Supply Management solutions
• Invacare Supply Group - Home Delivery Plus
• Respironics - SupplyDirect
• ResMed
• Other manufacturers or buying groups

61
Summary

• Prepare for different and higher inventory needs
• Use clinics to both contact and deliver
• Rethink your Retail space
• Consider Drop Shipping to reduce costs of holding
  inventory

62
Supply Replacement

• A structured set of processes and procedures
• designed to better setup, manage, track and
  proactively follow-up with patients
• to improve patient acceptance, comfort and
  results
• while growing your business
• and capturing the ongoing revenue associated with
  regular CPAP mask and accessory replacement.
• Better Outcomes Through Better Patient Care

and bill too!
63
Supply Replacement - Summary Part of a
Comprehensive Patient Care Model

• A Patient Care Model that includes regular OSA
  supply replacement
• Is good for the patient
• Is financially viable (for many payers)
• Is good for your business
• The more you plan, the smoother your efforts will
  be!
• What can you begin to do TOMORROW to build better
  patient records, opportunity for supply
  replacement success?

64
Supply Replacement - Summary Part of a
Comprehensive Patient Care Model

• Use a multi-pronged approach to contact patients
  about compliance and supply needs
• Consider 3rd party options
• Market your compliance program to referral
  sources and patient base
• Prepare for different inventory needs
• Better Outcomes Through Better Patient Care

65
The Ins and Outs of OSA Supply Replacement

• Questions?
• Thanks for your time
• Good Luck!