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In theory, health care consumerism is a straight-forward idea: Shifting costs to consumers, typically in the form of high-deductible health plans (HDHPs), gives them an incentive to make informed decisions about the health care services they purchase.

In practice, consumerism represents a significant challenge to providers’ bottom lines. A recent report reveals that for 74% of providers, patient collections take over a month. Further, 66% of providers said patient receivables are a primary revenue concern.

Part of the problem is many providers’ patient collection processes do not align with consumer preferences. For example, 88% of providers reported relying on manual and paper-based transactions for patient collections, but 46% of consumers prefer electronic communication for medical bills, while 65% prefer to pay medical bills via online portals or mobile apps.

This has left many patients in the dark about how much they owe and the available payment options. Many providers, including durable medical equipment (DME) providers, have been left without the tools and resources necessary to communicate sensitive financial issues, explain benefits coverage, or provide accurate and timely estimates.

As the nation continues to grapple with the COVID-19 pandemic, telehealth has become a critical means of delivering access to care for patients. For DME providers, it is more important than ever to ensure that the health systems and physicians’ offices they work with have a seamless means of ordering DME for patients within the telehealth workflow.

Defining patient access

Patient access is a mix of technology, process efficiencies and strategies to engender patient accountability, and it is based on three pillars of the revenue cycle process: enhancing the patient experience, increasing yield and containing cost.

Properly implemented, patient access processes allow providers to drive measurable and meaningful business improvements with tools that improve accuracy and increase revenue. Patient access has three goals: Help patients understand what they owe, make it easy to pay and set expectations.

To achieve these goals, a provider must invest in its patient access department and technology to provide the following:

  • Fast and accurate estimates of each patient’s financial responsibility
  • Forecasts of each patient’s propensity to pay
  • Multiple payment options and patient-assistance plans

Functions of a patient access program

Patients who know in advance how much they will pay are likely to be more satisfied. It is common sense to avoid surprising patients with higher bills than they were expecting. For an effective patient access program, providers must implement the following steps.

Conduct pre-appointment checks. Before receiving services, patients should know the provider’s payment options and assistance plans. They should know what insurance will cover and what their total financial obligation will be for the appointment. Pre-appointment checks, whether in person or through telehealth, should be part of every provider’s workflow.

Ensure billing is clear and concise. Patients often struggle to understand what they owe due to bills from multiple hospitals, physicians, and labs for the same episode of care. Often DME providers are one of the last services patients need in an episode of care, which makes clear and concise billing even more critical. Statements should be designed so patients can easily understand the language and format.

By using technology and building more flexibility into collections, providers can reduce their reliance on paper statements and reduce administrative costs. To interact effectively with patients, real-time adjudication and point-of-service collections with effective follow-up strategies are imperative.

Make it easy to pay. Patients have different expectations, practices and preferences regarding how they pay health care bills. DME providers have learned that a small technology investment can bring more flexibility to the collections process. For example, most DME practices already include options to pay by credit card, but relatively few organizations offer an online payment option.

The biggest opportunity to collect from patients is at the point of service, so providers should make it standard practice to collect payments while patients are onsite. To this end, leading DME platforms feature workflows that enhance providers’ telehealth strategies by ensuring that ordered products are delivered to patients remotely. These solutions make it easy for providers to identify a patient’s need for a product, create an order, discuss the costs upfront, then ship the product to the patient and bill appropriately.

Engaging patients as consumers

Even with greater transparency, encouraging patients to keep current with payments is an important task for providers. Accomplishing this will require consistent communication with patients. Many organizations underestimate how important it is to engage patients from the beginning and maintain positive relationships. By proactively addressing financial information and payment options, providers can improve patient engagement and satisfaction.

Steve Ingel is the executive vice president of DJO Healthcare Solutions, a leading provider of high-quality medical devices and technologies.

Lillian Phelps is the senior director of product management for Availity, the nation’s largest health information network.

The coronavirus pandemic’s effect on daily life has been unprecedented, and everyone—including business owners—has looked forward to returning to normal (in whatever shape that takes). Whether you find yourself in an area that has already lifted stay-at-home orders or is about to, there’s a lot to consider before resuming operations.

Especially in the health care space, your customers may be part of a vulnerable population. And to protect your customers, your employees and your community, it’s important to do your due diligence when opening your business to the public in the wake of this public health emergency.

When Should I Reopen?

Essential businesses like hospitals and clinics, grocery stores, gas stations, etc., have remained open, at least in part, during the pandemic. However, nonessential businesses have remained closed, disrupting operations and the bottom line. In the case of HME providers, equipment fulfillment may have remained in place, but most retail operations have likely been down.

As stay-at-home restrictions are eased and businesses are allowed to resume as normal, is it really safe to reopen completely? How do you know it’s the right moment? Consider the following to help you answer your questions:

  • Review recommendations from state and local governments, federal agencies, and your peers. The COVID-19 pandemic impacted every industry in every region, but it didn’t necessarily impact them in the same ways. Every state will handle their decision differently. That said, just because you’re allowed to open doesn’t mean it’s the right time. Look to the relevant orders and recommendations. Your local officials and peers will be especially useful resources, as they’ll have a better understanding of the population you serve.
  • Understand the risks. If and when you’re allowed to reopen completely, it may be worth doing so in phases to prevent additional risk. After all, COVID-19 may still be a risk in your area, even if it’s diminished. It’s critical that you perform a risk assessment before reopening to establish the specific steps necessary for your unique business to keep your staff and customers safe. Review guidance from the Occupational Safety and Health Administration (OSHA), state and local agencies, industry associations, as well as your local health department. We also recommend seeking the expertise of legal, insurance and other professionals.

How Do I Assess My Risk?

Now that we’ve established that resuming your business operations safely isn’t as simple as unlocking the front door, how do you determine the proper steps to take? Start by performing a risk assessment. The complexity can vary from one business to another, but all risk assessments share the following steps in common:

  • Identify hazards. Think critically about your exposures. It’s best to assume that someone exposed to COVID-19 entered your place of business. Walk the premises and consider high-risk areas, such as places where people linger or congregate like breakrooms. Next, consider the tasks employees perform. Does their job function put them at higher risk of exposure? 
  • Determine who is more at risk and how. After identifying hazards, look at who in your workforce and customer base might be at higher risk. For example, a high-risk individual may be an employee who meets with customers or a customer with preexisting medical conditions.
  • Analyze the risks. Once you’ve identified each risk facing your business, ask yourself: What’s the likelihood this risk will occur? If it does, what are the potential consequences? Some consequences to consider include potential financial losses, compliance requirements, employee safety, business disruptions and reputational harm to name a few.
  • Strategize. With an understanding of the threats facing your business, you can now develop a strategy for controlling and managing them. Some methods to consider include:
  1. Risk avoidance—involves eliminating certain hazards, activities and exposures from your operations entirely. For example, you might continue certain activities remotely to avoid unnecessary exposure for employees.
  2. Risk control—involves taking preventative action. This could include aggressive cleaning protocols or continuing to mandate the use of personal protective equipment (PPE).
  3. Risk transfer—involves transferring your exposure to a third party. If, for example, you regularly make deliveries to your customers, you could instead hire a third party to fulfill these requests on your behalf.
  • 4 Monitor the results. Risk management is a continuous process. As your risks evolve—whether due to COVID-19 or any other circumstance—you’ll need to monitor the effectiveness of your solution. Reassess regularly and make adjustments as necessary. 

How Do I Keep My Workplace Safe?

Risks and solutions can differ widely from one business to another. Fortunately, OSHA and the Center for Disease Control and Prevention (CDC) offer a host of workplace controls to consider. For instance, you should:

  • Enact administrative controls. Administrative controls include changes in policies or procedures that lessen individuals’ exposure to a hazard in the workplace. For example, you may continue reducing the number of employees in an area at a given time by alternating days or adding shifts.
  • Mandate the use of PPE. If your business decides to continue requiring PPE, ensure employees understand how to properly put on, take off, and care for PPE, as well as best practices and when it’s required. Create training material that is easy to understand for all workers.
  • Install engineering controls: Engineering controls remove hazards or place barriers between the worker and the hazard. Some common engineering controls following COVID-19 include:
  1. High-efficiency air filters
  2. Increased ventilation rates in the work environment
  3. Physical barriers, such as a clear plastic guard, placed between the worker and customer at the register
  • Be flexible: Be prepared to change your business practices to continue maintaining essential operations, as many did when the public health emergency first started. Adaptive measures can include identifying alternative suppliers, prioritizing existing customers, or continuing to temporarily halt or slow down some aspects of your operations, such as your retail space.
  • Speak to your vendors and partners: When crises like COVID-19 hit, we’re better off helping one another. Continue to discuss your response and reopening plans with your business partners. Share best practices with businesses in the communities you serve along with those in your supply chain.
  • Continue to encourage social distancing: Social distancing, sometimes referred to as physical distancing, is the practice that aims to minimize the spread of disease by increasing the physical space between people. Consider maintaining the following best practices:
  1. Avoid gatherings of 10 or more people. This also means continuing to limit the number of people in the workplace.
  2. Keep at least six feet between yourself and other people. Making aisles one-ways in your facilities and placing floor graphics reminding customers to keep their distance can help.
  3. Continue to host some meetings or appointments virtually. This might include virtual equipment setups and other telehealth options.
  4. Continue encouraging staff to work from home whenever possible.
  • Adjust staffing to manage various risk levels: Note that some employees may be at higher risk for serious illness, such as older adults and those with chronic medical conditions. Continue to minimize the amount of face-to-face contact higher risk employees have with others. Adjust their tasks so they can more easily maintain six feet of distance from their co-workers and customers.
  • Separate symptomatic employees: Employees who exhibit symptoms of illness should stay home. If one of your employees has a confirmed case of COVID-19, you should inform other employees of their possible exposure and instruct them on how to proceed based on the CDC Public Health Recommendations for Community-Related Exposure.
  • Support proper etiquette and hygiene: Encourage your employees to cough or sneeze into a tissue or their upper arm. Businesses should continue to encourage good hygiene to prevent further spread of COVD-19. This can involve:
  1. Tissues and no-touch disposal receptacles
  2. Soap and water for proper hand washing
  3. Hand sanitizer dispensers in multiple locations
  • Clean and disinfect the workplace regularly: To keep your employees and customers safe, it’s vital to continue sanitizing your workplace regularly and thoroughly. Some best practices include:
  1. Focus on frequently touched surfaces (e.g., workstations and registers, keyboards, telephones, handrails, and doorknobs), ensuring they’re properly disinfected. Check the label on your preferred cleaner to find the contact time needed to disinfect a surface.
  2. Discourage workers from sharing equipment (e.g., phones, desks, or other tools) when possible. If items must be shared, clean and disinfect them before and after each use.
  3. Provide disposable wipes so employees can easily disinfect commonly used surfaces before and after they use them.

What Else Should I Know?

Reopening your business in the wake of the COVID-19 pandemic may not be as simple as unlocking the front door, but there are plenty of resources available to help along the way. When in doubt, remember that your insurance agent or broker is in the business of helping you mitigate risk. Contact them when you need help determining what steps you need to take to open your business safely.

Adam Miller is a senior HME program manager for VGM Insurance. Reach him at or on LinkedIn.

ATLANTA – What will the Nov. 2-4 Medtrade look like in 2020? Wider aisles, sanitation stations, dedicated entrances/exits and reimagined registration areas are all on the table. The Medtrade team is discussing these and other possibilities for putting on the event coming out of the COVID-19 situation.

The March 3-5 Medtrade Spring in Las Vegas seems like a lifetime ago, and since then trade shows across the country have been canceled or put on virtually to varying degrees. As caretakers of the Medtrade show, we are taking a serious look at what the event at the Georgia World Congress Center (GWCC) might look like.

Fortunately, our partners at the GWCC believe strongly, as do we, that the health and safety of attendees must be the top priority. With that in mind, the GWCC recently announced their commitment to achieve GBAC (Global Biorisk Advisory Council) STAR accreditation for cleaning, disinfection and infectious disease prevention. They know, and we know, that this is a difficult time for many. Our team is here to tend to exhibitors’ business needs, as well as the concerns and questions of attendees.

While we are planning on staging, we are considering a virtual component after the show for folks who are not able to attend. We use the term bolt-on or add-on component. That could be webinars or full conference recaps after the show.

With the show still about five months away, we did not seriously contemplate the idea of going “full virtual” and/or canceling the event at this point. In fact, the Medtrade team and the EAB are optimistic, and I, too, am hopeful. That said, we can't be overly optimistic and we must have backup plans. As we sit here today, we intend to have the show in November in Atlanta. That is the goal.

For their part, EAB members sifted through presentation submissions, which had trickled in at first due to the COVID crisis, but picked up considerably after an extension. Medtrade usually receives more than 100 presentation submissions. This year, we ended up just shy of that number, but I was pleasantly surprised. The quality was solid and, in some cases, it was obvious that people had even more time to plan out their topics in detail.

Not surprisingly, there are several COVID-related topics and panels planned, primarily dealing with lessons learned and business operations during a crisis. Considering potential future guidelines, we planned to be ready for the question: Should we reduce the amount of conference sessions or make them smaller with socially distanced seating? If that happens, should Medtrade increase the number of conference sessions to account for the smaller classes?

All of those are on the table. We will consider the safety of every attendee first and foremost, while following the rules and regulations set out by the state and the facility. We will not be hasty in those decisions, and we’ll be developing an onsite preparedness plan that will account for many eventualities.

All of the above goes to the “what” of a possible staging in November, but what of the why? Some have asked: How relevant are in-person trade shows in 2020? I admit to being biased on the topic, but we’ve been asking the question and, thus far, the answer has been consistent: Face-to-face interaction is not dead, in fact, the craving for in-person networking may indeed be stronger.

Could it be that after all the pain, isolation and real human suffering that we are more inclined to seek each other out? It’s true that I’m in the trade show business, but it’s also true that I’m here because I’m a people person. We may not shake hands in the same manner, and perhaps hugs will be a bit more scarce, but seeing eye to eye remains important.

The idea of handling equipment and meeting (safely) so many people in a few days remains an amazing opportunity that has worked for quite a long time. I for one believe that Medtrade will endure, much like the HME providers who have proven so resilient throughout the years. I look forward to seeing you in Atlanta.

Mark Lind is show director for Medtrade and Medtrade Spring.

With COVID-19 permeating every aspect of our lives and our media experience, we look for the good in our communities and continue to celebrate the front-line workers: health care staff, truckers, grocery store clerks, gas station attendants and the list continues. They are the heroes tirelessly working so we can stay at home and abide by the shelter and place orders.

Have you wondered about the “sidekicks” who are behind the scenes making sure the heroes and heroines have what they need to save the day? Those who keep the “caped crusaders” going?

Some of the most famous of the “dynamic duos” are:

  • Batman and Robin
  • Aquaman and Aqualad
  • Batwoman and Batgirl
  • Mermaid Man and Barnacle Boy (you had to watch SpongeBob SquarePants to get that reference)

During a recent all-staff video conference with my team, I told them that if they ever doubted their importance in the health care continuum or viewed their jobs as just “paper pushers” now is the time for a paradigm shift. That’s right, your revenue cycle staff are the behind-the-scenes partners to the front-line health care workers.   Think about it: They are the invisible sidekicks that keep the superheroes going. You see, they are your intake, medical documentation, and billing and collections arms of your company.   

Gaining payment has always been important, but now with the world’s focus on the health care delivery system and the respiratory health of our population, your revenue cycle staff can truly feel the weight and importance of their day-to-day jobs. Without collections, your front-line team members and the patients they serve can’t receive the life-saving equipment and service. The collections of your revenue cycle staff fund your ability to purchase equipment to serve your patient base, pay salaries when many are out of work, and keep your superheroes outfitted in the PPE armor that protects them in the midst of a pandemic, just to name a few. 

Now is the time for a mindset reset of your “sidekicks.” They need to truly understand their importance in the front-line defense in health care. Throughout history, people have risen to the occasion in the face of great national tragedies and war. Patriotism goes on high and people come together for a common cause. 

This new perspective can drive performance and increase collections.  Amid this global tragedy, you can pull your in-house team together to make things work and click like never before. When people feel like their job has meaning, they work harder and look for ways to make a difference. This is a perfect time to show your team that their jobs are important and that they, too, are part of the success of the health care delivery system fighting COVID-19. 

Payers are easing up claims processing restrictions, certain audits have been suspended, Medicare sequestration cuts have been removed, timely filing limits extended, etc. With payers loosening their grips on our claims, it frees up some of the time of your staff to work on viable claims and improving production. Providers can take this negative and turn it into a positive not only from an employee morale standpoint, but also increased revenue generation.

And while this is occurring, your management can take note of processes that are necessary for day-to-day workflows and those that are in the words of today’s economy “non-essential” to a productive work product. Then take these notes and act upon them when the environment moves to our new post-COVID-19 normal.

The American spirit is strong, and we always rise to the occasion.  Show your “sidekicks” that you couldn’t go through this without them. Make them feel like their job has more value than they ever imagined. You will see them rise to a new level of performance and fight the good fight, along side your superheroes. 

Sarah Hanna is CEO of ECS North. She can be reached at or 888-811-2250.

by: Matthew Fischer - Monday, April 13, 2020

To aid businesses and their employees during the coronavirus crisis, the Small Business Administration is offering loans, called Paycheck Protection Program loans, up to a specific limit to cover payroll and other costs. The PPP contains a simplified application process (some may disagree) and fewer documentation requirements as opposed to typical loans. The PPP is available through June 30, 2020. If you are considering this program, it is important to determine the details before proceeding with the process, such as qualification standards, terms and loan forgiveness. 


Businesses with 500 or fewer employees may be eligible. This includes small businesses, sole proprietors, independent contractors, individuals self-employed,and nonprofits. There are exceptions.  These can be found on the SBA’s website. There are also ineligibility rules. For example, a company will be ineligible if an owner of 20% or more of the equity is presently on probation or parole; subject to formal criminal charges; or, within the last five years, for any felony, has been convicted, pleaded guilty, pleaded nolo contendere, been placed on pretrial diversion or been placed on any form of parole or probation.

Process and Terms

A PPP loan, which the SBA classifies as a 7(a) loan, is part of the $2 trillion Coronavirus Aid, Relief, and Economic Security Act (CARES) Act. Applicants can apply through any existing SBA lender or through any participating banking institution. Form wise, an applicant will be asked to submit SBA Form 2483 (PPP Application Form) and payroll documentation. Sample forms can be found on the SBA’s website. Businesses can receive two and a half times their average monthly payroll costs (excluding compensation in excess of $100,000 per employee) incurred 12 months before the date the loan is made. Other notable terms include a maximum loan limit of $10 million, no prepayment penalty, loan payment deferral for six months and no collateral or personal guarantees are required.


Loans will be forgiven if all employees are kept on the payroll for eight weeks, and the loan proceeds are used for payroll, rent, mortgage interest or utilities. However, at least 75% of the forgiven amount must have been used for payroll. In addition, to get the entire amount forgiven, employees’ salaries or wages cannot be cut nor can the full-time employee headcount decline. The Treasury Department has indicated that loan forgiveness starts with the submission of a request to the lender servicing the loan. The request must include documentation verifying the retention of employees, wages and payments on eligible obligations. Additional guidance on forgiveness is expected from the SBA.   

If a borrower does not let employees go or cut pay, the PPP loan is essentially a grant from the federal government. Applicants and borrowers should frequently check the SBA’s website for new guidance. The guidance released at the beginning continues to be amended, and the SBA has indicated that interested parties should continue to check back. Thus, it is important to stay up to date. If any of the requirements are not 100% clear, I suggest consulting with an attorney before seeking a PPP loan.

Matthew M. Fischer is an income partner in the Miami office of Zumpano Patricios. He can be reached at

On March 13, 2020, the Trump Administration announced regulatory flexibilities to help health care providers and states to respond to and contain the spread of coronavirus. Included in the announcement was that CMS will activate blanket waivers in an effort to ease certain requirements and to prevent gaps in access.

One of these waivers is to expand telehealth services. Under this new waiver, Medicare can pay for office, hospital and other visits furnished via telehealth across the country, including in patient’s places of residence starting March 6, 2020.  A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients.

Medicare beneficiaries will be able to receive a specific set of services through telehealth including evaluation and management visits (common office visits), mental health counseling and preventive health screenings. This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to a doctor’s office or hospital which puts themselves and others at risk.

These telehealth encounters can occur through remote communications technologies. Some of these technologies, and the manner in which they are used by HIPAA covered health care providers, may not fully comply with the requirements of the HIPAA Rules.

On March 19, 2020, the Office of Civil Rights announced that it will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency.

A covered health care provider that wants to use audio or video communication technology to provide telehealth to patients during the COVID-19 nationwide public health emergency can use any non-public facing remote communication product that is available to communicate with patients. OCR is exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency. This exercise of discretion applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19.

For example, a covered health care provider in the exercise of their professional judgement may request to examine a patient exhibiting COVID- 19 symptoms, using a video chat application connecting the provider’s or patient’s phone or desktop computer in order to assess a greater number of patients while limiting the risk of infection of other persons who would be exposed from an in-person consultation. Likewise, a covered health care provider may provide similar telehealth services in the exercise of their professional judgment to assess or treat any other medical condition, even if not related to COVID-19, such as a sprained ankle, dental consultation or psychological evaluation, or other conditions.

Under this notice, covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.  Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications.

Under this notice, however, Facebook Live, Twitch, TikTok, and similar video communication applications are public facing, and should not be used in the provision of telehealth by covered health care providers.

Covered health care providers that seek additional privacy protections for telehealth while using video communication products should provide such services through technology vendors that are HIPAA compliant and will enter into HIPAA business associate agreements (BAAs) in connection with the provision of their video communication products. The list below includes some vendors that represent that they provide HIPAA-compliant video communication products and that they will enter into a HIPAA BAA.

  • Skype for Business / Microsoft Teams
  • Updox
  • VSee
  • Zoom for Healthcare
  • Google G Suite Hangouts Meet

Note: OCR has not reviewed the BAAs offered by these vendors, and this list does not constitute an endorsement, certification, or recommendation of specific technology, software, applications, or products. There may be other technology vendors that offer HIPAA-compliant video communication products that will enter into a HIPAA BAA with a covered entity. Further, OCR does not endorse any of the applications that allow for video chats listed above.

Under this notice, however, OCR will not impose penalties against covered health care providers for the lack of a BAA with video communication vendors or any other noncompliance with the HIPAA Rules that relates to the good faith provision of telehealth services during the COVID-19 nationwide public health emergency.

OCR has published a bulletin advising covered entities of further flexibilities available to them as well as obligations that remain in effect under HIPAA as they respond to crises or emergencies.

Kelly Grahovac is the general managed for The van Halem Group.

Dan Starck
chairman, Council for Quality Respiratory Care

Editor’s note: The following letter was written by Dan Starck, chairman, Council for Quality Respiratory Care, and sent to CMA Administrator Seema Verma.

I am writing on behalf of the Council for Quality Respiratory Care (CQRC) to highlight how our members—the home oxygen, sleep, and ventilation therapy suppliers and manufacturers–are prepared to help during the COVID-19 emergency when patients diagnosed with the disease have access to the equipment and supplies they need to recover. For us to fully serve these patients, however, we need your help in trying to address some of regulatory restriction that will be a barrier to caring for these patients.

1. CQRC asks CMS to cover and reimburse equipment, supplies, and services provided to patients with a confirmed COVID-19 diagnosis who have been prescribed home respiratory therapy for the condition.

Under current law, home respiratory therapy, including oxygen, BiPAP, and ventilator, are covered and reimbursed only for beneficiaries with a diagnosed chronic condition(s). A diagnosis of COVID-19 would be defined as an acute condition. To treat confirmed cases of the virus, physicians are prescribing oxygen, Bi-PAP, and ventilators. The National Academies of Medicine had suggested using home oxygen as a way to address potential hospital overflow issues in a March 5, 2020, discussion paper. The discussion paper also notes that having access to BiPAP or mechanical ventilators will be important. Given the need to quarantine COVID-19 patients,  it is likely that rather than hospitalize all infected patients, the vast majority of patients will remain at home to receive treatment as a way to ensure the availability of hospital beds for higher acuity care patients. Having access to these home respiratory therapies at home may be particularly in rural areas, as well, especially in areas hit already by shortages due to the rural health care crisis.Therefore, we ask that CMS waive the current requirement that home oxygen, BiPAP, or ventilator coverage and reimbursement for Medicare beneficiaries be limited to patients with chronic conditions and allow for the provision and reimbursement of these services if a beneficiary has a confirmed diagnosis of COVID-19 and has been prescribed the home therapy.

2. CQRC asks CMS to reduce burdensome paperwork on physicians and suppliers, by allowing the Certificate of Medical Necessity, the test results confirming diagnosis of COVID-19, and the prescription to be sufficient documentation for determining medical necessity for patients with a confirmed COVID-19 diagnosis who have been prescribed home respiratory therapy for the condition.

During this crisis (and likely into the Fall of 2020), it is important to make sure that patients who have been prescribed home respiratory therapy as a treatment for COVID-19 and quarantined to avoid further spread of the virus receive the therapy in a timely manner. It is also important that suppliers, whose personnel will be with these patients in their homes, are reimbursed in a timely manner so that they have the resources necessary to maintain an adequate stock of equipment and supplies, are able to employ infection control protocols effectively, and can provide their workforce with appropriate personal protective equipment (PPE). 

Therefore, we ask that for purposes of determining medical necessity and auditing of claims, CMS suspend the requirements for medical record review for at least home respiratory therapy when prescribed to patients confirmed to have COVID-19 and being treated with these therapies. It would seem that the current CMN, prescription for the home respiratory therapy, and confirmation of COVID-19 diagnosis are objective documentation would meet CMS’ needs for protecting against inappropriate use of the therapies. It would also be helpful during the crisis to reduce the burden on the suppliers by suspending the medical record review for home respiratory therapy when there is a properly completed CMN and prescription to avoid suppliers having to spend time chasing doctors records when they are working to treat patients during the crisis.

3. CQRC asks CMS to suspend adding non-invasive ventilators from the Round 2021 Competitive Bidding Program to protect access to this therapy.

As the Food and Drug Administration (FDA) has recognized in reaching out to manufacturers of both invasive and non-invasive ventilators to ensure that there is a sufficient supply of these pieces of medical equipment during this crisis, having access to ventilator therapy will be critically important to many patients who test positive for COVID-19. 

While we understand that the Round 2021 competitive bidding program will not take effect until Jan. 1, 2021, we are concerned that the efforts to prepare for the new rates not only in the competitive bidding areas (CBAs), but also the non-CBAs where the new rates will be applied, could result in many suppliers reducing their inventory of NIV equipment and supplies or scaling back the services they provide. In addition, reducing the number of suppliers being able to serve CBAs effective Jan. 1, 2021, may have the unintended consequence of losing bidders exiting the markets prior to that date. Even though, it is possible that the outbreak of COVID-19 may abate over the summer, it also seems likely that another significant outbreak is likely to occur in the fall and winter of 2020-21. To avoid any disruption in the supply and be prepared to meet the likely increase in demand for NIV in the home setting, we ask CMS to remove NIV from the Round 2021 competitive bidding program.

We also would like to work with CMS to make sure the competitive bidding program rollout also does not result in problems for patients who need access to home oxygen and sleep therapies for patients with COVID-19 and consider modifying the rollout, if appropriate.

4. CQRC asks CMS to extend the current blended rate in rural non-CBAs for at least home respiratory therapies in 2021 to protect access to these therapies.

While the country is correctly focused on the immediate threat of COVID-19, health care providers and suppliers are also looking ahead, as we know CMS is as well. The CDC has recently announced as the viral outbreak has evolved, being exposed to the virus will be inevitable for many Americans and many will contract it during this year or next.  

The CQRC members are also looking ahead and trying to plan.  Having a new methodology coupled with COVID-19 exposure and increasing cases could cause havoc in rural areas if more patients require home respiratory therapies to treat the virus under quarantine or near quarantine conditions. Equipping our workforce to safely engage with these patients and their families will also take more resources than anyone could have anticipated during the competitive bidding process.  Rather than risk an access issue, we encourage CMS in the current rulemaking to indicate that because of the COVID-19 emergency, it will extend the blended rate in rural non-CBAs through at least 2021 for home respiratory therapies used to treat patients infected with the virus. Taking this step now is important to allowing suppliers and manufacturers to prepare and make sure they have the equipment and supplies in place, have resources for infection control, and are able to avoid potential disruptions in supply and workforce.

5. CQRC asks CMS to prioritize the provision of personal protective equipment (PPE) for home respiratory therapy suppliers whose workforce are providing equipment and supplies to COVID-19 patients in their homes.

Even though home respiratory therapy suppliers and their employees are less exposed than some health care providers (such as those in hospital emergency departments or some physicians’ offices), we know that those employees who are delivering equipment and supplies are in the unique position of having to enter a patient’s home and set up the equipment or provide supplies.  CQRC members take seriously protecting these employees. Yet, many members of the workforce understandably are concerned about their own health as well.

Some of our members are already having problems accessing personal protective equipment (PPE).  To make sure that the home respiratory therapy workforce do not become sick and are available to assist patients who are infected, we ask that CMS help us by allowing home respiratory therapy supplies to have prioritized access to PPE.  We also ask that CMS work with suppliers of PPE to avoid the increasing demand to lead to higher costs that could create access problems as well.


On behalf of the CQRC, our patients, and our employees, I want to thank you for the efforts CMS is making to ensure that Medicare beneficiaries have access to the medical services they need during the COVID-19 outbreak. CQRC and our members would welcome the chance to discuss how we can help make sure that Medicare beneficiaries who need home respiratory therapies in relation to a diagnosis of COVID-19 have access to the therapies they need.  Please do not hesitate CQRC’s executive director Kathy Lester if you would like to discuss our recommendations or there is additional information we can share with you about how ground ambulance organizations are helping during this crisis. We stand ready to help CMS, the Department, and the federal government in any way we can.

—Dan Starck, chairman, Council for Quality Respiratory Care   

The recent coronavirus pandemic is a good reminder that we should be planning now for the next pandemic. And the one after that. These events are matters of “when” they will hit, not “if.”

Natural disasters—whether severe ice storms, Hurricane Katrina or pandemics—also have reminded HME providers that they are first responders and should be built in to disaster protocols.  

There’s no excuse for Americans to get caught flat-footed, since we have done plenty of thinking, planning and responding already.

In 2008, the Agency for Healthcare Research and Quality, part of the Department of Health and Human Services, convened a two-day meeting to highlight issues and resources about “Home Health Care during an Influenza Pandemic.”  The resulting 85-page report has been worth reading ever since. The participants included physicians and public health representatives from universities, HHS, the Centers for Disease Control and Prevention, the Department of Defense and county health officials, as well as home health and HME providers. I participated as the representative from the HME sector.

The assumptions were that this event would quickly overwhelm hospitals and the need to quarantine patients would be paramount. Therefore, most people infected with a severe pandemic flu virus would receive care “in the home by family members, friends and other members of the community—not by trained health care professionals.”

It was a wide-ranging conversation that explored the basic needs and the outer limits of what a catastrophic outbreak would mean, ranging from the health needs of a massive, self-quarantined population to shortages of supplies, including body bags. 

The report covers issues like role clarification locally and nationally, supplies and equipment needs, reimbursement, tests and exercises, communications, workforce concerns, telehealth and legal issues.

While the initiative focused on home health agencies, there are implications for HME providers, too. A few basic take-always:

  • The home care sector will serve as an essential component of surge capacity in a pandemic.
  • Home care must be actively involved in planning and collaboration across all health care sectors.
  • Home-based care and monitoring technologies should be considered.
  • The surge of patients will strain the home health workforce.

A 2009 survey of HME providers found that 53% had established plans for responding to a flu pandemic and 23% had stockpiled related supplies such as N95 masks. The survey, conducted by the AAHomecare, was conducted in the wake of the swine flu outbreak. How many are prepared now?

Looking at the bigger picture, preparations for dangerous pandemics should be taken seriously by everyone in every corner of our society because they will require actions wider than health care and medical workers.

In 2003, I spent two days with Toronto public health officials during the SARS outbreak (Severe Acute Respiratory Syndrome) as part of a U.S. delegation from the National League of Cities to gather lessons learned. Toronto was struck by SARS but quick and heroic actions by their public health personnel contained it and may have prevented that very deadly disease from becoming a full-blown disaster for North America.

A few take-aways from that experience are worth remembering. While geared for local officials, they are apt for home care providers, as well:


  • Train and prepare for biological threats.
  • Review and establish clear legal powers and lines of authority to respond.
  • Develop a system for recording and tracking all related but unbudgeted costs.


  • Keep government offices in the loop.
  • Manage medical information about infected people.
  • Set up a mechanism to update all employees.


  • Coordinate messages to ensure they are consistent, correct, and frequent.
  • Target communications to key constituencies and audiences.
  • Prepare for an onslaught of questions that require both medical and practical answers.

The key lesson for HME providers: You have leadership and civic roles, as well as clinical responsibilities, in a pandemic. Plan for it, be at the table and demand recognition for your role as part of the response team. Again, this is about when, not if. 

Michael Reinemer is a communications strategist in Washington, D.C. He was VP for policy and communications at AAHomecare, 2004-13.


A New Year’s Resolution is “a promise to do something differently in the new year,” according to Merriam Webster.

For the HME industry, a few ways “to do something differently” in the new year and in the new decade, might include one or more of the following:

1) Software

Implement one or more new software initiative(s) that help you streamline the order-to-cash process. For example, mobile delivery and auto pay are software initiatives that have contributed significantly to improving cash flow for many HME providers.

2) Payer partnerships

Evaluate payer relationships to a) ensure you are being paid as delineated in your contract, b) you are constantly in communication with your contacts, c) you meet regularly to continue to show your value in keeping costs in line, and d) both parties feel the contract relationship is a good one.

3) Financial terms

Secure all financial arrangements up front, including private/self-pay, and all third-party payment that requires you to collect a co-pay. As more patients opt for managed Medicare (Medicare Advantage plans), staff will need to know when you are and are not contracted with a specific plan, etc. Further, as more patients pay cash for their products, upfront payment (and auto-pay for subsequent rental months and supply replenishment) should be a requirement. Making financial decisions prior to rendering service is a must to avoid uncollectible receivables.

4) Right people, right seats

Ensure you have the right people in the right seats on the bus. Assess your staff to be certain they are poised for changing roles within the company and industry. Having the wrong person in a position can be detrimental to an entire team and staff. Conversely, the right leader in a department can make all the difference in the success of your company. As needs change, so too will tasks and staff positions. Personnel needs today may be entirely different in a few months, especially as you ramp up for 2021’s competitive bidding round.

5) Competitive bidding

Be prepared for competitive bid results—simulate a bid awardee result, as well as a non-awardee outcome. Create a plan for either scenario and the various options. Being prepared should help you focus on your company’s strategic direction for 2021 and beyond.

6) Data to prove value

Use data and metrics to illustrate the value you add to patient care. After all, value-based care is common terminology today, if not an expectation by the payer and referral communities. Hospital readmission rates are a key measure for payers and health systems. As an HME provider, you can help reduce readmission rates and increase your overall value. Use data to show this outcome and realize that data is today’s tool for success.

7) Revenue cycle evaluation

Evaluate the order-to-cash process regularly to determine if there are ways to streamline the operational flow. Use staff to help with the analysis. Then document and train staff accordingly. Tightening internal control and expenses can make the difference between a profitable and unprofitable HME business.

8) Manage from reports

Always measure and monitor via reports to ensure you are maximizing productivity and results. For example, set goals based on average time to complete a task, such as order intake, documentation retrieval, etc. Set minimum standards and measure against them. Once you have a PAR performance level, set goals accordingly. Regular and stretch goals are a great way to motivate staff to improve performance.

9) Develop leaders

Focus on ways to build and develop leaders from under you. Once you have a leader, it is the leader’s job to train someone to take their place. A real leader is always looking to pay it forward so they can help others move up as they move up themselves.

10) Show appreciation

Celebrate the wins. Make sure staff feels appreciated for a job well done. Genuine praise for an accomplishment travels far. Make it contagious so everyone wants to receive the praise of those who already merit it. Those who don’t find favor in this will either leave or rise to the occasion.   

11) Say no

When you know a contract is not profitable, say no to the business rather than risk losing money. Stop taking poor referrals or ones that waste your time. This requires you to track your business by contract and/or by referral source.

12) Stay diversified

Stay nimble by not relying on one payer for all of your business. Conversely, with the extensive knowledge of guidelines and requirements expected by each payer, it is impossible to be everything to everybody. Too many or too few product offerings and payers make the business unsustainable.

Miriam Lieber, president, Lieber Consulting LLC is a business management consultant. She and her team offer on-site engagements to help improve operational efficiencies in the revenue cycle. They also offer remote coaching and mentoring for all levels of leadership. Miriam can be reached at

Colton Mason
senior vice president of Supreme Medical

Medical supply distributors and manufacturers are turning their attention to the rapidly growing field of home health care. They are also realizing something that may come as no surprise to you—it’s a really complicated field that’s undergoing a lot of change.

A group of more than 40 experts gathered in November at a Home Care Thought Leaders event in Arlington, Va., hosted by the Health Industry Distributors Association. They met to better understand the market and to strategize about how to deliver the best products for the best care in the home. I had the pleasure of moderating the event and one thing became very clear to everyone in attendance: Shipping a box to a front porch is a totally different ballgame than shipping pallets to a hospital or nursing home.

It’s about really knowing your customer—literally. Is it the patient, caregiver, payer, HME provider, or a combination of that group? It’s also about understanding that the ultimate user is the patient in their home—and they may be experiencing home care as part of an unexpected situation.

Considering the rapidly growing market with its reimbursement and policy pressures, the group of thought leaders brainstormed about how to address three key issues in getting those products to the home: product design, logistics, and sales and marketing. Here are some of their key takeaways:

Product design: Keep it simple

  1. Make it easy to use.
  2. Make it easy to unbox.
  3. Offer on-demand consumer education with instructions that aren’t clinically complex.
  4. Keep it reimbursement-friendly.
  5. Include instructions on who to call for troubleshooting.

Logistics: Make it seamless

  1. Consider the product weight. Does it require more than one person for carrying or set up?
  2. Prepare for urban versus rural delivery challenges.
  3. Offer “smart tracking” for certain items like temperature-controlled products.
  4. Educate drivers to perform a home “scan” rather than just dropping off products on the porch.
  5. Understand whether it’s important to have a required signature.

Sales and marketing: Understand your customer

  1. Connect with patients digitally.
  2. Educate yourself about likes/dislikes of the Silent Generation, baby boomers, and Gen X’ers.
  3. Understand that the Internet is the primary source of information
  4. Make reviews easily available and accessible.
  5. Offer marketing materials with a homecare focus, such as results data from homecare trials.

Colton Mason is senior vice president of Supreme Medical, a full-line medical supply distributor servicing home care providers. Mason is also the host of HME TV, an online series focused on the business success of the home medical equipment provider, which can be found on both YouTube and LinkedIn under the hashtag #HMETV. Visit or view his vlog at