If you have ever ordered DME, you know it is a time-consuming and sometimes frustrating process. There are ways to make it less frustrating. Durable Medical Equipment can range from blood sugar meters to hospital beds to wheelchairs and a lot in between. By definition, DME must be durable (obviously), used for a medical reason, used in your home, and expected to last multiple years.
Dealing with insurance companies isn’t always easy. Sometimes it feels like they make ordering equipment harder than it needs to be. Don’t give up, there are ways to make it smoother:
1. Know what you want and what you need. This sounds simple, but it is not. You need to make sure you need the equipment and you want it. For example, everyone told us we needed a Hoyer lift in our home to help lift our daughter from the ground. We believed them and went through ordering it. Once we had it at home, we realized it was too big and bulky to keep anywhere near where we may need it. It was a waste because we have never used it with our daughter. We learned from this mistake. We always make sure we have seen equipment in person and have seen it used to make sure we will use it.
Once you realize you want it, then you have to prove you need it. “Medical Necessity” is an important part of the process no matter what insurance you have. Learn this term. It will be your responsibility to show the equipment is solely for medical purposes. You need to show that there is a medical reason for providing the equipment. It will need to link to a medical diagnosis or treatment.
It can be easy. A child who cannot walk needs a wheelchair. But, do they need a power-standing feature? No, that is not primarily medical and insurance will not approve it. An electrical connection that isn’t covered will also be denied. A child in a wheelchair may want a tray for their chair to use at school. It might not get approved because there is no direct medical benefit. They might deem it an option for leisure or recreation and not cover it.
2. Understand your insurance plan. Your DME provider or therapist will have a good idea of what your insurance will cover, but it is your responsibility. We have had a lot of luck calling the insurance company and speaking to a specialist. Don’t stop with the first person who answers the phone. You may have a case manager if your child has a complicated case. Get to know them. It makes things easier.
We were told by everyone, even an independent case manager our insurance company hired to oversee modifications to our home, that no insurance company covers a car modification for a wheelchair under any circumstances. I called the insurance company and spoke to our case manager and she told me to submit the paperwork. We got multiple quotes for modifications, gathered the medical paperwork, and explained that we needed it because we might hurt her by carrying her in and out of the car. We mentioned it would improve her quality of life, but you should not rely on that argument because that is not a medical reason. They approved about $15,000 worth of modifications to our van, added a locking mechanism to her wheelchair, and paid for the maintenance of all equipment they paid for. It shows you shouldn’t be afraid of asking for something. The worst case is they say no.
3. Get all the paperwork in order. Stay organized, organized, and organized. Make sure you know what your insurance company needs to see for submission. Work with one therapist and one DME provider for each piece of equipment. If you have a private PT and a school PT and they both submit different forms to the insurance company, you have just complicated the process and it will take longer to sort it out. We used our private PT for all equipment until COVID and we stopped private PT. After, we either went through our school PT or through a DME that has its own PT. Our medical facility has this. This is the easiest. They do everything and it is all submitted together. Working with private or school PTs may take more oversight on your part.
4. Wait—Major equipment always takes a while. Getting a new wheelchair will take months, and getting a hospital bed may take a couple of days. When we needed a nebulizer, we got it the same day. When we needed a new shower chair (it has a lot of bells and whistles), it took about 3 months. It is what it is. We have not made this go quicker. Instead, we have adapted and know to order a new wheelchair months before we NEED it. We can always get a quick fix while we wait for a new one.
Once you have gone through the process a few times, you learn the specific tricks needed to make the process easier with your insurance company. Ask your child’s PT, OT, or SLP for advice. They’ve been through it a lot. They will be your best guide through this process. Doctor’s offices will not want to address major DME because they do not deal with the approval process, the therapists do. All of this is a learning game. If you learn what you need to do, it makes the process a lot easier.