The DMEplus network includes a broad range of over 6,000 cost-effective, local and national health care providers that cover many specialties. The extent of our network ensures we provide core products and services in all 50 states and the Caribbean territories. Our broad network also ensures we meet the needs of virtually any type of workers' compensation case.
DMEplus recognizes how quickly the cost of a claim can escalate when Durable Medical Equipment (DME) and home health care are involved. While these products and services can initially be critical in getting injured workers back on their feet quickly, they also have the potential for over utilization including frequency, duration, and skill. DMEplus evaluates appropriateness and cost containment opportunities for DME and home health care services through our Clinical Care Oversight program. Our Clinical Care Oversight team has extensive knowledge and skills in a variety of disciplines, including nursing, hospital discharge planning, case management and workers' compensation.
For acute and long term care, DMEplus identifies appropriateness of ongoing services, based on significant changes in an injured worker's claim through the use of our clinical staff including nurses, adjusters, home health evaluations, and nationally recognized industry guidelines. Additional indications can include spending levels that reach a specified threshold or service exceeding a reasonable timeframe. Some states may require utilization review for such services to determine medical necessity, which is an integration point between DMEplus and Coventry's Utilization Review department.
In the case of home health care services, the home health care provider is contacted and a home evaluation is performed. In about 20% of the cases, recommendations for changes in care, such as frequency, duration or skill level, are made with the adjuster's approval. Additional follow-up is carried out, and the treating physician is contacted to obtain new prescriptions or medical necessity letters where state regulations require it. Needed services are all scheduled through DMEplus which result in an average cost savings of 15%-20%. For DME products, the process begins with a similar clinical review process. Claims are identified and evaluated based on cost savings opportunities for alternative equipment or products, generic versus brand product changes, quantities needed, frequency of reorders, etc. Opportunities for savings, especially for high-dollar items, exist for about 40% of referrals and result in an average savings of 20%-30%. Once the review is performed, we contact the adjuster to review the recommendations, discuss savings, and to obtain approval. We then obtain any needed prescriptions, set a follow-up date, and schedule needed equipment or products.
DMEplus works closely with nurse case managers, physicians, and adjusters to ensure that each injured worker is getting the appropriate products and/or services needed to promote recovery without unnecessarily escalating claim cost. We do this by being highly knowledgeable and engaged in these claims to assist the adjuster in making better, more cost effective decisions that are based on clinical need.
