Complex respiratory: It’s not the product, it’s the program

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Tuesday, October 22, 2019

ATLANTA – As clinicians, respiratory therapists are more focused on patient care than profitability, but it doesn’t have to be one or the other, said speaker Dave Lyman.

It’s possible to build a strong complex respiratory program for invasive, non-invasive and multi-function ventilators that improves outcomes, that demonstrates the provider’s value to payers and referral sources—and that pays, he told Medtrade attendees at a session Monday.

“How do you measure outcomes; how are you using it to show your therapy efficacy?” said Lyman, vice president of VGM Respiratory. “It’s not the product, it’s what your program is. How do you educate the patient? How do you train the patient?”

Lyman pointed to HME providers with high CPAP compliance rates as an example of how a solid program pays off.

“All the manufacturers say it’s the mask,” he said. “The folks that have a good compliance rate—it’s because they have a program. It’s not about the mask.”

Unfortunately, there’s no real rulebook for success in complex respiratory. There’s not even a local coverage determination for vents, points out Joey Graham, executive vice president and general manager for Prochant.

In terms of what providers can and can’t get paid for, Graham said, we know that “payers will not pay for resupplies or replacement equipment. Most payers will pay for a second ventilator if the patient needs a second type of ventilator, often a portable vent. It’s not a back-up vent.”

Graham recommends holding payers accountable to the policies they do have. He’s seen payers denying monthly reimbursement for vents, saying they’re a purchase item, even though vents do not cap out.

“We like to send a copy of their policy, along with the appeal,” he said. “UnitedHealthcare, Anthem, Medicare—they all have policies; use it against them during appeals.”