Demonstrate due diligence

Sunday, November 30, 2008

Q. How do I deal with patients who require multiple mask re-fits without alienating the referral source, the patient and the bottom line?

A. Working in our industry has always required the successful provider to perform a “balancing act.” A good place to start is by selecting good partners. The better-respected sleep manufacturers offer a mask guarantee program. To take advantage of this program, staff must complete the free training offered by the manufacturer and complete some simple paperwork. As long as the patient’s mask fitting is conducted in person (no Internet or mail allowed) and the problem is reported within 30 days of the original fitting, the manufacturer will replace the mask at no charge. They will do this even if the patient is re-fit with a competitor’s product. Providers should note that they are generally not allowed to advertise or communicate this program to patients.

Some providers have had success using a strategy many of us abandoned long ago in frustration. That strategy is known as “common sense.” This less used option involves the provider going directly to the insurance company on behalf of the patient. Explaining to the insurance company that the failure of a specific device for the patient is no different than failure of other therapies or medicines that often don’t work when first tried. It is widely recognized that disease management often requires “tweaking” to get the desired outcome. It is uncommon for payers to refuse to pay for a second medication or therapy when the first one must be abandoned. Paying for a second appliance is no different. This argument is most effective when providers can show there were no errors made in sizing.

Documenting and using these options will demonstrate to your patients and referrals your due diligence in assuring successful outcomes, while not eroding your bottom line.

Kelly Riley is director of The MED Group’s National Respiratory Network. Reach her at <a href="mai