How to Avoid Product Substitutions with Your DME Provider Protection Status
DME products

by Samantha Kuplicki, MSN, APRN-CNS, ACNS-BC, CWS, CWCN, CFCN

Ordering wound care dressing supplies can prove to be a frustrating task for many providers and clinicians. Unfortunately, I have encountered many health care providers that describe feelings of dread when working with their durable medical equipment (DME) counterparts.

Product substitution has been a prominent issue, especially of late with many reimbursement changes coming down the pike. This can lead to revenue loss via providing the patient with clinic supplies, and frustration for all parties involved. I hope this discussion will offer readers increased awareness regarding distributor product substitution, and help to bridge the knowledge gap in working with DME providers. The practice of product substitution impacts everyone in the "village" of wound care – patient, health care provider, clinic staff, DME provider, product manufacturer, marketing, etc. Let's discuss a few tips for how the wound care "village" can effectively vet their distributors to avoid this scenario.

Product substitution shouldn't be a necessity, as most products are covered by insurance and readily available. It is unfortunate that some DME providers do not make preventing product substitution a priority. This practice can occur even when the requested DME supplies are in stock, leaving clinicians to manage patient care with inferior and/or inappropriate products. Ordering providers should arm themselves with the basic knowledge of what wound care dressings and other items are covered versus not covered under most general payor policies.

Unfortunately, sometimes subtleties are lost in translation.

Reasons Why DME Supplies Get Substituted

Lack of appropriate product receipt by the patient can often be mistaken for the DME provider not stocking the product, when in reality the requested product is not covered per the patient's policy/LCD (local coverage determination).

Example: Bob has a neuropathic ulcer on the plantar aspect of his foot. It has minimal exudate and no infection is suspected. Bob is not adherent to his offloading plan of care due to his job at a warehouse, where he must walk great distances to perform his duties. Dr. Dan orders a non-bordered foam dressing and a bordered foam dressing to offer a protective layered effect under Bob's knee-high AFO with cut out insert made of adhesive felt. Bob receives the box of supplies from World's Best DME, and finds only the gauze and tape. He calls the clinic and does not understand what happened.

In this situation, the health care provider was unaware that most absorbent/padded foam products require that the wound assessment have moderate or greater exudate documented in order for patient's insurance to cover the specified foam dressings. World's Best DME would have been doing the "village" a great favor by immediately calling the clinic staff and informing them that the patient's insurance would not pay for the products and explaining the rationale. This simple action would not only have saved Bob, the clinic staff, and Dr. Dan’s valuable time, but may have served to prevent the issue from occurring again.

Additionally, the DME provider may indicate a product is 'out of stock', or 'not covered', when in reality, the product cost exceeds the reimbursement. A good DME company will explain that this product is not stocked due to the monetary loss by the DME company to provide it based on the LCD criteria, or whether it is truly non-covered.

Example: Patient Jane is seen in a hospital-based outpatient clinic by Dr. John. Jane has a highly exuding venous ulceration, which her husband dresses every three days. The dressing regime consists of cleansing with saline/gauze, covering the periwound area with no-sting skin protectant, covering the wound bed with IODOSORB* followed by AQUACEL®, and finally, 3M™ Coban™ 2 Layer Compression.

Jane's wound is dressed in clinic, and the order is sent to DME ABC. Jane and her husband are informed that the supplies should arrive in two days, a full day ahead of schedule for the next dressing change. When the order arrives, Jane's husband finds Multidex® Gel, Maxsorb™, cast padding, and 4" cohesive bandages. He calls the clinic to ask what he is supposed to do with these supplies, as they are not the same as the ones he was shown during the previous clinic visit. He learns that they received product substitutions from the DME provider because they had the same HCPCS codes as the supplies ordered by the health care provider. Jane and her husband are dissatisfied with the situation and ask to be seen in clinic immediately.

Does this situation sound familiar? I can only assume many of you are nodding your heads.

In the above scenario, it is not to say that the products Jane and her husband received are inferior, but for Jane's particular plan of care, there are likely many reasons why the specific products were chosen. The health care provider may feel that one product demonstrates superior wicking action under compression versus competing brands. The take home point is that every patient is different, and products are generally selected for reasons other than the Medicare listed category for reimbursement (e.g. "gel filler", or "alginate").

No Substitutes: Streamlining Your DME Process and Communications

Now, don't fret—let's discuss a few simple ways to remedy product substitution issues with your DME providers. Following are some general tips for establishing a relationship and expectations with the DME companies you work with.

1. Set up a meeting with the DME area representative. Get to know each other! Discuss mutual expectations. This should be done regardless of the company's size or reach. Sometimes relationships with multiple DME providers is required due to the multitude of insurance companies that clinics deal with. Not all DME providers are in network with EVERY payor.

2. Discuss frequently ordered products and determine if the DME provider regularly stocks these items.

3. Create "cheat sheets" for health care providers and staff so they can quickly determine if a requested product is available from a specific DME provider or covered by a patient's insurance. It is prudent to be familiar with HCPCS codes for products, and have cursory knowledge of the most frequently used products in clinic and what category they belong to (this sounds like rocket science, but I PROMISE it is not).

4. Review method of supply ordering (fax, email, direct EHR gateway submission, etc.) and determine the most efficient method for submitting supply orders. If the orders are not sent and received correctly and in a timely manner, this sets the entire process off kilter!

5. Review the supply order form, and streamline as to best fit the needs of the health care provider/clinic staff and DME ordering process. Simple check boxes make everyone's lives easier. Be sure to include a DO NOT SUBSTITUTE note on orders. If substitutions are OK, let the DME provider know! This can be a time and money saver as well.

6. Set up a contact person at the clinic who will regularly communicate with the DME area representative or liaison

Have any of you experienced issues similar to these? How has your business addressed the issue of DME product substitution? I hope these tips have created points for discussion among health care providers and staff, and will contribute to a well-oiled patient care machine! With frequent changes to the rules of reimbursement in the wound care game, sometimes we are left nodding our heads in agreement with the wisdom of Socrates: "The only true wisdom is in knowing that you know nothing" (about wound care supplies!).

About the Author
Samantha Kuplicki is board certified in wound care by both the American Board of Wound Management as a Certified Wound Specialist (CWS) and by the Wound, Ostomy and Continence Certification Board as a Certified Wound Care Nurse (CWCN) and Certified Foot Care Nurse (CFCN). She serves on the American Board of Wound Management (ABWM) Examination Committee and also volunteers for the Association for the Advancement of Wound Care.

Disclaimer: Information regarding coding, coverage and payment is provide as a service to users. Every effort has been made to ensure the accuracy of the information. However, Kestrel Health Information, Inc. and its subsidiaries do not represent, guarantee or warranty that the coding, coverage and payment information is error-free or that payment will be received. Users should always verify coverage policy, medical necessity requirements and coding instructions, and should review bulletins issued by the specific payor.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.


#1 A good DME Provider would not attempt substitution without the clinical prescriber's authorization. The request for substitution should first be accompanied by an explanation as to why the requested substitution is being made.
#2 A good DME/MedSurg sales rep should be prepared to not only detail the inventory available but they should know all the billing parameters and clinical qualifications imposed by the various funding sources in the trading area. I would tell our sales reps to be prepared to explain to clincial prescribers "what we need from then for us to get paid". Some clinical prescribers don't want to have anything to do with this thought. "That's your problem". .However, if a clinicain wants to do a complete job for the patient the clinician will want to write orders that can not only be filled, but orders the DME company can file a clean claim and get paid. Clinicians should want to place orders for their patients with DME companies that act as if they are going to be around next year. Companies that can tell good documentation from bad (so the claim is not denied), know the reimbursement rules of claims management and follow them, don't take short cuts in paperwork to make their company "easy to work with", work with a "live" inventory on the premise and have enough product knowledge and reimbursement knowledge to fill an order with one phone call and not create a communications nightmare!!! being there next year also means being able to handle reorders with the same precision.
#3 There is a new word that has been coined by the United States Department of Justice, "Co-conspirator". Clinicians need to know their DME providers are following the rules. The penalty phase can look like the domino effect in living color.

Chuck, thank you for reading and for your comment!

I am in agreement that this practice should not occur with any DME provider, but unfortunately, that does not stop it from happening. And yes, prompt communication should definitely be a regular part of the DME/clinician relationship in the event a substitution is unavoidable. I echo your sentiments regarding a solid relationship with DME providers being integral for success, as well as ensuring regulatory compliance from all parties!

Hi Samantha, I work for a DME provider, and am actually quite shocked to read that these types of substitutions could possibly happen. In both scenarios you described in your article, those substitutions would be for products with DIFFERENT HCPCS codes than what were ordered by the MD. For example, if the DME company receives a physician's order for a foam dressing, there is no way that CMS would reimburse the DME for gauze and tape. Any DME provider should know that the claim would be denied upon additional review if you aren't even sending products from the same HCPCS category. What would be FAR more common would be for the MD to order Brand X bordered foam, and the DME company would send Brand Y bordered foam. That claim WOULD be covered by CMS because you are billing AND providing products with the same HCPCS codes. Other common problems that we do see as DME providers are orders for products for which there is no reimbursement, or in products ordered in combinations or quantities that are not covered by CMS. These problems should always be communicated to the patient/caregiver prior to dispensing because of the problems they could cause clinically.

However, I do firmly agree that the steps you outlined above should help curtail those types of issues. If you have a close relationship with a DME provider, they can often steer you toward acceptable protocols that are covered (or vice versa, you can steer them toward which brands you prefer). The BEST DME companies will have someone on staff that can help with clinical questions: for example, "the MD ordered Product X, but you say that isn't reimbursed by CMS. What do you carry that is similar, but reimbursed?".

Misty, I am so sorry for such a tardy reply. I appreciate you reading my article, and thank you for taking the time to reply. I was also very shocked to see these types of things happen, and am unsure how any company could remain viable while undertaking such substitutions that are not congruent, coding-wise. I am glad to hear from someone in the industry that my suggestions may assist others in best serving their patients. I have been so fortunate as to chiefly work with amazing DME providers, while interactions with less than stellar companies has been kept to a minimum :)

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