May 27th 2020

Utilization Management Vendor for Durable Medical Equipment



As a trusted advisor to my clients, I’ve had significant outreach recently regarding, “What can eviCore do to help me better manage Durable Medical Equipment (DME) post-COVID?”


With the wide-ranging clinical expertise available here at eviCore, I reached out to Dr. Erica David-Park, a board-certified specialist in physical medicine and rehabilitation with 15 years of direct clinical experience. She is currently eviCore’s Senior Medical Director for Post-Acute Care and Durable Medical Equipment. I asked Dr. David-Park the four questions I’m hearing the most. I found her answers to be informative and worth sharing with you.


Nathan Kalkofen


Question #1: Given the extra emphasis to get patients back home safely in today’s healthcare environment, how can we ensure that the most appropriate DME supplies are being delivered to our members?


Dr. Erica David-Park


In our current healthcare landscape we are finding that it can be beneficial to manage many patients right at home. According to the Centers for Disease Control’s established estimates, on any given day 1 in 31 hospital patients contracts at least one care-related infection. Today, the COVID-19 crisis has dramatically changed the healthcare environment. Management of patients at home is often the safest option, particularly for the elderly and those with chronic medical conditions.  To ensure appropriate and safe management at home, patients may have need for durable medical equipment (DME). For example, if the patient has a lung condition with low oxygen levels, supplemental oxygen may be needed. If the patient has developed muscle weakness, a walker or a wheelchair may be needed to assist walking and prevent falls. eviCore’s DME program can evaluate the totality of the patient’s needs to ensure that the patient’s medical and functional needs are met with the correct equipment to maximize their safety at home.  In summary, the correct equipment helps reduce the likelihood of adverse health outcomes and hospital readmissions.



Question #2: Can a DME management program really enhance our plan’s savings opportunities, member satisfaction, and continuity of care? 


Dr. Erica David-Park


To formulate medical-necessity decisions, eviCore’s DME management program applies the expertise of specially trained nurses as well as medical directors who are board-certified physical-medicine and rehabilitation physicians. The use of the specialized expertise is important because various types of specifically configured and customized DME, with associated accessories, are available. On the other hand, eviCore’s DME program can also determine when a generalized or non-custom item can adequately meet the member’s medical needs, and at less cost. The alternative recommendations for equally effective but more economical items, when appropriate, can result in substantial savings opportunities for our plans.


eviCore’s DME program works cooperatively with eviCore’s Provider Engagement Team to educate the DME suppliers and treating physicians on the types of equipment that can best meet the member’s needs. We employ a strong focus on outreach, including tailored outreach directly to the patient when that is needed and appropriate. Our expertly applied outreach and attention to detail results in increased member satisfaction.


In addition, our DME management program works hand in hand with the rest of the post-acute care team to ensure seamless continuity of care. For example, we can work closely with members receiving care in a skilled nursing facility to fully assess their DME needs and facilitate a safe discharge home. We can apply follow-up services to ensure prompt and accurate delivery and appropriate, safe use of the equipment. Periodically thereafter we can determine if the equipment still fully meets the member’s needs, or if an alternative type of equipment would be better suited at that point in time.



Question #3: Are the HCPCS codes being managed through a program like this the same for all health plans, or can they be different based on the unique needs of our health plan and its members? 


Dr. Erica David-Park


The HCPCS code management can be tailored based on the unique needs of the individual health plan and its members. As an example, one of our health plans serves a pediatric special needs population. The approach to management of their DME needs has been precisely customized based on their conditions, functional deficits, and indications for specialized case management. Only a flexible and multifaceted DME program like eviCore’s can adequately respond to these situations of unique requirements.



Question #4: Are the savings more attributable to a network arrangement or utilization management (UM)?


Dr. Erica David-Park


Good cost savings can derive from a combination of network management and utilization management. These two types of management can work hand in hand to maximize the cost savings. However, UM drives the majority of these savings.








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