HOME HEALTH CARE patients have at least one thing in common: They all have to sleep. And because of their ailments, whether it's multiple sclerosis, asthma or pressure sores, they need special beds and support surfaces that will address their specific conditions.

According to home medical equipment providers, getting the customers the right beds and surfaces is a vital part of setting up the proper home care environment. And with the plethora of product and payment options in the market today, HME providers can play a pivotal role in helping patients and their clinicians find the equipment that best fits their therapeutic needs and financial abilities.

"Customers generally aren't too sure what their needs are," says Lynn Trimble, president of Trinidad Medical Consultants, Dallas. "So we try to show them what their needs are and then balance those needs with what they can afford."

PATIENT NEEDS One of the first steps in assessing patients' needs and assisting them in selecting beds and support surfaces is to gather all the information possible that may have an impact on the type of bed or support surface that is eventually purchased.

Some key first questions about beds include:

* What is the patient's age, weight and height?

* Is an extra-long or obese-capacity bed necessary?

* Is the patient ambulatory or in a wheelchair?

* Is the patient able to transfer in and out of bed?

* How much weight can the patient pull with each hand?

* Does the patient currently have any skin breakdown problems?

* If so, on what part of the body are the wounds, and what type are they?

* Is the patient on any medications?

* Is the patient incontinent?

* How long will the bed be needed?

* Will the bed be on a first or second floor?

As for support surfaces, providers suggest asking the following:

* Does the surface conform to the patient's bony prominences?

* Does it provide maximum patient immersion?

* Does it have significant memory?

* Does it "bottom out"?

* Does it prevent skin maceration?

* Does the surface relieve shear forces caused by patient movement?

* Is patient comfort addressed?

But be forewarned: This information-gathering process may be much more interactive than merely having patients fill out a questionnaire, say providers. The challenge is to attain accurate and precise information-and some customers may not be able to clearly articulate their medical conditions, let alone their needs.

"The intake of information from the patient is a science but also partly an art form that requires carefully listening to the client," says David Bouslog, president of Chesapeake Medical Supply, West Conshohocken, Pa. "Even though their everyday actions are routine, some patients have never thought about exactly what they're doing."

Bouslog adds that while HME providers try to be as clinically adept as possible, they must not attempt to make any independent clinical assessments when they encounter issues that are beyond their own knowledge. Instead, providers must rely on therapeutic input from doctors, nurses, and occupational and physical therapists.

Indeed, deciding on the right bed or support surface is a collaborative endeavor that often involves other parties with a vested interest in making sure that customers get the appropriate products. Depending on the customer, providers may need to coordinate with nurses, doctors, hospital discharge planners, long-term-care facilities, home health agencies, nursing homes, even insurance case managers.

MEDICARE DEMANDS What else does it take to provide customers with the beds they need? Determining who will pay for the bed and any additional support surfaces. Most providers bill Medicare, so when advising patients about beds and surfaces, they must take into account its many rules and regulations.

Medicare allows for HME providers to charge for beds over 15 months as capped rental items. (Purchasing beds is usually a consideration only if the patient is likely to need the bed over a longer period.) Medicare will also cover manual beds only under the following circumstances:

* When the patient needs special traction equipment that cannot be attached to a regular bed.

* For pain alleviation and for positioning the body in ways not feasible in an ordinary bed.

* For body positioning due to a medical condition that is going to last for at least 30 days.

* For any needed head elevation that is more than 30 degrees.

* When other solutions, such as pillows and wedges, have been tried and failed to achieve the desired result.

While Medicare does not cover fully electric beds, it will pay for semi-electric beds if the patient has a frequent need for body position changes and/or immediate changes in position where no delay can be tolerated. Medicare also covers side rails when they are an integral part of or an accessory to a bed.

Other third-party payers-such as Medicaid, health maintenance organizations, and workers' compensation-also cover semi-electric beds and other associated equipment if they are deemed medically necessary. The good news is that their reimbursement criteria are generally less stringent than those of Medicare.

When preparing bed reimbursement claims for Medicare-or any payer, for that matter-providers will once again need to work closely with physicians, nurses or other medical professionals to get the documentation submitted properly and in a timely manner. The certificate of medical necessity for a bed, for example, should describe the client's medical condition, note how severe it is, and explain whythe client requires certain positioning to promote good body alignment, prevent contractures or avoid respiratory problems.

When it comes to support surfaces, Medicare separates products into three reimbursement categories.

* Group I: This category includes alternating pressure, foam, air, gel and static products.

* Group II: This set of products includes alternating and low-air-loss mattresses and low-air-loss overlays.

* Group III: Air-fluidized bed systems make up this final category.

Medicare covers alternating-pressure systems and static products for clients who are at high risk of developing pressure ulcers. It also provides reimbursement for Group III products with a CMN signed by a physician that indicates the patient's diagnosis, the length of need and the degree of patient mobility. Re-certifications are required every 30 days.

According to providers, while HMOs, workers' compensation and other health insurers often cover basic support surfaces when skin breakdown is present, many payers deny coverage for prevention. The only exception: Some third-party payers will consider reimbursement for certain high-risk patients.

If they approve funding, payers will usually allow rental fees or a rent-to-purchase plan but will also demand documentation of clinical improvement to continue funding. Moreover, when the skin is healed, payers will expect rented support surfaces to be returned unless they are non-returnable.

PAYMENT TRENDS In general, say providers, Medicare's process for reimbursing hospital beds and support surfaces is simple and straightforward. If a patient meets the necessary medical criteria and gets a doctor's prescription, Medicare will pay the bill.

"Ninety percent of the time, we can fit a patient's needs within the Medicare parameters," says Hank Horton, president of Georgia Extended Medical, Woodstock, Ga. "In fact, the more complicated products are sometimes not suitable for home care because they're too overwhelming to the family caregivers. The simpler products with the needed features work best for home health patients."

But with the cuts in Medicare funding, providers lament, reimbursement levels for beds are not what they used to be. Patients are often required to pay a certain amount out of their own pockets. And it is only those with the financial means who can consider buying a bed that most closely fits their specific needs, as opposed to settling for something that they may not be fully satisfied with but that offers better reimbursement.

In recent years, note providers, more patients have opted to purchase specialized rehabilitative beds equipped with a greater number of features. And while certain payers, such as Medicare, are unwilling to provide any funding for such specialized beds, other payers may be willing to coordinate some sort of arrangement.

"If there is a long-term problem, we try to work it out with the customers up front so that they can stay on the equipment," says Tom Oliver, chief operating officer of National Wound Care, Champaign, Ill. "We talk to the insurance companies to determine what works best long term. For example, a patient may get a higher costing product initially but then step down later on to save cost to the payer."

In most cases, providers report, specialized beds are sold as cash retail items. And what drives sales, say providers, is the fact that these products fit in with an emerging trend among patients to manage their own ailments.

"What's happening in this market is that people are starting to pay attention to more preventive issues and are looking more at the long term," says Robert Hickman, president of Decubiti Concepts, West Berlin, N.J. "The mind-set is changing these days. People are starting to look at how they can prevent something from happening in the future. Even though it may cost a lot upfront, they know it will be much cheaper later on."

Now that's good thinking. HC