VGM Wound Care Diabetic Program Guide by vgmassociates

www.vgm.com/woundcare

DECIDING IF A DIABETIC PROGRAM IS RIGHT FOR YOUR BUSINESS

THE IMPORTANCE OF THE DIABETIC MARKET

As a home medical equipment and healthcare provider, it’s important to note that you will encounter patients who either have diabetes or will develop diabetes sometime in their lifetime.

What Is Diabetes?

According to the CDC, diabetes is a chronic (long-lasting) health condition that affects how the body turns food into energy. Most of the food we eat is broken down into sugar (also called glucose) and released into the bloodstream. When the body’s blood sugar goes up, it signals the pancreas to release insulin. Insulin is a hormone needed to unlock glucose from the bloodstream to get into the body’s cells.

In those with diabetes, the body either doesn’t make enough insulin or can’t use the insulin it makes as well as it should. When there isn’t enough insulin or cells stop responding to insulin, too much blood sugar stays in the bloodstream, which, over time, can cause serious health problems, such as heart disease, vision loss, and kidney disease.

There isn’t a cure yet for diabetes, but healthy lifestyle habits, taking medicine as needed, getting diabetes self-management education, and keeping appointments with healthcare professionals can greatly reduce its impact.

The Different Types of Diabetes

Type 1:

Type 1 diabetes is when the body is not effectively able to produce insulin. Symptoms of type 1 often develop quickly, and it’s usually diagnosed in children, teens, and young adults. People with type 1 diabetes have to take insulin every day to survive. Currently there is not a cure, and we do not know how to prevent type 1. Approximately 5-10% of the people who have diabetes have this type.

Type 2:

Type 2 diabetes is when the body does not use insulin properly and is unable to keep the blood sugar at normal levels. Type 2 diabetes generally develops over many years and is usually diagnosed in adults. In recent years although, with unhealthy lifestyles, children, teens and young adults are being increasingly diagnosed. This type of diabetes can be prevented or delayed with healthy lifestyle changes such as healthy eating and getting regular physical activity. 90-95% of people with diabetes have type 2.

Gestational Diabetes:

Gestational diabetes occurs in pregnant women who have not been previously diagnosed with diabetes. Gestational diabetes usually goes away after the baby is born but having it does increase risk for developing type 2 later in life. Gestational diabetes does put the baby at higher risk for health complications, and they are more likely to become overweight as a child or teen.

OPPORTUNITIES AND CONSIDERATIONS IN THE DIABETIC MARKET

In addition to being an important market, diabetes also isn’t going anywhere. But does that mean it’s right for your business? Let’s look at some of the other opportunities and considerations that may help you decide.

Diabetes Is On The Rise

There are many reasons why diabetes has become the forefront in healthcare. Numbers from the CDC tell the story:

• 38.4 million people of all ages had diabetes in 2021.

• Diabetes is the eighth leading cause of death in the U.S.Diabetes is the number one cause of kidney failure, lower-limb amputations, and adult blindness.

• In the last 20 years, the number of adults diagnosed with diabetes in the United States has doubled.

Looking For Expertise

Along with the aforementioned reasons to get into the diabetic market, perhaps the most important is this—patients, payers, and caregivers need a knowledgeable partner. They’re looking for a provider who fully understands the diabetes market and can be a great resource for them now and in the future. So, as diabetic supply provider, you become an even more essential part of the patient care continuum.

WHAT ARE YOU BEING ASKED FOR?

For home medical equipment providers, there are various categories within the diabetic arena you can choose to enter (we’ll cover these in more depth in the next section).

Generally, we talk about the following product categories:

• Blood Glucose Meter

• Glucose Test Strips

• Continuous Glucose Monitoring

• Insulin Pumps

Even if you’re not currently providing the items mentioned above, maybe you’re being asked for them, because it’s a good probability the population you are serving has or will have diabetes at some point in time.

The easiest place to start is with the people you already work with. You’ve already developed a rapport with the patients you serve. Start documenting some of the items they ask about as you work with them. You could send a survey to them, but it may be as simple as noting what items they’re inquiring about when they come in or during a home visit.

Payers may also be asking you about diabetes products and supplies, but your referral sources especially provide a great opportunity for research. They’re already sending patients your way, so it’s worth contacting them to discuss what you can do to help provide the care their patients need.

GETTING ADDITIONAL DATA

After you’ve discussed potential offerings with your current referral sources, it’s worth reaching out to other sources, such as endocrinologists.

There are other resources available to ease your way. VGM Market Data has the nation’s largest and most comprehensive claims database. This allows you to:

• Identify and rank high-value referral sources

• Find out who is referring patients to your competitors

• Target your team to make the biggest gains

VGM Market Data can tell you almost instantly whether developing a diabetes program is right for you AND where you should focus your resources to be the most successful.

CONSIDER PAYER REIMBURSEMENT

You’ll also want to check the payer reimbursement rates that will be available should you decide that a diabetic program is right for you.

The easiest place to start is with the Centers for Medicare and Medicaid Services (CMS). CMS’s fee schedule is a matter of public record, so you can begin your research even if you don’t currently hold DME or pharmacy licensure. The Medicare fee schedules can be found at http:// www.cms.gov/Medicare/Medicare-Fee-forService-Payment/DMEPOSFeeSched/DMEPOSFee-Schedule.

As you look at the fee schedules, you’ll notice there are multiple rates for each item. There are separate reimbursement rates for rural areas, non-rural areas, and competitive bid areas. It is important to know which portion of that population you are serving, so you know which reimbursement rates are applicable to you. For Medicare FFS beneficiaries, reimbursement rates are based on the permanent address on file with Social Security Administration.

Commercial payers’ fee schedules are not public; however, some are known to base their fee schedules on a percentage of CMS’s schedule. When looking into fee schedules for commercial payers, start with the payers you already hold a current contract with. You probably already have the fee schedule outlined in your contract. Even if you don’t currently hold any contracts with payers, that doesn’t mean you won’t be able to access them. It just requires a little more legwork. Contact the payer relations department for each commercial payer you’re interested in.

Along with reimbursement rates, you’ll want to take note of any expectations payers—CMS, commercial, or otherwise—have outlined for providers who supply diabetic supplies to postacute patients. Typically, these expectations/ requirements can be found in a payer’s provider manual, which can usually be found on their website or requested in printed form.

To make things a little easier yet, there’s HOMELINK. They contract with numerous insurance companies and other payer sources to provide ancillary services at the in-network benefit level. Reach out to HOMELINK to find out how to become a credentialed provider within their network.

By joining the HOMELINK network, providers gain access to HOMELINK’s payer contracts. HOMELINK also affords the opportunity for providers to process claims at the in-network benefit level that would otherwise be considered out-of-network if the provider were to submit them directly to the payer.

WHEN IN DOUBT, CONTACT VGM

As you’re looking at getting into the diabetes market, you’ll probably find yourself wondering how your staff is going to accommodate all the necessary aspects. VGM Education has educational courses to inform your staff on the basics of diabetes.

VGM’s vendor partners have solutions that can help you implement and grow your program in the most cost-effective way. We’ll cover some of our recommendations in the coming sections.

If at any time you have questions or need assistance along the way to developing a diabetes program, don’t hesitate to contact VGM at 800-568-7039.

GETTING STARTED

Let’s say you’ve read through Section One, done your homework, and determined that the diabetic market is right for your business. Before you begin developing your program, there are still a few things you need to do to lay the groundwork. Follow the steps below to get started.

BLOOD GLUCOSE MONITORING

As noted in Section One, when we talk about diabetes in the home medical equipment space, we’re primarily referring to blood glucose monitors and supplies. There are other categories, such as diabetic shoes and inserts, but for getting started, you’ll want to familiarize yourself with blood glucose monitoring. The categories to consider are:

• Blood Glucose Meters

• Glucose Test Strips

• Continuous Glucose Monitoring

• Insulin Pumps

Insulin Pumps

An insulin pump is a small, computerized device that helps manage diabetes by delivering insulin continuously throughout the day and night. It mimics the way a healthy pancreas would release insulin, providing a steady flow of insulin (basal rate) and additional doses (bolus) at mealtimes or when blood sugar levels are high.

Here’s how it works:

Infusion Set: The pump is connected to your body through an infusion set, which includes a thin tube and a small needle or cannula inserted under the skin.

Basal Insulin: The pump delivers a continuous, small amount of insulin to keep blood sugar levels stable between meals and overnight.

Bolus Insulin: You can program the pump to deliver extra insulin doses at mealtimes or when your blood sugar is high.

Insulin pumps offer several benefits, such as fewer needle sticks, more precise insulin delivery, and easier management of blood sugar levels. However, they require regular monitoring and maintenance, including changing the infusion set every few days and ensuring the pump is functioning correctly.

Blood Glucose Meters

This is the traditional option for people with diabetes. The process to use this type of meter is as follows:

• Insert a glucose test strip into the meter

• Poke a clean fingertip with a special needle (called a lancet) to get a blood droplet

• Carefully touch the test strip to the blood droplet

• Wait for the meter to display the blood glucose reading

Meters vary in the number of features they offer. Some even allow for testing on areas that are less painful than the fingertip, such as the palm or arm.

Glucose Test Strips

These strips work with the blood glucose meter. Glucose in the blood react with chemicals in the strip to create an electric current that travels to the meter.

Continuous Glucose Monitors (CGMs)

Approximately 30% of people with type 1 diabetes now use a CGM. This uses a sensor placed under the skin to measure the blood glucose level, which is transmitted to a device worn on the body or even a smartphone. Even patients using a CGM will often need to use a traditional blood glucose meter and test strips to calibrate the CGM.

The sensor is a small device inserted under the skin, typically on the belly or arm. This sensor measures glucose levels in the interstitial fluid, which is the fluid surrounding the cells in your body.

The receiver is a device that displays the glucose readings collected by the sensor.

The receiver allows you to view your glucose levels in real-time, track trends, and receive alerts if your glucose levels go too high or too low.

The transmitter is the component that sends glucose readings from the sensor to the receiver.

Some CGMs have the transmitter pre-attached to the sensor, while others require you to attach the transmitter separately1. The transmitter plays a crucial role in ensuring that you receive realtime glucose data, helping you manage your diabetes more effectively.

INCREMENTAL PRODUCTS

When you’re helping a patient with their diabetic needs, they’ll also be looking for products such as skin barrier wipes, transparent dressings, adhesive remover wipes, tape, etc. If your patients aren’t buying these products from you, they’re likely purchasing online or from a big box store—that means you’re missing out on opportunities to increase cash sales on products that can actually encourage patient compliance. Take a look at the Vendors & Products section of our members-only porta to find vendors that supply them.

GEMCO Medical

One source for everything in diabetes care. From the latest advancements in continuous glucose monitoring and insulin therapy, GEMCO leverages close manufacturer relationships to provide innovative products, reimbursement information and the education to keep customers ahead of the curve!

They carry the most popular and advanced Continuous Glucose Monitors (CGMs) for diabetes management. Our top brands include: Abbott, Dexcom, Medtronic, and Seneonics.

GEMCO also carries insulin pumps and all related supplies, including infusion sets, reservoir syringes and cartridges, batteries, prep wipes, tape, and liquid adhesive. Currently GEMCO offers top brands including: Medtronic, Tandem, Omnipod, and V-Go. Learn how to get started today.

GEMCO and VGM Financial

GEMCO also offers a finance program through VGM Financial. Learn more about this program.

Medline

Medline helps simplify your operations, enhance the quality to your patient, and target new revenue while you are focused on your business. Partner with the homecare leader and grow your business. Medline understands your business and industry challenges and helps you achieve operational and revenue efficiencies and goals. From quality healthcare products to costsaving business solutions, we help you make a difference in your patients’ lives every day. When you partner with us, your success becomes our business.

They’re here to answer your questions about their products and provide any guidance you need. Get in touch to learn more about their blood glucose monitors and supplies.

McKesson Medical-Surgical has a vast selection of diabetic testing supplies including glucose test strips, glucose monitors, glucose meter controls, lancets, and more. Shop our diabetes testing products from top brands including Abbott, McKesson Brand, Ascensia Diabetes Care and Bayer.

PREPARING FOR THE MARKET

To further prepare for entering the diabetic market, it’s important to understand what the marketplace is like in your area. Here are some steps to take:

• Interview your current referral sources and ask them what they like or dislike about their current provider.

» If they don’t have a provider, ask what they would like to see if they were to go with you.

• Who is the competition for the category you are looking to provide?

» What is their price? What is the market share in the marketplace? Why do customers choose the competition? What don’t they like about the competition?

• Look to VGM for vendor partners to interview as well.

UPDATE YOUR CMS 855S FORM OR PECOS

The first thing you need to do to get started is let the National Supplier Clearinghouse (NSC) know that you’re entering the diabetic market and which product(s) you are adding to your portfolio. This simply requires you to update your CMS 855S form or go through PECOS electronically. You also need to check the state in which you are providing this service for any license requirements that may be applicable

• Head to www.cms.gov/Medicare/CMSForms/CMS-Forms/Downloads/cms855s. pdf, complete, and submit the form

• Or, update PECOS electronically, and follow the instructions for adding a product/service to your offerings

That’s it. Once the NSC processes the update, they’ll know you will be submitting diabetic supplies for reimbursement.

NOTIFY YOUR ACCREDITING BODY THAT YOU’RE TAKING REFERRALS

You’ll need to contact your accrediting body and inform them you’re taking referrals for diabetic products. They’ll go over the next steps and any requirements there may be, such as policies, procedures, and other forms.

If you’re in the market for accreditation, VGM partners with the Healthcare Quality Association on Accreditation (HQAA). HQAA makes the accreditation process easy for HME providers. They even pair your organization with an accreditation coach to help you through the entire process.

DEVELOP POLICIES AND PROCEDURES

As part of your compliance initiatives, you’ll need to have your company policies and procedures documented.

CREATE ANY NECESSARY FORMS

You’ll also need to ensure you have the necessary forms at your disposal. In most cases, this means familiarizing yourself and your staff with which forms are required. In others, you’ll want to create forms specific to your organization to help with documentation.

Visit VGM’s members-only portal for some of the most common forms, including:

• Continued Medical Necessity - Dear Clinician Letter

• Supplies for Continuous Glucose Monitoring

EDUCATE YOUR STAFF ON MEDICARE LCD AND COMPLIANCE REQUIREMENTS

Local coverage determinations (LCDs) are decisions made by Medicare Administrative Contractors (MACs) on whether a service or item is reasonable and necessary (R&N). Home blood glucose monitors (BGM) and therapeutic continuous glucose monitors (CGM) are covered under the durable medical equipment benefit. In order for a beneficiary’s DME to be eligible for reimbursement, the R&N requirements must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.

Coverage Criteria

Effective for Dates of Service April 16, 2023

To be eligible for coverage of a CGM and related supplies, the beneficiary must meet ALL of the following initial coverage criteria (1-5):

1. Beneficiary has diabetes mellitus (ICD-10 code list in the LCD-related Policy Article); and,

2. Beneficiary’s treating practitioner has concluded that the beneficiary (or beneficiary’s caregiver) has sufficient training using the CGM prescribed as evidenced by providing a prescription; and,

3. The CGM is prescribed in accordance with its FDA indications for use; and,

4. Beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the criteria below:

a. The beneficiary is insulin-treated; or

b. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the following (see the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section of the LCD-related Policy Article (A52464)):

i. Recurrent (more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan; or,

ii. A history of one level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia

5. Within six (6) months prior to ordering the CGM, the treating practitioner has an inperson or Medicare-approved telehealth visit with the beneficiary to evaluate their diabetes control and determine that criteria (1)-(4) above are met.

The beneficiary has received appropriate training in the use of the device as evidenced by a prescription (criterion 2), the CGM is being prescribed in accordance with FDA indications for use (criterion 3), and the CGM is being prescribed to improve glycemic control for a beneficiary who is insulin treated or has a history of problematic hypoglycemia (criterion 4).

For the initial coverage of a CGM, there must be sufficient information in the beneficiary’s medical record to determine that the beneficiary has diabetes mellitus (criterion 1).

Following the initial prescription for a CGM, for ongoing coverage there must be a visit every 6 months. There must be sufficient information in the medical record to determine that the beneficiary continues to adhere to their diabetes treatment regimen and use of the CGM device on a daily basis.

Supplies

When a non-adjunctive CGM is covered, the related supply allowance is also covered.

The supply allowance is billed as one unit of service per 30 days. The supply allowance for supplies billed with non-adjunctive system encompasses all items necessary for the use of the device and includes, but is not limited to:

• CGM sensor

• CGM transmitter

• Batteries

CONTACT VGM WITH QUESTIONS

As always, if at any time you have questions or need assistance along the way to developing a diabetic program, don’t hesitate to contact VGM at 800-568-7039

DEVELOPING YOUR PROGRAM

Throughout the previous two sections, you’ve analyzed if a diabetic program is right for your business and established the foundations for your program to get started. In this section, we’ll outline the various aspects of a well-developed program and recommend solutions for your organization. Let’s get started.

MANAGE YOUR RISK WITH PROPER INSURANCE COVERAGE

Medicare requires that providers carry comprehensive liability insurance. However, you shouldn’t stop there.

VGM Insurance Services

We partner with VGM Insurance to help providers get the coverage they need. No one understands HME industry risks like VGM Insurance, and they underwrite and service all of their policies in-house. They can also provide the necessary surety bonds if you’re billing CMS. It’s never too early to reach out. Contact VGM Insurance to learn more and get a competitive quote today.

ORDER PROCESS

Increasingly, prescriptions are moving to digital. That’s why it’s important to consider a prescription platform to help manage how you receive prescriptions from the physician.

DMEscripts

DMEscripts LLC, is an independent ePrescribe company dedicated to improving the patient, prescriber and provider experience by eliminating inefficiencies and reducing paperwork. DMEscripts aims to drastically improve the current order-to-delivery process by empowering and accelerating the widespread adoption of an electronic ordering application for DME. DMEscripts utilizes proprietary ePrescribe software to operate an open network for any DME supplier to join at no cost to prescribers or patients.

GoScripts From Brightree

GoScripts is a robust, end-to-end, digital solution that streamlines the prescription documentation process. GoScripts empowers you and puts documentation orders, renewals, recerts, and insurance verification all at your fingertips. With the innovative technology of GoScripts, your prescription documentation is complete and accurate the first time—so patients don’t have to wait.

Parachute Health

Parachute Health brings companies into the digital age with its comprehensive e-Prescribing platform for DME ordering. It simplifies the order intake process, improves patient care, reduces costs, and improves your bottom line (helps you get paid faster) by changing the way you do business.

Parachute dramatically reduces order errors, insurance claim denials, and time spent processing orders by providing a seamless, alldigital solution that seamlessly integrates with current IT systems such as Brightree, Epic EHR, and many more.

INVENTORY MANAGEMENT

Since you’re entering a new market, you’ll have extra inventory to manage. VGM Wound Care partners with Brightree, which offers a robust cloud-based solution.

Brightree

From purchasing and warehousing to shipping, tracking, and billing, Brightree’s inventory management and delivery software integrates e-purchasing and fulfillment solutions so you can tackle your inventory and delivery challenges.

WORKFLOW

There’s no denying that regulatory and billing requirements have become more complicated, which slows down the process, can lead to errors, and wastes time pushing papers around. Through our partnerships, VGM has recommendations for helping you streamline your workflow.

The van Halem Group

The van Halem Group offers both pre-screen programs to help you prevent overpayments leading to recoupments and audit protection to help you avoid an audit or navigate the process should you find yourself subject to an audit.

Brightree

Brightree’s web-based platform is another great option that lets providers significantly decrease workflow processing time. The main goal is to make work better, faster, and more rewarding. If you’re not already using Brightree, you can even request a hands-on demo on their website.

EQUIPMENT SETUP AND EDUCATION

Now more than ever, it’s important to have a resource for training and education in the home for HME products and services.

PATIENT SATISFACTION AND ENGAGEMENT

One of the best ways to display our value in the diabetic market is to show the positive impact providers have on patient outcomes. And one of the best ways to do this is by engaging with your patients to ensure they’re happy with their care.

pulseM

The pulseM platform allows businesses to manage their online reputation by engaging with patients via SMS and email to communicate pre-appointment reminders and post-appointment feedback. 90% of texts are read in the first three minutes. This level of communication allows homeowners and caretakers to feel safe and secure by knowing who will be showing up to their door as well as give you the opportunity to capture valuable feedback that can enable growth and continued training for employees.

MARKETING AND SALES EFFORTS

In addition to contacting your current referral sources, you’re going to want to get the word out that you’re providing glucose monitoring services. VGM has several partners that can help in this area.

VGM Forbin

VGM Forbin specializes in building HIPAAcompliant websites and developing online marketing strategies that include social media, search engine optimization, and reputation management. From mobile responsive and results-focused online marketing services to online portals that help you operate your business more efficiently, VGM Forbin creates solutions to meet your specific needs.

Strategic Imaging

Strategic Imaging is dedicated to relevant marketing through personalized direct mail. Let Strategic Imaging help you get a better response rate with their top-quality variable data and variable image printing. They combine years of printing expertise and state-of-the-art digital imaging with data management and programming specialists for target marketing and direct mail campaigns.

VGM Off the Shelf

VGM Off the Shelf (OTS) offers effective, cost-conscious standard and customizable marketing options to help you build your brand fast. Guides, handbooks, fliers, and inserts are all available through VGM OTS.

VGM Market Data

By providing VGM members exclusive access to the largest and most comprehensive DME, O&P, PT, and Infusion claims database in the country, VGM Market Data can help you put your money in the right place. VGM Market Data can help you identify your main competitor’s top 20 referral sources. Or, it can help you find your top 50 referral sources by volume who send you less than 50% of their patients. These are just a few examples of the valuable data they can provide. Target smarter with VGM Market Data.

VGM Financial Services

VGM Financial Services has partnered with GEMCO to provide equipment financing. Learn more about this program.

STILL HAVE QUESTIONS? CONTACT VGM

This Diabetic Program Guide is just the beginning. We regularly update the membersonly portal with resources and solutions to help you develop and grow your diabetic program. But if you can’t find what you’re looking for or you have any questions at all, we’re here to help.

Wound Care

RESOURCE AND VENDOR CONTACTS

As a VGM member, you have access to a network of vendor partners and the opportunity to get great deals on products, services, and solutions for all your diabetic program needs.

Discover all vendor partners at www.vgm.com/portal/vendors/.

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