How To: Get Insurance to Cover Equipment & Therapy

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Summary

In this episode of CareLab, Dr. Brandy Archie and Emilia Bourland discuss the intricacies of getting insurance to cover equipment and therapy. They delve into what qualifies as durable medical equipment, the limitations of insurance coverage, and practical tips for maximizing insurance benefits. The conversation highlights the importance of understanding the healthcare system's current framework and navigating it effectively to ensure the necessary support for aging in place and caregiving.

Key Takeaways

• Durable Medical Equipment (DME): Items like hospital beds, oxygen, wheelchairs, and patient lifts are typically covered by insurance, but many other useful items, such as shower chairs and grab bars, are not.
• Insurance Limitations: Understanding the definition of DME is crucial as it explains why some necessary items for home safety and convenience are not covered.
• Medicare Advantage Plans: These plans may offer additional resources like over-the-counter benefits, which can be used to purchase items not typically covered by standard Medicare.
• Healthcare System Structure: The fee-for-service model focuses on paying for actions rather than preventative measures, which affects the coverage of equipment that could prevent more serious health issues.
• Navigating Insurance: Being proactive and informed about what insurance covers can help maximize benefits and ensure that necessary equipment is acquired.

Transcript:

Emilia Bourland, OTR, ECHM, CFPS
Welcome to CureLab.

Dr. Brandy Archie
It's Care Lab Day and I'm so excited about it. How are you?

Emilia Bourland, OTR, ECHM, CFPS
It is Care Lab Day. It's a great day. It's always a great day when it's Care Lab Day. And I have a question to get you started.

Emilia Bourland, OTR, ECHM, CFPS
Okay, so my kids love to play Would You Rather? And so I thought it'd be fun to start with a kid inspired Would You Rather? And I'm just gonna go ahead and say like, my kids, these are always gnarly and I never wanna choose. But here we go. Okay, are you ready for it?

Dr. Brandy Archie
Oh lord, yes.

Dr. Brandy Archie
Oh, nice.

Dr. Brandy Archie
I'm not ready but I'm gonna do it anyway.

Emilia Bourland, OTR, ECHM, CFPS
Okay, would you rather have 500 rusty nails driven into your back?

Dr. Brandy Archie
Gosh.

Emilia Bourland, OTR, ECHM, CFPS
Or would you rather swim in a pool full of infectious material?

Dr. Brandy Archie
Okay, I'm gonna go swim in the pool of infectious material. Here's the reason. While I might die from whatever infectious thing happens in that pool, I might not. And if you send 500 nails in my back, I'm definitely done. And if I'm not done, yeah, and if I'm not done, I'm in a lot of pain. Because at some point, I'm gonna get out of this pool, right? And so then I can treat whatever illness I acquired from being in there.

Emilia Bourland, OTR, ECHM, CFPS
Okay.

Emilia Bourland, OTR, ECHM, CFPS
You think so?

Emilia Bourland, OTR, ECHM, CFPS
I feel

Emilia Bourland, OTR, ECHM, CFPS
That's true, but I mean, like, there's some gnarly stuff out there. I feel like you could survive 500 rusty nails. I mean, one, tat in a shot.

Dr. Brandy Archie
Okay. I'm not Jesus. Jesus had three. So...

Emilia Bourland, OTR, ECHM, CFPS
Well, okay, I guess we didn't define how big these nails are. I feel like.

Dr. Brandy Archie
Are they thumbtacks? No, they're nails.

Emilia Bourland, OTR, ECHM, CFPS
These, they're like regular size nails. They're like nails that you use to like build a house. They're not like, they're not crucifixion nails.

Dr. Brandy Archie
I feel like a contractor would balk at all of this because there's no regular size nail. There's no standard. Is it one inch? Is it three inches? Is it five inches?

Emilia Bourland, OTR, ECHM, CFPS
That's true.

Emilia Bourland, OTR, ECHM, CFPS
See, this is the problem with would you rathers. There's too many details that you have to know. My kids get so annoyed with me because I always refuse to choose. I'm like, those are both terrible options. I don't want either. And they're like, but you have to pick. I'm like, I really don't. I can just, I can go left, I can right, or I can turn right back around. That's what I'm choosing to do here. And then they're like.

Dr. Brandy Archie
Thank you.

Dr. Brandy Archie
You're a bloodsport.

Dr. Brandy Archie
Your best game is just a whole point of what you'd rather. That's why it's a horrible and awesome game at the same time.

Emilia Bourland, OTR, ECHM, CFPS
I... Yeah, it's true. Well, clearly I'm not good at it. But neither are you, because you're also asking a bunch of Claire. You just have to... I think you is... Well, are you allowed to ask? You... Okay, that's true.

Dr. Brandy Archie
No, I made a decision. I made a decision. You asked me about my decision, but I made a decision.

Emilia Bourland, OTR, ECHM, CFPS
Actually, I made it bad because then I started to get into the details of it. Oh, that is the recurring theme.

Dr. Brandy Archie
Yes.

Dr. Brandy Archie
Yes, Borland kids, I hope that you are glad that we had this conversation. Maybe she will be a better player next time y'all try.

Emilia Bourland, OTR, ECHM, CFPS
Yeah.

Emilia Bourland, OTR, ECHM, CFPS
Probably not.

Emilia Bourland, OTR, ECHM, CFPS
All right, should we care lab something? Okay.

Dr. Brandy Archie
Let's care lab something. I think that one of the things that I get asked the most about is financial and related to all of the things that come around, aging, caregiving, aging place, all that stuff, because you know, this is America and everything costs something. And so I think it'll be really useful if we could chat about what our resources are in order to

maximize what our entrance is covering and understand what it doesn't cover so that we can plan in advance and be able to make a plan that works if that makes sense.

Emilia Bourland, OTR, ECHM, CFPS
Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
Yeah, I think that's a good topic to talk about as well, because I think there are a lot of ways that we can often utilize our benefits that we're just not aware of, that can really lead to less benefit utilization later on in the form of us not needing as many significant services or having hospitalizations. So yeah, I think this is a great topic.

Dr. Brandy Archie
Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
Uh, where do you want to start?

Dr. Brandy Archie
Um, well, let's start with adaptive equipment and durable medical. Um, because, you know, clearly that's my jam. So let's start there. Um, and that's the thing that everybody asks like, oh, well, how do I use my Medicare to pay for this? And you can't. And I'm going to tell you why you can't. So, um,

Emilia Bourland, OTR, ECHM, CFPS
Okay. Yeah.

Emilia Bourland, OTR, ECHM, CFPS
Can I just say, I love that we're like, let's talk about how you can get insurance to cover things. And then the very first thing is, well, you can't.

Dr. Brandy Archie
not going.

Dr. Brandy Archie
But listen, I don't like to bury the leak, y'all. I'm just gonna tell you up front. But I'm gonna tell you why you can't, which is gonna help you understand what you can get covered. Because I really feel like you should use your insurance to do the things that it will do because you've been paying into it for a long time and they are very rich. And so let's get some benefit out of it. So the definition of durable medical equipment is that not just that it's for a medical reason, that's what Jay Wright thinks it is, it's really...

Emilia Bourland, OTR, ECHM, CFPS
Uh, yeah, that's fair.

Dr. Brandy Archie
This equipment is necessary for somebody based on their diagnosis specifically.

which means by default, it's not helpful for somebody who doesn't have a diagnosis. So let me give an example. I can breathe this regular room air, no problem. Somebody with COPD will have a hard time with that. They need oxygen. Therefore, oxygen is coverage, durable medical equipment. You can get that at home because they really need to have it in order to live and also because of their diagnosis, whereas I don't.

A grab bar, a ramp, a shower chair. I can use all of those things to be beneficial in my life to keep from falling or just to relax in the shower or whatever. At the same time, somebody with a hip replacement also needs those things. Therefore, it is not durable medical equipment and it is not covered.

So the thing that, because the thing that happens is some proactive people will call Medicare and say, I need some durable medical equipment, is it covered? And they're gonna say, yeah, it's covered. But what you're asking is the wrong question, because what you're thinking about is a shower chair, and they're thinking about a wheelchair. And a shower chair doesn't count as durable medical equipment, so it's not covered. But there are a few things that are. So first of all, does my explanation make sense?

Emilia Bourland, OTR, ECHM, CFPS
Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
Yeah, your explanation I think makes total sense. But I also want to say that it's stupid. Not you and your explanation. But I mean, let's call a spade a spade. It is actually dumb to not pay for things that can prevent harm from happening upfront and instead wait for something bad to happen where that person's

Dr. Brandy Archie
Yeah.

Emilia Bourland, OTR, ECHM, CFPS
quality of life really, really suffers, or perhaps they have a life ending event, and we're paying tens of thousands or hundreds of thousands or maybe even millions of dollars for things that could have actually been prevented if we were willing to provide equipment that could be used at a preventative level. So yes, your explanation made sense.

Dr. Brandy Archie
Yep.

Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
The policy? For the record, CMS, not that you're listening to me, but I think it's dumb.

Dr. Brandy Archie
But they should. But you know, this did not happen by accident because that's why history is so important.

Emilia Bourland, OTR, ECHM, CFPS
Mm.

Dr. Brandy Archie
This is why healthcare is broken, because the way our system is set up is fee for service. We pay for a thing to be done because it's a very capitalistic mindset. I mean, it's what we do with everything else, right? If I go buy groceries, I'm paying for the groceries that I'm getting. I'm not paying in advance and then getting a ration of them afterwards. I'm paying for what I bought. We have set healthcare up the same way. We pay for what actions get taken.

And so that means we, by default, don't pay for things that don't happen. So no, there's no mechanism to pay $100 for a shower chair or a tub transfer bench instead of $30,000 for a hip fracture because we fell trying to get out the shower. Because we didn't set the system up that way.

Emilia Bourland, OTR, ECHM, CFPS
Mm-hmm.

Dr. Brandy Archie
And so I think people are recognizing that. And also our system is not sustainable in this way. And so that leads me to what you might be able to get covered now because there are some interesting things happening that are not widespread, but it's worth checking. So I talked about all the things that are not covered by insurance and I will talk about what is covered. But in this vein, if you're on a Medicare Advantage plan, their goal is to have you not

use the healthcare system. And so, there.

Emilia Bourland, OTR, ECHM, CFPS
as much as possible.

Dr. Brandy Archie
much as possible. So they're trying to flip the model of our pay fee for service into a value based plan. And so that's why some Medicare advantage plans will proactively send you band aids and blood pressure cuffs and stuff like that, or give you this magazine that you can get some over the counter stuff out every quarter at a certain amount. Because that's not stuff that they really actually cover. You can't like bill your insurance for it. But they're like, let's let us just pay a little bit on this.

you do this, it might prevent something else from happening. So use those resources to see if you can find anything in there that is useful to you. Instead of just getting band-aids, which you probably can buy at CVS, maybe save up your dollars and use it to get that shower chair or to buy a grab bar so then you can have somebody install it or whatever. Sometimes those basic things are in there. And it's worth asking if you're on a Medicare Advantage plan.

Let that not be for me to say I'm an advocate of Medicare Advantage plans. But if you're already on one, let's use the benefits that you can access from it. So there are some things that are happening, and eventually it'll change. But right now, that's kind of the only way to deal with it. We have to. We literally have to.

Emilia Bourland, OTR, ECHM, CFPS
Because we'll be bankrupt if we don't change. We literally have to, even if you actually don't give a hoot about like people and their health and their quality of life, we have to change because financially we will be bankrupt if we don't actually change the way that we think about and deliver healthcare.

Dr. Brandy Archie
Yep, absolutely. So, now there are a few things that do qualify as durable medical equipment that you can get covered and you should. And the five things that come into the home are a hospital bed, oxygen, a wheelchair or a walker, a patient lift, like a Hoyer lift or a sit to stand lift, and in the very rare occasion, a bedside commode.

That's it. That's all the things that like modify your home, that get covered by insurance. And so, um, most of the other things that do get paid for.

modify your body, like a catheter being placed, or wearing glasses, or you know, those kinds of things. If you think about it in those terms, it helps you understand that how to divide and what's going to get covered. And so that's a small amount of things, but they do have a pretty high cost. And so I'm a big advocate that if you need those things, you try hard to get them from insurance. So are you surprised by how few things are covered that go into the house?

Emilia Bourland, OTR, ECHM, CFPS
Well, no, because I'm an OT.

Emilia Bourland, OTR, ECHM, CFPS
But I think most people, yeah, will be super surprised by the very few number of things that go into the house, unless, of course, they've tried to get any of the stuff covered, and then they were probably told, no, can't do that, we can't do that, we can't do that. Oh, you can't get into your bathroom? Well, then you can have a three-in-one, which is another name for bedside mode, folks. But yeah, it is shocking how small that number actually is. And of course,

Dr. Brandy Archie
Yeah.

Dr. Brandy Archie
Yeah.

Emilia Bourland, OTR, ECHM, CFPS
I think that we do a pretty good job of being creative with those items as much as we can to like make them work as well as possible. But you know, it would still be great if we could get other folks, other things, other things for folks as well.

Dr. Brandy Archie
Yeah, I think it's also really important for clinicians to know because I get people that ask, like clinicians that ask all the time, well, how do I get this covered by insurance for my patient? I'm like, I'm sorry, you cannot. You can get these other things, but these things that you're asking for, I cannot. And they're just like, what? They need it medically. Yes, they do. I agree with you. However, other people could use it and benefit from it too, and it's not covered.

So for the five things, there are rules for getting it covered. And just because it is coverable does not mean that you qualify. If you understand the rules, then you can use the rules to your advantage is how I feel about it. So let's dive into the ways to do this. So let's say you're a person, let's do it. I'm trying to make it not very technical, but it does have a few steps. And it can easily be complicated. So get your notes out, people.

Emilia Bourland, OTR, ECHM, CFPS
Let's do it.

Emilia Bourland, OTR, ECHM, CFPS
So get out your notepad, folks. Get out your notepad.

Dr. Brandy Archie
you need to know this. This is why it's important to know because I think most

of us as consumers of healthcare think, oh, I need a hospital bed. My doctor will write an order for it. I shall receive it. And essentially that is how it works. But there are a lot of steps in between that the ball can get dropped in. And so I want you to know all the things that must happen. That way you can ask the right questions when you don't get the thing. Okay? So very first thing is you got to qualify for this device. And I'm not going to go into

Emilia Bourland, OTR, ECHM, CFPS
Mm-hmm.

Dr. Brandy Archie
that I can definitely give it to you just reach out to me and I'll help you. So you got to qualify based on diagnosis and such. Then the doctor needs to see you in his office or at the hospital see you face to face. A virtual visit can count and in his notes he or she needs to write Mrs. Smith needs a hospital bed because of xyz and then they also need to write a prescription.

Those two documents, they're treatment notes, and the prescription needs to go to a DME provider. You only have about five in your area, because Medicare only works with about five per urban area. You can find that information on Medicare.gov, but hopefully your provider already has somebody that they work with.

They got to send it to them. They're going to make sure that they've got the right documentation, meaning you qualify, and they're gonna send it to Medicare, and they're gonna approve it, and then they're gonna send it out to you. So it is theoretically simple, but.

you got to have all the right check boxes. And so if the right check boxes exist, but they didn't write it down, it's likely never happened. So now the DME company needs to go back to the doctor and say, hey, Mrs. Smith doesn't qualify for a hospital bed because of that diagnosis code, it doesn't work for that. And they got to either rewrite it or come back to you and say, I'm sorry, we can't get you a hospital bed. And so that's generally the process for all five of those devices.

Some of them are simpler than others. Like oxygen, I mean, it's pretty cut and dry. What kind of diagnosis is covered for that? Doctors know how to write that. It happens quickly. We know we need to have it. They've made a very smooth process. Whereas wheelchairs, super complicated. Yep, really fast.

Emilia Bourland, OTR, ECHM, CFPS
Ooh, that gets complicated, especially if you need a power chair, folks. That is, that can be a very complicated process. Yep.

Dr. Brandy Archie
And it's essentially the same process, but because you need to justify every individual part on the wheelchair, usually you need to have a therapist's evaluation as part of this too. And then the doctor signs off on that. And so I would highly recommend that if you need a wheelchair that you use your insurance to get it. If you need a wheelchair and a walker, please buy the walker out of pocket and use your insurance for the wheelchair. Because a wheelchair costs hundreds or thousands of dollars depending on what you need, a walker costs less than $100.

Emilia Bourland, OTR, ECHM, CFPS
Mm-hmm.

Dr. Brandy Archie
So there's great reason for having both, but Medicare won't pay for both. So just use it for the wheelchair.

Emilia Bourland, OTR, ECHM, CFPS
I also think, so one of the things that people don't necessarily understand about wheelchairs too is there is a huge number of ways that wheelchairs can be customized. They don't all look like that same wheelchair that you see kind of wheeling people in and out of the hospital or in and out of skilled nursing or whatever it is. Those are basically like, those are like standard wheelchairs that come in slightly different sizes essentially, but they all have the same basic parts and move in the same ways. But you can get customized wheelchairs.

Dr. Brandy Archie
Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
And I really encourage people, if it's a situation where someone is going to be wheelchair bound for the rest of their life, and they have things that they want to do with their life, ask about getting a custom wheelchair, getting an evaluation for that custom wheelchair. Talk with the therapist who is treating that person or who is treating you early and often about what that process looks like to get that ball rolling early, because...

Having a, if you are going to be wheelchair bound for the rest of your life or for a very prolonged period of time, having a wheelchair that fits properly, that functions well, is going to have an enormous impact on how you do everything for the rest of your life and will have an enormous impact on your health for the rest of your life as well. So,

And it can take a long time to get these custom wheelchairs, one, approved, and then to get them built as well. So that is absolutely something to know about and to advocate for yourself.

Dr. Brandy Archie
So.

Dr. Brandy Archie
I also want to push, well define wheelchair bound because yes, if you can't use your legs anymore, you're very wheelchair bound. You've got to use it to get around. However, I would expand that definition to include if we're gonna need to use a wheelchair for the rest of our lives, that we get a custom one. Because there's also great reason for an 80 year old lady with a lot of arthritis and pain and shortness of breath to have a custom wheelchair. Because she needs to use it to get from point A to point B.

Emilia Bourland, OTR, ECHM, CFPS
Mm.

Emilia Bourland, OTR, ECHM, CFPS
Mm-hmm.

Dr. Brandy Archie
be able to transfer out of it by herself and get to her bed or her other chair, but because she's short of breath and has a lot of pain with walking, she needs it to get from here to there. But that's not the typical person that you think of as being wheelchair bound.

And so she needs a custom wheelchair too, because the standard wheelchairs that exist may be too wide for her. And you get a custom one, you actually get it narrower, which makes it actually easier for her to push. And she got shoulder issues, we can move the wheels forward so we don't have to push, bring our arms back as far to push and have an effective push.

And so I like to push people to consider a custom wheelchair if there's gonna be need for it for an extended period of time, whether that's for paralysis and inability to walk at all, or even if it's just for getting from point A to point B consistently. So get a custom one and not the one that's off the shelf.

Emilia Bourland, OTR, ECHM, CFPS
Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
Yes, and if you are wondering if, well, if a custom wheelchair is thousands of dollars and, you know, we're giving a custom wheelchair to a little old lady who maybe we don't know how much longer she has left to live in her life, is that financially worth it? If you're asking yourself that question, which I'm sure people who are listening to this are, then the answer is still yes, honestly. Even if we don't take into account the fact that

Dr. Brandy Archie
Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
Now that lady is going to be able to participate more. She's going to be able to function better. Maybe it's the difference between being able to feed herself and needing assistance to feed herself. Like a wheelchair can really affect that finite level of functioning. But even if, let's put all of that aside, is it financially worth it? Yeah, probably. Because a well-fitted seating system is also going to prevent things like wounds. It's going to be more likely to prevent

Dr. Brandy Archie
Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
contractures, which is where joint gets stuck from not moving for a prolonged period of time, it's going to, again, because let's say someone is in a more functional position to eat, it's going to help prevent things like pneumonia from aspirating on food or on drinks. And all of those are really expensive medical problems that have to be treated, like very, very expensive. So is it financially worth it? Yeah.

Dr. Brandy Archie
Mm-hmm.

Dr. Brandy Archie
Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
Absolutely.

Dr. Brandy Archie
And the time is worth it too. So you mentioned about how long it can take and you know, the average amount of time it takes to get a custom wheelchair is three months. However, what I would say is not all that's an average. And there are many companies that can help you get that faster. If you understand the process, which I just told you about, then you can move the slow part along. The three months is not for building it or even Medicare approval. They're mandated to get approval back within, I think, 14 days, 10 or 14 days. Um, so it's not even that.

of it is pretty fast. It's usually the paperwork and somebody didn't write enough stuff. They faxed it but the people didn't get it and nobody's actually checking on it. So like you should be poking the bear and saying like asking the question. Did you send it to the doctor's office? Yes we did send it. Okay call the DMHQ. Who did you send it to? I sent it to this company. Okay great I'm gonna call them. Did you get it? No we did not get it. They didn't call to tell you they didn't get it. They didn't even know they were supposed to get it. So it's just floating in the ether. So now you got to call them back and say doctor

Emilia Bourland, OTR, ECHM, CFPS
Mm-hmm.

Dr. Brandy Archie
please send it again. And like that's the part that slows the whole thing down. It's not getting the documentation right or getting it to the right place.

And so if you can push that a little bit, you can get it sooner than three months. Um, and the DME provider often is able to give you a loaner and you should ask for that. And so instead of leaving the hospital with a standard wheelchair based on high end weight, say, I would really like to have a custom wheelchair because it'll be lighter weight. I didn't even mention that. Um, which is huge for putting the in and out of the car, pushing it on carpet, all that kind of stuff. Um, can you connect us with somebody to do a wheelchair evaluation?

even if it can't get done at the hospital, because sometimes the timing is not right for that. But they can get you started, and they can get you a loaner, in the meantime, while you're waiting for your share.

Emilia Bourland, OTR, ECHM, CFPS
I'm really glad that you said that because the other bit of this, speaking of getting things paid for, is that Medicare is not going to buy you multiple wheelchairs right in a row, right? They're going to buy you one wheelchair every five years. Is that still right? Every five years?

Dr. Brandy Archie
Right.

Dr. Brandy Archie
That is still right. Yep.

Emilia Bourland, OTR, ECHM, CFPS
Yeah, so like once they buy you a wheelchair, even if it's one of those standard wheelchairs, they have bought you a wheelchair and they are not going to replace it for five years. So this is all the more reason to make sure that wheelchair that you are going to get is the correct wheelchair for you or for the person that you're caring for.

Dr. Brandy Archie
now and for the future. So if we have progressive disease process happening, we should be considering what things are going to be like five years from now and try to get that sooner. And that's why we write an evaluation because we can talk about all that as clinicians. And so the other thing I want to say though too is as a clinician though, if you find somebody, you start to work with someone who got a chair a couple of years ago, if there has been a change in status, you can get another chair.

Emilia Bourland, OTR, ECHM, CFPS
Mm.

Dr. Brandy Archie
Your documentation just needs to demonstrate that significantly. So let's say somebody did get a standard high weight wheelchair. And now you're seeing them in home health, I don't know, a year later. And that's not working for them. And you can document a decline in their functional ability.

As long as you write towards that and say, they already have this kind of wheelchair, it is causing XYZ problems, they've had these changes in their strength or level of ability, so now we need this, it can get covered and I've done that multiple times. So it's all about how you paint the picture and write the documentation. But it's always better if we do the right thing first. So let's not like try to have to lean into that. Let's think.

future aspect as we first get the first year.

Emilia Bourland, OTR, ECHM, CFPS
I also think this kind of highlights a good point in particularly what you said about sometimes people have progressive conditions and what they need today either needs to be modifiable to meet what their needs are going to be tomorrow or we need to understand how those needs are going to change. And that's one really good reason why, you know, sometimes people can be very tempted to just go online and order a fancy wheelchair. Maybe they have the money to just pay out of pocket to go ahead and get a wheelchair rather than jump through all the hoops.

Dr. Brandy Archie
Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
of using Medicare or whatever their commercial insurance might be. But the fact is, as a lay person, it's actually really, really difficult to find that correct wheelchair, make that correct choice, understand what that future looks like. So even if that is something that that's what you want to do, you want to just go ahead and buy yourself a wheelchair, you still need to work with a qualified licensed therapist who is experienced doing wheelchair evaluations. And

who can help guide you in that process. Because otherwise you will end up wasting a lot of money on something that probably isn't gonna work as at least like best case scenario, it's probably not gonna work as well as you need it to, or that person needs it to right now. And worst case scenario can actually cause significant physical harm to that person and hurt their quality of life, as well as cause different medical problems. So work with your professionals. We're here for you.

Dr. Brandy Archie
Mm-hmm.

Dr. Brandy Archie
Yep.

Dr. Brandy Archie
And the other functional reason for that too is that, because insurance pays for it for once every five years, that also means that wheelchair provider is your servicer for the next five years. If you buy something out of pocket, you're gonna be on the hook for figuring out how to get that fixed if that's needed. But if you get it through insurance, then you can go back to that wheelchair provider and be like, oh, this broke or this is not working. Can you come help me with that? The answer is yes. And now you have a service provider for it. So I really advocate for people

Emilia Bourland, OTR, ECHM, CFPS
Mm-hmm.

Dr. Brandy Archie
to get hospital beds and wheelchairs because you get a service provider.

Emilia Bourland, OTR, ECHM, CFPS
So I think that this kind of segues into another topic really well, which is that how do you actually get connected with a service provider? Especially if you, let's say it's someone who maybe they haven't had a sudden healthcare event, they haven't had a sudden illness or injury, they haven't just been in the hospital, they haven't gotten out of rehab. Maybe they are declining a little bit, but they're certainly not sick enough to go to the hospital or something like that.

What can those people do and how can they begin to actually access services so that they don't get to the point where they decline to the point where they have to go to the hospital for something or they have a significant change in their ability to function. And I mean, I think one of the things that folks think of all the time is, of course, well, you can go to your primary care doctor. And that is definitely a, that is an important step for entry into getting

in connection with some providers. But I think it's a little bit bigger than that. Do you want to speak to that a little bit?

Dr. Brandy Archie
Yeah, so I think if you haven't noticed over the episodes that we've talked about, so many ways to do stuff in advance and try to prevent problems before they happen. And because we're huge advocates of that and that's like the way to go. And so this is another opportunity to do that. And so you don't have to have an acute event and go to the hospital and get services. If you notice that you're having changes, like you're talking about Amelia, you can enact that.

directly and get a therapy provider to come see you or you go there. I would say that starting with the primary care provider is probably the best way to go about it, but you can because you're going to need an order in order to get started with therapy. But if they're not automatically offering that to you, you can ask for it and you can say, Hey, we're having some challenges at home. And

We've had some close calls and falls. Can we get some therapy? They're gonna always say yes. They might not just automatically think of it, but if you ask that, they're like, oh, sure. And so if the person is homebound, meaning it's a very big challenge for them to get out of the house on a regular basis, then you can get home health to come to the house and provide therapy. If they're not homebound, you can go to outpatient. If they're not homebound, but you want somebody to come to the house,

are lots of mobile outpatient practices that will bill insurance for outpatient but will still come treat you at your home. So you got a lot of options that you don't have to like start at the hospital level and like do whatever they're prepping you to do one step after another. You can initiate it.

Emilia Bourland, OTR, ECHM, CFPS
Yeah, and I would agree that like the easiest point of entry is to probably talk, go and talk to your primary care physician about the problems that you're having. But I do want to reiterate that a lot of times they their go to won't necessarily be to think of getting you started on therapy right away. It's not because they don't care. It's not because they don't know about it. It's just because they're really busy people. They have a lot of things going on in their head. And you know, sometimes for physicians, their first go to is think about

you know, medications or things that they themselves can directly provide the intervention for rather than, you know, referring to another service provider. So if it's, if, if it's, if, if you go and you have that conversation, Hey, you know, I'm having a harder time getting up from my chair. I've noticed it's harder. I'm getting really tired when I'm taking a shower in the morning. I've noticed it's harder to do X, Y, Z, you know, I've fallen a couple of times. These are all indications that.

Dr. Brandy Archie
Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
really a therapist should be involved. And so if it's not something that your doctor is bringing up, please make sure that you are actually asking for it and advocating for it. I will say also that, you know, depending on the state where you live, there are some states where you can just call up a therapy provider directly, and you can go ahead and start therapy services. And frankly, even if it's not a state where they have to have an order, you can still do that. You can, you can call up.

a local occupational therapist, a local physical therapist, you can tell them your problem, and they will help direct you for what you need to do in order to get them into your home or for you to get into their clinic. Trust me, they know exactly what has to be done in order to see you as a patient. You don't have to be an expert on that. They will definitely direct you and they will help you with that process too. So that's always a good thing to know as well.

Dr. Brandy Archie
Mm-hmm.

Dr. Brandy Archie
Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
If you don't, if you want to just go direct to the source, which I'm a big go direct to the source person in my own healthcare, if I possibly can, then by all means, give them a call, ask them how to do it and they'll get you set up.

Dr. Brandy Archie
Yep.

Dr. Brandy Archie
Mm-hmm and half the times they'll do it for you, you know, like you tell them what the doctor is They'll send an order over to the doctor and they'll sign it and you don't have to have a face-to-face visit in order to get started With outpatient you do for home health, but you don't have for outpatient services And so they could just sign an order and you can just get started so Don't feel like you got to get to the point of which you are Struggling so much that you're having a falling one to the hospital. You can be proactive The other thing I'd say is like I don't think I think we

Emilia Bourland, OTR, ECHM, CFPS
Yeah.

Dr. Brandy Archie
underutilized some of the resources that our insurance does pay for. And so, for example,

Emilia Bourland, OTR, ECHM, CFPS
Yeah.

Dr. Brandy Archie
Many Medicare and Medicare Advantage plans give you a discount or free membership to a gym through the Silver Sneakers program. And so maybe you don't need a therapist, but you just know that you need a little bit extra umph and some work. You can go to the gym probably for free. You can call up the number on the back of your insurance card and they'll tell you what benefits you have, including things like pain management and chiropractic and acupuncture. And like some of those things are starting to be

with small number of visits in your plans. I just think that people don't know about it. So another resource, even though it's kind of irritating, is to just call your insurance company directly with the number on the back of your card and say, I'm struggling with this, can you help me? And they're supposed to be able to help you navigate the system. And also the people that are in their network in order to get connected with.

Emilia Bourland, OTR, ECHM, CFPS
Mm-hmm.

Emilia Bourland, OTR, ECHM, CFPS
Yeah, that's.

Dr. Brandy Archie
The other thing I want to add to that, one more thing I should add to that is if you are maybe caregiving for someone who has a lot of problems and you're needing to call and ask for help from insurance frequently, you can ask for a case manager and they are supposed to give you one. So that instead of calling the 1-800 number and getting a different person every time, you get to talk to the same person who understands what y'all are going through. It can help you do the next thing. And so it's worthwhile if you...

feel like you're in a deep hole and you need a lot of help to get out to ask the insurance company for a case manager.

Emilia Bourland, OTR, ECHM, CFPS
That's a really good tip. I actually, I did not know that. I had no idea. And that is like, that's a game changer. I mean, just having to call your insurance company about anything over and over again and talking to a different person every time, you know, telling to tell the same story to a different person who may or may not interpret it correctly or may or may not read the notes. I mean, it just, it's enough to make anyone wanna scream and bash their head against the wall. So having a case manager, if you're dealing with a situation,

Dr. Brandy Archie
Yeah.

Dr. Brandy Archie
Yes.

Dr. Brandy Archie
Totally.

Emilia Bourland, OTR, ECHM, CFPS
where someone is needing to use a lot of benefits or resources, wow, game changer. That's awesome.

Dr. Brandy Archie
Yeah, they don't really offer that upfront, but it's definitely available. And they want to do that too, because of course they want you to decrease how much you're using the healthcare system. I mean, in theory, they should think that they should want you to be more healthy. But the real answer is they want you to spend less of their money. So if you talk to them in their words and say, listen, we have a lot of problems going on here and I really want to coordinate care, is there a care manager or somebody that I can work with directly to help get some of these problems solved? They will find one for you.

Emilia Bourland, OTR, ECHM, CFPS
What do you think it would be like to live in a world where we just got healthcare because it was the right thing to do and people just deserve to be healthy so that they can be functioning members of society? Like, what would that be like?

Dr. Brandy Archie
Healthcare should be a right instead of a privilege, but it's a privilege in this country.

Emilia Bourland, OTR, ECHM, CFPS
It should be a right and not a privilege. And unfortunately, that's just not really the way our system is set up. But it would be a beautiful world.

Dr. Brandy Archie
You know, it would be a beautiful world. And I hope to be an advocate to do the top-down method of changing the system, because it does need to be changed. But everybody right now who's listening to this needs services now. And so that's why I push you to push your insurance company to do what it promotes it's gonna do, and call them and push them to do it. And because...

Emilia Bourland, OTR, ECHM, CFPS
Mm-hmm.

Dr. Brandy Archie
They're just, you're taking all our money and not putting any of it back out. And so you need to make sure that you're using your benefits wisely. The, not wisely, frequently. That's what I wanna mean. You should just be using your benefits. That's what they're there for. Not just the emergency benefit, but all of the preventative benefits that are built into your plan. The other thing I didn't add that I should is that if you are a veteran,

Emilia Bourland, OTR, ECHM, CFPS
Yeah, using your benefits. That's what they're there for.

Dr. Brandy Archie
you should connect it to the VA. And they are, when we talk about Medicare, yeah, and because most people are on Medicare and you might be on Medicare and still be a veteran.

Emilia Bourland, OTR, ECHM, CFPS
Mm.

Oh my gosh. 100%. Yeah.

Dr. Brandy Archie
But if you are a veteran, you should really get connected with your local VA. That does not mean you have to change your primary care doctor to a VA primary care. They're happy to have you keep your primary care, but you need to get in the system because there are some things that are just way better in the VA system. For example, all that stuff I said is not covered by insurance, the VA pays for it and they will send it to your house. So grab bars and shower chairs and all that stuff. They don't give you a whole lot of options about it, but they will send it to you.

Emilia Bourland, OTR, ECHM, CFPS
covered.

Mm-hmm.

Dr. Brandy Archie
you gotta get it installed, but they will send it to you. And so...

Emilia Bourland, OTR, ECHM, CFPS
Actually, the VA will do grab bar installations. Again, obviously, if you're a veteran, you're going to know what I'm talking about here. A lot of this depends on your service connection, about what exactly you can access. Some of these things you can access almost no matter what your service connection is. But if you have a certain level of service connection, you can not only have grab bars installed, you can have chair lifts installed. You can have your bathroom.

Dr. Brandy Archie
Absolutely.

Dr. Brandy Archie
Yep. Remodeled.

Emilia Bourland, OTR, ECHM, CFPS
remodeled. You can have doorways widened. You can have all kinds. I mean, the VA will do so many really big home modifications, honestly, for folks if there is a need and you have that service connection there. And you never know until you go and you get in the system and you have an advocate and you ask the questions. But there are some really... And of course, the VA has gotten a bad

Dr. Brandy Archie
I am Saturday.

Dr. Brandy Archie
Yep.

Dr. Brandy Archie
you get connected.

Emilia Bourland, OTR, ECHM, CFPS
a lot of things that you know probably should have gotten a bad rap for but it is also at heart an organization that really does want to take care of folks and has extraordinary benefits that you cannot get anywhere else in this country so if you're a veteran go get them you earned it you earned it go get it

Dr. Brandy Archie
Yep.

Go get him. Yes.

Yeah, including caregiving and having a caregiver come. There are a lot of benefits there. I will tell you that navigating the system is not easy, but we are telling you now, the cheat code is, you just need to know that they do it, and then you just need to keep asking. And they'll push you through to the right system or the right things. There's always a protocol in order to keep going, but just know that there's options available for you. So first step is get connected if you're not connected. If you're already connected, then ask your VA provider

Emilia Bourland, OTR, ECHM, CFPS
Mm-hmm.

Dr. Brandy Archie
out this stuff.

Emilia Bourland, OTR, ECHM, CFPS
Yeah, if you are just working on getting connected with VA benefits, I really recommend, and you're not sure where to start because it can be intimidating. It is a big process and there's a big bureaucracy to get through there. I really recommend getting in touch with the local VA ombudsman. They can be very, very helpful as an advocate and to help you navigate through that process, like incredibly helpful. And every VA should have an ombudsman that you can get the contact information for and you can contact them directly. There are also a lot of...

almost every I'm going to guess probably every city in America has a like veterans resource group and benefit like VA benefits group. They're not necessarily connected directly with the VA. I'm not going to like name any outright because there are so many of them. They're not necessarily they aren't the VA, but they are groups that help to advocate for veterans to access those resources. And they're great places to go to get started and get

get some help as well if you're just feeling like the process is too intimidating or it's going to take too long. But first off, I mean, call your VAs on Budsman, see what they can do for you and how they can educate you, how they can advocate for you. There's local community groups as well to kind of get your foot into the door and see what the steps are. And then, you know, once you're in, just use it. It's there for you.

Dr. Brandy Archie
Mm-hmm.

Dr. Brandy Archie
Absolutely. So do you think the Kira lab did? Yeah. Yeah, yeah. I give us a plus.

Emilia Bourland, OTR, ECHM, CFPS
I think we care labbed it. I think we care labbed it pretty good today.

Emilia Bourland, OTR, ECHM, CFPS
All right, oh, excellent, we got a plus. All right, well, if you enjoyed the episode, please make sure you're liking subscribing. Please share this with anyone who you think might benefit from it. And we will see you next time on CareLab. Bye.

Dr. Brandy Archie
Hahaha

Dr. Brandy Archie
See ya.