Medical/Surgical Vendor Questions

1. A client is upset because they have had compression stockings for years and are now not eligible. What do I say?

The AADL program provides funding for support stockings for specific medical conditions based on a medical assessment of need. To be eligible for coverage of support stockings through AADL, a client must have signs and symptoms of Chronic Venous Insufficiency Class 2 or Class 3 (CVI 2 or 3); conditions where there is poor return of blood from the feet and legs back to the heart.

Prior to September 2005, clients could receive AADL coverage for support stockings by presenting a prescription from their doctor. However, it was found there were individuals receiving the support stockings that had conditions other than CVI 2 or 3, and complications, such as chronic wounds or amputations were occurring. As a result of these concerns, AADL implemented a best practice guideline. Under the new AADL process, comprehensive lower leg assessments are mandatory to prevent possible complications.

For further information regarding the provision of support stockings, please have the client contact Ms. Lauran Chittim, Program Manager (Medical/Surgical), toll-free by dialing 310-0000, then 780-422-4846 when prompted.

2. Can I give the client more than their two-month AADL medical/surgical supply?

No. For example AADL’s benefit year starts July 1, if the client gets their two month supply on July 1 for July and August and they come back the beginning of August wanting their two month supply for September/October, it cannot be supplied until September.

AADL’s maximum quantities are based on best practice and research. These quantities are reviewed on an annual basis. If the client needs more, there should be a reassessment done by a healthcare professional. Then, if after the reassessment, the client needs more the Quantity and Frequency Review (QFR) process can be used provided the authorizer clinically supports the client’s request. The healthcare professional may also suggest other strategies and/or products be used. If the client declines a reassessment or does not wish to follow their authorizer’s clinical directions, they are 100% financially responsible for any quantities above the authorized two-month amount.

3. What does the pricing for the medical/surgical products mean?

All the pricing for the medical surgical benefits is based on the benchmarking principle. Each price is based on a specific manufacturer product‘s retail price for the smallest amount that the vendor has to buy. Each vendor signs their benchmark contract agreeing that they will provide clients with choice of product at shelf price, sale price, or benchmark price which ever one is lower. This gives the client choice of product and the vendor choice of different brands provided that they meet AADL’s generic description for that particular product.

4. Do I have to offer the client products at or below the benchmark price or can I just offer products above benchmark price?

As an AADL vendor you must offer clients products at or below benchmark price, sale price or shelf price which ever one is lower , you cannot automatically direct the client to buy products that would incur extra cost above any 25% co-pay cost that they may have.

5. Do we have to follow manufacturers' expiry dates for medical/surgical products?

Yes, expiry dates are on items for the supplier and consumer’s safety. For example, if you provide the client with outdated flanges for their stoma and an adverse reaction occurs, as the supplier, you could be held liable.

6. The client has called our store and wants a six-month supply of their medical/surgical product(s) because they are leaving the country. Can I supply this?

No. If a client requests a supply greater than two months, please direct the client to call one of AADL’s medical/surgical manager or medical/surgical clerks for approval. Once approval is obtained, AADL will contact your store and grant approval to provide the client with a greater than two-month supply.

7. Can I give a client all three pairs of their compression garments at once?

No. This is not recommended. All initial clients should only receive one pair initial this ensures the following:

• compliance
• that the pressure and length of garment is clinically appropriate

8. What if the client doesn't agree with the above rationale and wants all three compression garments at once?

It is recommended that you have the client sign the AADL’s fitter’s form acknowledging that you recommended that they should take one pair initially. This protects you if, for example, the client comes back and states they are the wrong length or wrong pressure. You have proof that it was recommended that the client only takes one pair, you are not liable for taking the stockings back and the client must pay for any new pairs.

9. What should I do if the client refuses to try to don and doff their compression stockings independently during the fitting?

Again, it is recommended that you document this on the AADL’s fitter’s form and you have the client sign it.

10. What should I do if the client comes back in the second year of their authorization and refuses to be re-measured?

Document this on the AADL’s fitter’s form and have the client sign it stating that they declined re-measuring. This will protect you if any concerns or problems arise.

11. What should I do if the client wants pantyhose but is only authorized for below-the-knee compression stockings?

The client can pay the additional charges for the pantyhose length. You would bill AADL the compression code that the client is authorized for and then the client would be responsible for any cost sharing and the additional charges, such as the up-grade cost to pantyhose. It is also recommended that this is documented on the fitter’s form.

12. Do clients have to go through AADL for a breast prosthesis or can they go through their private insurance carrier?

Technically, a client should have a choice to go through their private insurance. However, private insurance companies views AADL as first payer. Please explain to your client that it is recommended that they be assessed by a registered nurse authorizer for a breast prosthesis through AADL. AADL will then pay 75% (if the client is co-pay) to our maximum price. Then the client can submit a claim to their private insurance for their co-pay, any up-charges and bras that have been purchased.

13. What should I do if my breast prosthesis client refuses to go through AADL for funding?

You should explain that AADL will not reimburse. This means that if their insurance carrier denies their claim, the client will be 100% responsible for the cost of the breast prosthesis.

14. Does AADL cover swimmer protheses?

No. You should suggest to the client they may try to access their private insurance for possible coverage.

15. Why does AADL not fund mastectomy bras?

Unfortunately, AADL is not financially able to provide bras as these are a very personal item and are normally purchased by the client. If the client has private insurance, you should suggest that the client try to access their carrier for possible coverage.

16. Can clients be authorized for syringes for diabetic management?

No. Alberta Health and Wellness provides an accountable grant to the Canadian Diabetic Association (CDA) that is managed through "Alberta Monitoring for Health". Please direct your client to CDA’s web site for information and the application form for assistance.

17. Can I provide a client with a pull-up style of diaper under the AADL diaper code?

Yes, provided it meets AADL’s absorbency standards.

18. Are children's swimmer diapers covered by AADL?

No. AADL does not provide benefits for convenience and/or lifestyle.

19. Are children's "wet feel" diapers covered by AADL?

No. AADL does not assist with toilet training. AADL’s program is for clients with moderate to severe urinary and/or bowel incontinence who, unfortunately, are not expected to gain continence.

20. Are baby wipes and skin creams covered by AADL?

No. AADL is a minimal assistance program. We suggest you link the client to a registered nurse as she may have other more economical suggestions which may produce better outcomes as some products contain ingredients that are drying and may promote skin irritation and/or breakdown.

21. If a client is authorized for 400 of item M200 and 400 of item M242, can I supply 800 products every two months?

No. AADL quantity maximums for incontinence supplies are 400 every two months for any type of combination. This quantity is based on best practice and current research. Please note: Product absorbency rates have greatly increased over the years; thereby decreasing the quantity of products a client requires.

22. If my client is authorized for M200 and M243 but only wants M243 coverage every two months, can I supply only M243 product?

No. M243 is a booster line, designed to be worn inside a full brief, diaper or M240 for extra absorbency. If your client is only needing M243, please alert the client's authorizer and AADL's program manager immediately. Your client will need to be reassessed.

23. Can I provide the client with the total maximum amount of diapers authorized for them (for example, 2,400 at one time)?

No. Vendors are only able to supply a client with their two-month maximum authorized amount for the current two month period.

Also clients should not need all their products at once. Storage could be an issue and, if products are damaged (for example, become wet), the client will be out that entire product and will not qualify for more product funded through AADL.

24. Can I set up automatic deliveries to the client?

No. A client or legal guardian needs to call the vendor every two months if they require more supplies. AADL does not endorse automatic deliveries as the program is based on need.

25. Can I substitute other incontinence products under the client's authorization code for products that are not on the program?

No. You are only able to provide products that meet AADL’s generic description and absorbency standards.