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Keeping Patients at Home with Improved Outcomes Through the Use of Quality Incontinence Products and HME Providers

Friday, June 26, 2020 @ 07:06 AM  posted by jbuytaert

Courtesy of AA Homecare


Incontinence, also known as the loss of bladder or bowel control, is a common problem among older adults as well as people with disabilities. Urinary incontinence can lead to unwarranted physical, psychosocial, and economic burdens on both the patient and their caregivers. This is the first of a two‐part white paper series to address the types of products and services needed to successfully manage an individual’s incontinence needs; the next paper will address the use of ostomy and urology products.

Annual costs of managing and treating incontinence in the United States is estimated to cost $65.9 billion, with $51.4 billion directly related to medical care, such as medical treatments/procedures, supplies, medication, hospitalization, long‐term care stays, physician visits, and laboratory tests (Coyne KS, 2014). Failure to properly manage incontinence results in medical complications including incontinence‐associated dermatitis (a known precursor to ulcers and pressure injuries), urinary tract infections, falls, and psycho‐social issues.

Home Medical Equipment (HME) providers who provide incontinence products and services are critical to patient (end user) care and cost management. They work with the prescribing health care provider and end user to properly manage the individual’s incontinence needs by matching the person with the appropriate product(s) to ensure proper fit and size and providing essential services and ongoing monthly support in a costeffective homecare setting. To optimize end user experience and outcomes while decreasing utilization and the overall cost of care, HME providers use high quality products that meet or exceed the National Association for Continence (NAFC) premium standards.

However, recent payer trends in the Medicaid and MCO market have challenged the HME provider community. Unsustainable rate reductions prevent HME providers from being able to provide premium products, as well as products that meet the patient need and optimize self care, and provide services such as monthly consultations with the end user/caregiver to manage incontinence. Without these premium products and services, the total cost of care increases significantly while patient outcomes and satisfaction deteriorates.

By ensuring adequate reimbursement for quality products by reputable HME providers, payers can achieve the triple aim of improving the end user’s experience and quality of life, creating better health outcomes, and reducing the overall cost of care.


People with Incontinence

51% of females and 21% of males deal with incontinence at some point after 65 years of age. Females are 1.7 times more likely than males to become incontinent during their life span (Gorina, 2014).

Studies estimate that bladder incontinence alone costs $20 billion dollars annually (American College of Chest Physicians, 2014). In addition to the cost associated with products and services needed to manage an incontinent condition, many complications and added costs can be attributed to daily management. Adults who suffer from incontinence also have a high risk of falls, UTIs, and complications with skin breakdown due to being in contact with the high acidity of urine and or stool (Health Economics Resource Center, Department of Veterans Affairs, Sanford University School of Medicine, 2002). Incontinence also affects sleep quality, which can lead to increased daytime sleepiness, increased fall risk, and cognitive impairment among other problems (DeMarinis M, 2017). Incontinence can contribute to social isolation which can lead to depression; according to the Boston Area Community Health Survey as published by the National Institutes of Health, symptoms are also linked to “anxiety… fear of incontinence, and hopelessness” (Kupelian V, 2009) (Elstad E, 2010) (Tang D, 2014).

Social stigma and misperceptions surrounding incontinence may prevent many people from seeking treatment, creating a significant but underacknowledged public health burden (Elstad E, 2010) (Hägglund D, 2007).

Beyond the impact on quality of life for individuals with incontinence and those caring for them, incontinence may have important public health consequences. People with incontinence tend to be less physically active and more socially inactive than those with normal bladder function. Many women describe their symptoms as a barrier to physical activity and thus a cause of weight gain. Decreased physical activity helps explain the strong association between urinary incontinence and obesity and diabetes in women. Diuretics exacerbate urinary incontinence and may decrease adherence to commonly prescribed cardiovascular medications. Furthermore, nocturia and urgency are linked to increased risk for falls and fractures in older adults.

Incontinence Types, Products, and Standards

All levels of incontinence can be categorized by one or more clinical types:

Stress: The unintentional loss of urine due to physical movement or activity putting pressure or stress on the bladder; ICS: “Compliant of involuntary loss of urine on effort or physical exertion including sporting activities, or on sneezing or coughing” (International Continence Society Steering Committee and ICS Working Group, 2019).

Urge: Occurs when one has a sudden need to urinate and the bladder contracts when it shouldn’t, causing some urine to leak through the sphincter muscle holding the bladder closed; ICS: “Complaint of involuntary loss of urine associated with urgency” (International Continence Society Steering Committee and ICS Working Group, 2019).

Mixed: This type of incontinence is a combination of stress and urge incontinence; ICS: “Complaints of both stress and urgency urinary incontinence, that is, involuntary loss of urine associated with urgency as well as with effort or physical exertion including sporting activities or on sneezing or coughing (stress)” (International Continence Society Steering Committee and ICS Working Group, 2019).

Functional: A form of urinary incontinence in which a person is usually aware of the need to urinate, but for one of more physical, environmental, or mental reasons they are unable to get to a bathroom. ICS: “Disability associated incontinence: Complaint of urinary incontinence in the presence of a functional inability to reach a toilet/urinal in time because of a physical (eg, Orthopedic, neurological) and/or mental impairment” (International Continence Society Steering Committee and ICS Working Group, 2019).

Overflow: This type of incontinence occurs when one is unable to completely empty their bladder, leading to overflow which leaks out unexpectedly. One may or may not sense that their bladder is full; ICS: “Complaint of urinary incontinence in the symptomatic presence of an excessively (over‐) full bladder (no cause identified)” (International Continence Society Steering Committee and ICS Working Group, 2019).

Reflex: Similar to urge incontinence and also known as over‐active bladder, this type of incontinence is when the bladder goes into an involuntary muscle spasm and one gets the sudden urge to urinate even if the bladder is not full.

The first step for one with incontinence issues is to be evaluated by a clinician, where a clinical assessment can be made on the appropriate treatment and incontinence management for the individual. Per the American Urological Association, behavioral therapies are first explored along, which may be accompanied by drug therapy and/or other non‐invasive options. Additionally, incontinence products may be prescribed to manage the individual’s incontinence needs (Gormley EA, 2012).

To ensure that end users are accurately managed, it is important for payers to contract with HME providers who are trained to provide the correct absorbent products that meet one’s needs. There are many factors to consider when choosing the correct product for an individual including but not limited to product type, type of incontinence, gender, size, and mobility. Examples of incontinence products include protective underwear (adult pull ups), briefs (adult diapers), bladder control pads, under pads, and male guards.

NAFC recommends that adult incontinence products dispensed by HME providers be required to meet at least the standard level of the following key performance indicators: Rate of Acquisition (speed of which urine is drawn away from the skin), Rewet Rate (ability of the product to retain fluid without leaking back out to wet the skin), Retention Capacity (capacity to hold fluid without rewetting the skin), and Breathability (air permeability across fabric at controlled differential pressure).

Although standard parameters and values should be the minimum level required, premium quality levels will result in better care for end users. Products that meet the premium quality have higher absorbency and good rates of acquisition and rewet rates which prevent the skin from extended exposure to urine that can cause incontinence related dermatitis, potential pressure injuries, and in extreme cases wounds. Additionally, premium quality products have high breathability which assists in maintaining healthy skin and lowers the risks of UTIs. All these complications of incontinence and their associated costs to treat can be avoided or dramatically reduced by the consultative services of a quality HME provider coupled with the use of NAFC premium standard incontinence products.


Product Selection and Order Requirements

Significant care is taken to train the HME provider’s intake staff on selection of products appropriate for their clients based on their level and type of incontinence, health conditions, mobility, manual dexterity, body habitus, and personal preference. The HME provider consultant will demonstrate multiple products from several manufacturers and make recommendations based on necessary absorbency levels, body shape, and available caregiver assistance. For example, a small framed, ambulatory woman with stress urinary incontinence would require a different incontinent product from a small framed, bed‐ridden woman with fecal incontinence or a large man with urinary urge incontinence.

The HME provider’s staff who make original recommendations to the end user or caregiver receives several hours of product training prior to a face‐to‐face or phone consultation and continues to receive regular updated training on incontinence products as manufacturers change or add to their product lines. They must be able to assess end users’ needs as well as that of the caregiver to determine appropriate product. Once the product is selected, they must be able to determine garment size requirements. Manufacturers will provide a size chart, but there is tremendous flexibility in how a product will fit from one manufacturer to the next, and body shape must be taken into account. For most new users of incontinence products, or for a user that wishes to try a different product, providing product samples of different sizes and/or styles is important to find the best product for each individual. For example, waist and hip measurements will provide a starting point, but differences in height, weight, and leg circumference may make adjustments necessary. After samples are provided, the consultant must follow up with the client to determine if one of the products suits their needs or if additional samples are required.

Once a product has been selected, medical necessity must be verified if the client wishes to have the products covered by a state Medicaid program. This is usually completed by obtaining a prescription from his/her health care provider. The HME provider must collect the client’s information necessary to contact the health care provider and determine insurance coverage. The health care provider is sent the request for a prescription for their patient which must be completed according to state requirements. Often, the prescription is missing necessary information and must be returned to the health care provider to accurately complete the prescription according to state requirements. Depending on the state or the product requested, the company may also be required to collect chart notes from the doctor. This step involves educating the health care providers and usually requires multiple back and forth requests for additional information from doctors before the company is able to obtain a valid prescription. Any items which are outside the typical request, such as quantities over the allowable or bariatric sizes, also requires a prior authorization before sending an order. The employee submitting the order must then educate the end user on quantities allowed for each product, which varies based on the insurance payer, and verify insurance coverage.

After an order has been sent, the invoice can be submitted to insurance for processing. Some payers require that the claim first be submitted to Medicare for denial before it is sent to the insurance company that is expected to pay for the order. Depending on the complexity and type of insurance involved, payment may require submitting to a series of payers. Medical billers that submit these claims are highly trained on how to submit claims following different rules and using different codes for dozens of different insurance payers.

Recurring Monthly End User Follow‐Up

A recurring order should not be automatically fulfilled. Payers should follow best practices and require that an end user is contacted on a monthly basis prior to shipping the next order. The HME provider’s staff must verify that the end user is still living in the same facility or address, that their insurance has not changed, that their medical condition has not changed, that the end user wants to receive a follow up order from the company, and the amount of product the end user has remaining. The staff will also check to be sure that the product seems to be meeting their needs, and if not, work to address the problem and offer additional samples. The staff must determine how much product the client has on hand and how much is expected to be needed for the coming 30 days. If there has been a change in medical condition or insurance, the process must begin again to check eligibility with the new insurance payer and find out the requirements of the insurance company to determine what products and quantities of products will be allowed.

Prescription and other medical necessity documentation must be charted and checked to be renewed prior to expiration. Depending on the doctor’s request and insurance payer’s requirements, a prescription can be good for only one order or may include up to 11 refills, but in no event can an order be sent and billed when a valid prescription is not in hand.


Individuals in the healthcare sector are likely familiar with the Institute for Healthcare Improvement’s Triple Aim of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare.

As this concept is applied to treating and managing the incontinent patient, the focus centers upon:

  • Improving the patient experience,
  • Lowering costs, and
  • Better healthcare outcomes.

HME providers play an essential role in partnering with the end user to manage their incontinence. It is the HME provider’s role to give end users back their dignity so they can live an active lifestyle and socialize/integrate within their community. This is accomplished through a consultative approach with the end user and/or their caregiver. Matching the end user with a product that meets or exceeds the National Association for Continence premium standards is essential—but selecting the right product or products and ensuring that the size and fit are appropriate for the end users while providing ongoing supportive services are also key elements.

Ongoing interaction with the end user/caregiver that includes at a minimum monthly communication with the end user/family is essential to ensure that the products continue to meet the end users’ needs. Weight gain or loss, activity changes, or degree of incontinence will all require changes in product selection for the end user. It is incumbent on the HME provider as a partner to the end user to address these changes. Matching the end user with the right quality product to manage their incontinence eases the burden on the end user and his/her caregiver, lessens the need for product changes, and ultimately results in lower utilization of products and cost savings for the payer as well as less fatigue/burnout for caregivers. This may in turn lead to fewer caregivers seeking more‐costly alternative sites of care such as a nursing home, to the benefit of end users, caregivers and payers alike.


HME providers are in a unique position to help manage the end user’s incontinence needs in a cost‐effective homecare setting with quality products that enhance quality of life while preventing avoidable health complications. However, this is not possible without sustainable rates that enable HME providers to provide the quality products and essential services detailed above for those with incontinence. By ensuring that reimbursement rates are sufficient, quality HME providers can continue to provide the quality products and services that maximize end users’ outcomes, keep overall health care costs at a minimum, and give end users back their dignity while continuing to live independently.

Works Cited

American College of Chest Physicians. (2014, September 16). American College of Chest Physicians Releases New Recommendations for Treating Urinary Incontinence in Women. Retrieved from American College of Chest Physicians:‐newsroom/american‐college‐ofphysicians‐releases‐new‐recommendations‐for‐treating‐urinary‐incontinence‐in

Coyne KS, W. A. (2014, February 20). Economic Burden of Urgency Urinary Incontinence in the United States: A Systemic Review. Journal Managed Care & Specialty Pharmacy, 130‐140. Retrieved from

DeMarinis M, N. D. (2017). Holistic Continence Care: Promote Sleep Hygiene, Improve Outcomes, and Reduce Risk in Your Community. Attends Healthcare Products.

Elstad E, T. S. (2010). Beyond Incontinence: The Stigma of Other Urinary Symptoms. Journal of Advanced Nursing.

Gorina, Y. S. (2014, June). Prevalence of Incontinence Among Older Americans. Retrieved from National Library of Medicine:

Gormley EA, L. D. (2012, December 1). Diagnosis and Treatment of Overactive Bladder (Non‐Neurogenic) in Adults: AUA/SUFU Guideline. Journal of Urology. Retrieved from

Hägglund D, W. B. (2007). Fear of Humiliation Inhibits Women’s Care‐Seeking Behaviour for Long‐Term Urinary Incontinence. Scandinavian Journal of Caring Sciences.

Health Economics Resource Center, Department of Veterans Affairs, Sanford University School of Medicine. (2002, December 8). Health‐Related

Consequences of Overactive Bladder. Retrieved from National Institutes of Health:

International Continence Society Steering Committee and ICS Working Group. (2019, February). The International Continence Society. Retrieved from National Institutes of Health:

Kupelian V, R. R. (2009). Association of Urologic Symptoms and Chronic Illnesses in Men and Women: Contributions of Symptom Severity and Duration. Results from the Boston Area Community Health (BACH) Survey. Journal of Urology .

Muller, N. (2013). The Development of National Quality Performance Standards for Disposable Absorbent Products for Adult Incontinence. Ostomy Wound Management , 40‐55.

Tang D, C. D. (2014). Impact of Urinary Incontinence on Healthcare Resource Utilization, Health‐Related Quality of Life and Productivity in Patients with Overactive Bladder. In B. International, Functional Urology (pp. 484‐491). John Wiley & Sons Ltd.

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