All posts by Howard's Medical Supply

Beginning to end, the wheelchair fitting experience: how to be effective, efficient and empowering

Why is it so hard to get a wheelchair covered by insurance? The short answer is most insurances don’t want to give them out if they are not medically necessary. We can go round and round philosophically about this and a lot of people today are just saying, “I will pay for it with cash so I don’t have to hit the appointments.”

For those wanting to get a wheelchair covered by insurance, it takes three to tango and if all three are not bought in, the wheelchair can’t succeed. So who are the three and what is their role?

1. Patient–In wheelchair seating it starts with the patient. He/She must attend all scheduled appointments, participate in the trial of equipment if it is unsure whether they can use it, understand the realistic timeline for obtaining the equipment, communicate with the team (about demographics, trial results, equipment fittings, etc.), demonstrate the safe use of the mobility equipment and attend follow up training/fittings (as appropriate). We have had several patients where the they were never bought in and the process never finished. Other times, the patient has gone out of their way, and has been very satisfied with their equipment and their increased mobility.
2. Therapist–Therapist do not have to get involved unless we are working with ultra-lightweight wheelchairs, tilt-in-space, or high-end complex rehab powered mobility; however multiple times they are involved in a standard wheelchair. It is their job to complete a thorough mobility evaluation, provide mobility training (during evaluation and treatment sessions), write the Letter of Medical Necessity including equipment justification, communicate with the team, write addendum (s) to the Letter of Medical Necessity (as appropriate), direct follow up mobility training sessions (as appropriate), and pressure map current and/or new equipment (Howard’s realizes that not all PT/OT’s do not have this equipment which is why we offer this service and have our own pressure mapper). We have found that not all PT/OT’s have the time to do all that is required for all wheelchairs. Ask your therapist if they are willing to do this. If not, we have a list of all therapists in the Yakima Valley who are willing to do mobility and wheelchair evaluations and would be willing to let you know who they are.
3. Vendor–The vendor has an important job as we have to not only provide the equipment but also have to bill it. It is our job to also attend requested appointments, complete home trial form (fax or electronic)*, provide updates to the team: additional documentation needed, insurance approval/denial/pend, delivery date of approved equipment, communicate with the team, attend follow up training/fitting sessions (as appropriate), pressure map current and/or new equipment as indicated, and help with the maintenance and warranty of the equipment. We have a team of five in the rehab department of Howard’s so this really helps as we are orchestrating talking with everyone involved. At Howard’s we have Dawnie who answers most of our rehab calls and coordinates the process. Aleah leads our team and verifies all paperwork and usually is the one submitting it to insurances as well as orders the equipment. Erik and Daryl are the ATP’s. And we have multiple Operations Technicians who help in certain deliveries and warranty work.

The reason why so many get frustrated in the mobility process is if ONE of these requirements is missed, it can prevent a wheelchair from being dispensed and paid for by the insurance.

In summary these are the hoops one has to go through:
1. Referral
2. Evaluation
3. Follow up appointments (as necessary)
4. Home Trial (depending on equipment)
5. Face-to-Face
6. Paperwork to insurance
7. Equipment approved
8. Equipment delivered
9. Follow up appointments (as needed)

We know, the process is hard but this is the dance we have to play. Give us a call at 654-9899 and the team at Howard’s would love to work with you and your family in this process.

Here is a typical timeline for getting a wheelchair.

Erik Mickelson
Erik is the CEO and ATP of Howard’s Medical a local durable medical equipment supplier in Yakima, Washington that has four locations in Ellensburg, Selah, Yakima and Sunnyside in Central Washington. I will be blogging this week from the ISS (International Seating Symposium) in Nashville, Tennessee. Most of this process in this blog comes from N. LaBerg and the wheelchair clinic in Minnesota.

Why should we care about dynamic seating with wheelchairs?

I sit still all the time. Hopefully you can see the sarcasm as I write this. My parents have told me from the time I was born, I have moved constantly. When we seat our patients in wheelchairs it is imperative to know that our patients move. Just because one is in a wheelchair and their ambulation is compromised does not mean movement comes to an end.

What is this? A suspension for a manual tilt-in-space wheelchair. These can be added to help make the patient’s ride in their chair more comfortable. Especially helpful going over thresholds. Unfortunately not normally covered by insurances but well worth the $399 to have the pair installed.

Think as you read this blog how many times you move. So what does this mean for wheelchair users whether they are a 8-year-old CP patient or a 85-year-old dementia patient? They want to move in their chair just as much as you do. The average person moves every 20-30 seconds shifting in their seat, moving their arms, etc.

Some of the items I never considered dynamic (i.e. which means movement) would be air bladders on cushions (i.e. A Roho cushion) or even stretchable shoulder harnesses. These are nice because even though the patient may be in a wheelchair, it allows for movement.

At Howard’s I have a handful of patients who have broken footrests because they push on them throughout the day. There are dynamic wheelchair footrests on the market that actually extend and then retract with a spring allowing the wheelchair user to fidget in their chair.

One of my favorite items we learned about is someone has finally made a suspension system for tilt-in-space wheelchairs. No one in their right mind would ever drive a car without suspension. Today’s mountain bikes have a suspension system. Wheelchair users complain that going over thresholds can cause them pain. We can now install a suspension system to let your loved one to help with “impact dampening.” I put the words “impact dampening” in parentheses because if we ever were to have them covered by insurance this is how it has to be phrased because insurance do not count comfort.

Dynamic Footrests move when you press against them. What you see here is one footrest (on the left) that has a spring in it and moves out. The other footrest (on the right) goes out and articulates up too.

If you have questions about dynamic seating, give us a call at Howard’s and talk to one of our two ATP’s on staff.

Erik Mickelson
Erik is the CEO and ATP of Howard’s Medical a local durable medical equipment supplier in Yakima, Washington that has four locations in Ellensburg, Selah, Yakima and Sunnyside in Central Washington. I will be blogging this week from the ISS (International Seating Symposium) in Nashville, Tennessee.

And my oxygen concentrator is beeping . . . !!!

I’ve been running the after-hours phone calls for Howard’s for over a decade now and have heard about every phone call possible. I won’t spare you all of the details of most calls but I can tell you what the most common call complaint is, my oxygen is not working.

Oxygen Tubing: The most common source for Howard's after-hours phone calls.
Oxygen Tubing: The most common source for Howard’s after-hours phone calls.

Here is the question, why?  You have a perfectly good oxygen concentrator and all of a sudden it stops working. Now, in most of these instances it continues to run but it will start to beep telling you something is wrong with it.  Here are the top three reasons why it has stopped:

  1. The main reason a concentrator stops producing oxygen is kinked tubing. Think of a garden hose. When you kink it, it inhibits how much water comes through the hose.  The same happens with oxygen tubing and this is the case with about 80% of our phone calls.  The telltale sign this is wrong with the one’s oxygen concentrator is everything else runs fine and frequently there will not be a warning signal as frequently as soon as other problems.  You know this is the problem when the ball on the concentrator drops down below zero.
  2. The second most common problem with an oxygen concentrator is a beeping concentrator.  When it beeps, there can be a number of reasons why and the beep just means that something is not running properly.  This used to be Howard’s number one problem.  This moved down to our fourth most common problem once we started being very proactive in changing them. The manufacture for Respironics says they have to be changed once every two years but it is our policy to change them every six months or every time they come into our store because an affordable filter is cheaper than a 2am service call.
  3. Next is the beeping concentrator because of a patient or caregiver moving it too close to a wall.  This is primarily a problem with our Respironics Everflow since it has a flat back.  It can be moved directly against walls or drapes which can then block intake flow.  As a result the concentrator will then not be able to have air flow in.

This are the big three reasons your concentrator may beep. There are a few others but are rare.  We have had an occasional blown motor (typically after 20,000 hours), the sitz beds will get clogged (in this case the concentrator will beep but the purity will drop and it will need to be rebuilt), and there are a few other reasons too.

As always, make sure you do business with a local oxygen company that maintains a 24-hour on-call number and does business in your town.  Nothing is worse than having an oxygen problem and having to wait for the company to “ship” your replacement to you as is the case with certain companies.

If you have any questions about your oxygen service, give us a call at Howard’s: 654-9899

Erik Mickelson

Team Lead for Howard’s

Good things at Howard’s: Hiring on both the Customer Service and Operations Team

We are hiring at Howard’s!

We posted our current job openings on Craig’sList ( Currently we have two full-time customer service positions open, one part-time customer service position open, and one operations team member position open.

If you are interested in the position please apply through the Craig’s List Ad and change the subject line to “I’m Howard’s Material!” This lets us know you are not a robot.

Good luck!Howard's Medical

Come join our team in operations!

Looking to be part of an amazing team? We’d love to have you join Howard’s Medical!


● “To enhance the quality of life for the community of Central Washington by providing high-quality home medical equipment and supplies with a compassionate touch.”

Primary Responsibilities Include:
• Fixing and clean broken inventory
• Work hand-in-hand with other team members helping them with their jobs
• Help the outside of Howard’s look as great as possible
Secondary Responsibilities Include:
• Must have basic computer skills, determines the best method for fixing items
• Resolves patient complaints by identifying problems and coordinating appropriate corrective action
• Keep an orderly delivery vehicle, must be able to efficiently load and unload van and setup equipment in patient’s homes
• Must be prompt, courteous, and be able to emphasize customer-service making our customers fell they are the most important delivery you do every time
● Flexible (40 hours/week)

● Hourly $10-12/hr.  401k, and spiffs are available.
Once through the probationary period (3-months), other benefits are available too if you perform beyond company standards.
● Up to $30/month at a local gym reimbursement if you work out at least 12+ times a month. Other spiffs can be added to this list as well.


● Pass background and drug check prior to first day on the job.  Must be at-least 18-years old with high school degree.

• Must be flexible, dependable, maintain positive attitude, and have the ability to solve problems
• Will adhere to company manual and not use any illegal drugs, consume alcohol or smoke on the job, must pass complete background check
• Must be 18 years of age or older, pass background check and drug-test, and be able to lift at-least fifty pounds

Once you master your current tasks and job, you will be eligible for promotion within the company.  We have had three current team members start in this position and be promoted within our company. THIS IS NOT A DEAD-END-JOB!

***If you are interested in this job, please respond to our Craig’s List advertisement with a copy of your resume.  In the subject heading of the email, please change it to “Attn: Mr. Ferguson” this will let me know you are not a “bot”.  If you do not do this, we will not look at your application.  Once you do this, we will email you 6-8 email questions for you to answer and email back to us.  This helps us go through the hundred or so emails to see who we should interview.  Trust us, it is a fun exercise unless you don’t like to think.

Also, do not stop by our store and drop off your resume UNLESS you have current DME (durable medical equipment) experience in the last 36-months, then this okay. In these cases still submit your resume via email so we can email you back the questions. Last if you don’t have a resume, we are going to recommend you build one so you can apply to be part of an amazing team.***

If you missed the link, here it is again!

Howard’s beats industry billing standards by 60%!

No medical supply ever publicizes their billing numbers; however, I want to let everyone know what the team at Howard’s is up to. According to CMS standards, on the first round of audits for Medicare, the average durable medical supply has 85% of their claims denied by Medicare when they are audited. Now, there are four rounds of appeals, so even though this means only 15% of claims are paid on average in the first round of appeals, it gives you an idea the number of claims Medicare denies that comes across their books.

Last week, Howard’s Medical received our numbers for the last forty-five days. We are running at a 25% denial rate for our Medicare claims, a full 60% better than industry average!

How do we do it?

  1. We communicate with your providers and know the rules for billing equipment inside and out in regards to medical supplies. Just as you want your accountant to know the tax rules inside and out, we know medical supply rules inside and out.
  2. We have an amazing team. They take the time to verify your eligibility, work with you when you are in the store, ask the right questions so when we bill your claims everything goes through and it gets paid.
  3. We also know when an item is not going to be covered. For example when a patient is in a nursing home or hospice, Medicare does not cover most medical equipment.

One other question you might wonder, a 25% denial rate still seems high. You are right, it is. A few other thoughts on this:

  1. There are multiple rounds on the appeals processes when we bill claims. The 75% success rate for Howard’s is just for round one. If we have one of your claims and we fail in round one, we look to see why we failed, verify the reason and sometimes it is a very simple reprocessing of the claim. Other times we have to contact your provider and ask for addendums to chart notes. Worst case scenarios we do have to pick up equipment.
  2. Other insurances for the most part are significantly easier to bill than Medicare. So if you don’t have Medicare take heart, life is much easier for the billing side of things for your medical supply company.
  3. Medicare is slowly working on things. There are a number of bills in congress working to streamline things. Please contact your senator and congressperson and ask them to ease up on the audits. We are not anti-audits because they prevent fraud but in high school if you get 99 out of 100 on a test this is an A+. With a Medicare audit, a 99 out a 100 is a failure that has to be fixed!

If you have any durable medical or respiratory billing questions, give the team at Howard’s a call, we really do know what we are talking about and have the numbers to back it up: 509-654-9899.

The “Why” Behind Kittitas Medical

Howard’s Medical formally announced last week we are opening a third location in Ellensburg. I am a “why” person so this post will seek to explain why we are opening a new location. 

Two years ago, we would not have considered moving to the Kittitas Valley. There was a great respiratory supply company (KVH Home Respiratory) and KittitasMedicala great local pharmacy that provided other DME supplies (durable medical equipment) and billed Medicare. Both companies have since stopped providing these items, so as of June 1, 2015 there is not a single DME storefront location in Kittitas County.

Ellensburg is similar to Selah where Howard’s Medical begin in 2004. They are both small towns where getting to know individual customers and providing excellent customer service still really matters.

Why call our new store Kittitas Medical instead of Howard’s Medical? Howard’s is a local name well-known to Selah residents since the late 50’s and we want Kittitas Medical to mean the same to the residents of Kittitas Valley. We are not going to be “just another business” in town, we want to come alongside you, serve you and help maintain your independence in the home for as long as possible. We will be available for consultation, instruction, and a kind word to help out.

We have signed our lease at 800 South Pearl in Ellensburg across the street from the Rite Aid pharmacy. To the north of us is the DSHS building which houses Canyonview Physical Therapy, Memorial Services Clinic, Dr. Jeffrey Ventre’s monthly wheelchair clinic, Pinnacle Sleep Center, and monthly visits from Cascade Foot & Ankle and Yakima Urology. Across the street from us is the Super 1 Grocery store. Behind us is the medical practice Family Health Care of Ellensburg.

Our main goal is convenience for the residents of Kittitas Valley. We are currently waiting on a permit to partition out part of our store, and we plan on opening August 1, 2015. We will employ a full-time, in-store Team Lead as well as a full-time Delivery Technician for those customers who cannot make it into the retail location. Both of these team members have just been hired and we will be announcing them next week so stay tuned!

We are looking forward to serving your family this year. Our slogan is, “Our family serving your family’s health care’s needs.” We don’t take serving lightly, so let us know what we can do to help you be as independent as possible, both inside and outside your home.


Erik Mickelson and the rest of the team at Howard’s Medical and Kittitas Medical Supply


KVH in Ellensburg Discontinues Home Respiratory Program

Howard’s found out about two weeks ago that KVH (Kittitas Valley Healthcare) was going to discontinue their home respiratory program. Since Howard’s is a hometown and locally owned company, this broke our heart to hear their home respiratory program was closing their doors after serving their community for over twenty years.

Howard’s currently served Kittitas Valley once a week so we are planning on increasing our service to Kittitas County with daily deliveries Monday through Friday to compensate.  Here is their official press-release that was released earlier today.

We are also planning on hiring a full-time operations technician to be based out of Ellensburg.  If you know of someone who would be a great team member have them apply at Howards through our link on Craig’s List.

If you have any questions, please give us a call toll-free at 800-469-7131.


Team Lead for Howard’s Medical


Howard’s now offering daily deliveries to Ellensburg

Picture taken last Friday just before a thunderstorm.  It is only a 32 minute drive from our Yakima store to Ellensburg.  We will be making this drive Monday-Friday going forward.
Picture taken last Friday just before a thunderstorm. It is only a 32 minute drive from our Yakima store to Ellensburg. We will be making this drive Monday-Friday going forward.

Howard’s is pleased to announce we are now offering daily medical supply and oxygen deliveries to Ellensburg and Kittitas County.  We have always served Kittitas Valley but we have previously done so every-other week.

What does this mean for Ellensburg? If you are one of our current customers please just call a day ahead and make sure your delivery gets on our delivery vehicle each day.

With six current delivery technicians, two ATP’s (highest level of wheelchair certification) as well as two RT’s (respiratory therapists), Howard’s is excited and committed to serving the Kittitas Valley.  As always, give us a call at 509-654-9899 or 800-469-7131 (toll-free) if there is anything we can do to assist you.

What do you look for in an oxygen provider in the Yakima Valley?

This is our standard concentrator for home use by Philips Respironics.
This is our standard concentrator for home use by Philips Respironics.

As I touched on last week in my MedTrade blog, the medical supply world is changing at the pace of a bullet. We are currently hiring two new team members here at Howard’s this week (click to apply) and I love talking to potential team members for our team. We have an intensive interview process to join our team. For someone to join our team, he/she must go through five different interviews! Unfortunately this makes it slower for us to hire, especially when we need bodies immediately to help answer the phone. The good news is when we do hire someone, we end up with team members that stay at Howard’s for the long haul.

Yesterday while interviewing a potential new team member who had also interviewed at one of our competitors, she mentioned to me that our competitor does not do 24-hour oxygen patients, only nocturnal. I want to lay our cards on the table here to bring you into the world of leading a DME. If you or a family member is an oxygen patient, the store that supplies the medical supply is reimbursed anywhere between $90-210/month for the base concentrator depending on insurance and allowable. This base fee ONLY covers the concentrator which is the machine that makes oxygen in your home.

For our patients that only need oxygen at night (we call these patients nocturnal use only), this is all he/she needs. However, over time, most patients move into a category where they need oxygen 24/7 and in these instances also need portable oxygen if they go to church, to the store, or do anything out of the house. For these patients they would need either a portable oxygen concentrator (battery operated poc, see picture below) or aluminum tanks to run their errands.

All insurances also reimburse for portable oxygen. There is a major problem though and this should concern everyone in the industry: PORTALBE OXYGEN IS ONLY REINBURSED AT BETWEEN $25-60/MONTH!

The reason I write this in all caps is the reimbursement for portable is below almost all supplier’s cost. The way companies like Howard’s and other respiratory providers stay in business is we make a higher profit on the home concentrator unit which makes up for our patients we lose money on with our POC’s and tanks. At Howard’s , we also emphasize efficiency and try to predict which patients needs oxygen ahead of time. Last, we also go the extra mile with a lot of patients until they learn how to use their oxygen efficiently. We had one patient two years in a row need emergency oxygen delivered to their house on Easter. We waived the emergency charge because this was a planning error but we wanted this patient to be able to attend their local family gathering.

We carry three different kinds of POC's as well as aluminum tanks.  Call us to talk about which kind of portable option is best for you and your lifestyle.
We carry three different kinds of POC’s as well as aluminum tanks. Call us to talk about which kind of portable option is best for you and your lifestyle.

Here are a few things you need to know about home and portable oxygen:

  1. Even if you only need nocturnal oxygen, make sure your supplier you work with does both nocturnal as well as portable oxygen. Even if you are nocturnal use now, there may be a day in the future when you need 24/7 service and you need to make sure your supplier can take care of your needs.
  2. Make sure your supplier has a respiratory therapist on staff. Some suppliers make you call into a RT out of the area and do a phone consultation. Howard’s has two RT’s on staff and sometimes one needs more than a phone consultation and a RT needs to listen to breathing sounds and report back to your physician.
  3. Make sure your oxygen company has a 24/7 number they attend to after hours. We do! Even test it (preferably at 10pm and not 2am) to see if they actually answer the phone like they say they will. If you do this, tell them you read my blog as I or one of my team members will be picking up the phone.

Erik at Howard’s