Business Solutions

Flexible Staffing

A whole new range of creative outsourcing and innovative staffing services are helping HME providers operate businesses that can respond to market challenges, function more efficiently, and deftly dive into new market opportunities.

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The words flexibility and focus rarely go together. Flexibility implies change, while focus conveys constancy. However, the HME industry is one environment where the two are not mutually exclusive concepts. If anything, HME providers need flexibility in order to maintain their focus.

And what’s that focus? Working with referral partners and caregivers to ensure patients have the care, service and equipment they need to enjoy an optimal post-acute outcome. Are processing claims and collecting co-pays, for example, part of that core mission? Some would emphatically say yes, while others would argue those processes draw providers away from the ultimate task at hand. If that’s the case, then why not hire someone else to do it?

Now, let’s take the discussion a step further: What about clinical staff? Could you offload some clinical tasks in order to improve your patient and referral partner focus?

If anything, the answer depends on the provider, but if we look at outsourcing and staffing services catering to HME providers, it’s clear that the options for offering available to providers go much further than just claims processing.

For several years, there has been a range of outsourced billing services available to the market, but more recently, we have seen the types of outsourcing and staffing options expand into many more provider workflows, including clinical processes. Thanks to technology tools such as cloud-based software systems and telehealth, there are many more ways for providers to consider where, when and how they might seek staffing and outsourcing solutions.

That’s the kind of flexibility that can foster focus. Let’s take a look at some outsourcing and staff solutions that are currently available to get an idea of what’s possible.

Tactical Back Office

HME staffing firm Tactical Back Office was born out of an HME provider seeking a new approach to creating flexible, scalable teams for HME businesses. The company trains and connects remote workers based in the Philippines with U.S. HME providers to balance their staffing needs.

“Tactical Back Office was born out of our DME company when the rural rollout occurred in 2016,” says Tactical Back Office founder Todd Usher. “We took that big 60 percent pay cut, and we couldn’t quite pay people the $15 an hour plus what they were demanding, so this was the next best idea.

“We started hiring our Philippine team and that worked out well for us, so that’s how the idea started,” he continues. “And then we launched Tactical Back Office with a sleep lab locally in Fresno that took on their first personnel, and we’ve grown from that point.”

So, what’s the difference between a staffing service and outsourcing? If a provider outsources work, it pays for remote or on-site, outsourced personnel, or if it works with a third-party billing and collections company, it might pay a percentage of revenue collected. If there are staff issues or anything like that, the provider works through a point person at the company.

However, using a staffing agency such as Tactical Back Office, the personnel are the provider’s employees and are managed and administered in the usual way. TBO still pays the employee, but it checks in with the HME provider to confirm hours worked. TBO also administers HR tasks such as processing PTO, pay, sick time, local holidays in the Philippines, double time, and overtime.

“When we onboard them with us, we put them through training and then we assign them to the client,” Usher explains. “They are not shared with any other client. … We assign personnel directly to the client or the HME provider, and it is their employee from that day forward.”

As mentioned, Tactical Back Office’s team is based in the Philippines, which allows TBO to keep the cost of its labor lower than what it would pay domestically. The company trains its team in billing procedures, HME software systems, reimbursement LCDs, and all the skills and specialized knowledge required to carry out the various workflows in an HME business. TBO’s team members work the same hours as the provider’s staff so that they seamlessly fit into the provider’s operations. The only difference is that they are working remotely.

In terms of English skills, people in the Philippines have been speaking English since they were in kindergarten, which enables them to engage with other employees and anyone in a patient’s care continuum without problems. And if there are employees whose English isn’t “spot on,” Usher says those employees can still work in back-end roles, such as posting or billing.

Having the necessary knowledge, skills, training and language means TBO’s team members are now carrying out a variety of roles at HME businesses.

“A lot of folks, because of our name, think it’s just back office, like billing and posting,” Usher notes. “When in fact, most of our team members are doing front office work. They are answering the phones. They’re acting in an operator role. They’re directing phone calls. They’re handling resupply patients and hospital discharges. They’re handling hospital beds. We even have hospice folks that are being assigned to process hospice orders.”

And how are TBO’s employees doing out in the field? There are many longerterm employees that have thrived since the company first launched its services, according to Usher.

“They are getting promoted to new positions within the businesses or clients that we have. So we don’t actually do the promotion,” he says. “The clients are so impressed with the quality of personnel they’re getting that they call us and say, ‘I need to promote this person,’ for whatever role that might be. It’s usually intake lead, intake supervisors, and senior intake positions.

“That’s the success that we’re experiencing, because we’re providing this personnel, and the DME or HME provider recognizes the fact that they haven’t had that quality of personnel before and they want to reward them for it,” Usher continues. “Which is really encouraging for us, because we get to see these people succeed and actually get promoted through the ranks because of the hard work that they’re doing all on the provider’s behalf.”


There are lots of HME service categories that involve highly specialized knowledge and expertise. A couple of examples of that would be sleep therapy and respiratory care. Both services involve clinical staff — respiratory therapists — to be involved in the process, not just to ensure optimal outcomes but also to ensure that reimbursement requirements are satisfied. Traditionally, those workflows have involved the RT working directly with the patient and usually in person. However, with travel costs, time and the limitations of performing front-line healthcare work during an ongoing public health emergency, provisioning that in-person care and consultation can get expensive and logistically inefficient.

Enter rtNOW, which provides its team of “tele-respiratory” therapists that help offset that cost and complication, as well as act as a pressure relieve valve that lets provider clinical staff focus on more in-depth care issues. Using videoconferencing and IT innovations, as well as rtNOW’s remote RTs can carry out tasks such as scheduling new PAP setups; ongoing PAP follow-ups to ensure adherence for therapeutic benefit and billing requirements; and virtual remote ventilator follow-ups.

“What we do for the HME customers is mostly allow their respiratory therapists to stay with the patients and people that need them the most,” says Chuck Stadler Jr., RN, president and CEO of rtNOW. “It’s about keeping the resources available for those patients who really need the respiratory therapist in-person the most, and we can be there for them in other more virtual-type scenarios.

“Some of the services that we offer HME companies are CPAP setups, CPAP adherence programs, and the monthly or quarterly ventilator check programs,” he continues. “So some of these patients are healthy patients otherwise, but they just have questions, and they want to be able to get them answered in quick and not necessarily an in-person format. Oftentimes we can get there quicker because we can be there virtually.”

The technology backbone for this is CoreLink, a HIPAA-compliant video chat system that links to rtNOW’s respiratory therapists or the provider’s therapists. The HME provider logs into the system, enters a patient phone number or email, and a link that is valid for one hour is sent directly to the patient. When the patient clicks on the link using their computer or handheld device, a video conference with the RT automatically begins.

In terms of human resources, rtNOW employs a team of respiratory therapists with management levels and leadership in place, to ensure that it can care for the company’s various provider customers.

“Then we hire additional respiratory therapists as more customers or more volume from those customers comes on board, and we integrate them into our team, focusing on how we do things but also how we do things as a direct reflection of how our customers like to do things,” Stadler explains.

In terms of how things get done, because rtNOW has been doing this for a while and is very focused on specific workflows, it has been able to refine those processes to ensure better outcomes. Take the company’s adherence program, for example. The company had its first batch of patients come out of a 90-day program at 90 percent adherence.

“We have a very detailed process of getting patients set up virtually,” Stadler says. “Every customer is a little bit different on where we get inserted in the process, but generally speaking, we’re talking about adherence before we can even talk about the setup, because it’s that important to us. We want to make sure that, if we’re going to set this patient up with a device, not only are they going to use it, but they’re going to feel comfortable using it and want to use it for not just the first 90 days, but for years to come.”

Telehealth Clinical Evals

Another example of an outsourced staffing company leveraging telehealth is Telehealth Clinical Evals. One of the four services comprising ATLAS Technology Service Group (the other three being ATLAS Enterprise Software, ATLAS Clinical Eval Software, and ATLAS – FIOS Business Services), Telehealth Clinical Evals maintains a staff of licensed physicians, therapists, and PT/OTs that provide face-to-face evaluations via HIPAA-compliant audio/video conferencing for mobility and sleep providers.

For mobility, the TeleHealth Clinical Evals team performs evals for both power and manual mobility equipment, including Group 2 and Group 3 power wheelchairs, rigid frame, and K1-5 manual wheelchairs. For sleep providers, its staff can perform sleep evaluations, ongoing CPAP compliance evaluations, and annual CPAP prescription updates.

The model creates a more collaborative, real-time process that eliminates the time-consuming, stop-start communication that can happen during evals, says Maxine Paul, the vice president of Operations for Telehealth Clinical Evals. That translates to a much faster, more straightforward process.

“We look at it as a team approach, where we have the doctor and/or the therapist, we have the ATP, and we have the patient together on the video conference,” Paul explains. “We can collaborate and finish this report together and eliminate the back-and-forth corrections. We have the paperwork back to the provider in days.

“I’ve been in this industry a long time, and I’ve never seen the evaluations and deliveries go this fast,” she adds. “Most of the providers we’re helping are delivering equipment in under 30 days, which is unheard of.”

Of course, telehealth really took off during the Covid-19 pandemic because of the need to socially distance, but the convenience, efficiency and effectiveness was an instant hit with medical and clinical professionals, HME providers, and patients, explains Dr. Scott Martin, MD, the medical director of Telehealth Clinical Evals.

“… From a patient standpoint, patients adored the process,” he says. They didn’t have to leave the solace of their home that didn’t have COVID at the time. And it was simply a much more personal interaction.”

Additionally, the ability to conduct the evals via telehealth offers a literal window into patients’ lives that can benefit their care, Martin notes.

“It’s allowed us to interview a patient and the family in their own home and get a real concrete understanding for what that home dynamic is like, not just for the patient, but for the caregivers,” he explains. “Because patients are only going to do as well as the care they have at home, and the equipment that caregivers have to assist that loved one with at home.”

And that assessment of the home situation can go a long way into ensuring that the home environment is optimized for the patient’s care beyond just the wheelchair, for example. The patient might, in fact, need a whole lot more in terms of home medical equipment. Finally, being able to remotely connect has let the physicians and licensed clinical professionals on Telehealth Clinical Eval’s team see things they would never have seen before.

“We were seeing these patients for wheelchair evaluations because a lot of them were having acute events, and at the time we were doing these wheelchair evaluations, we saw massive needs,” Martin explains. “There were some people literally sleeping on mattresses on the floor, with horrible bed sores. They had no home medical equipment, none. They didn’t have shower chairs; they didn’t have hospital beds; they didn’t have low air loss mattresses. Some of them didn’t have simple transport chairs to be able to get in and out of the house.”

Naturally, those insights create all new abilities to get patients the HME items they need to ensure they get the full complement of care that they need.

An Expanding Universe

These are just three services using technology in new and interesting ways to offer new outsourcing and staffing options to HME businesses. As mentioned at the outset of this story, a whole range of outsourced billing services paved the way for outsourced workflows. (That’s no surprise given the immense complexity of DME/HME billing, as well as the various workflows and management layers attached to that aspect of running an HME business.)

Outsourced billing companies include companies such as Prochant (, ACU-Serve (, Sunknowledge Services (, Medbill (, and MedBillingExperts (, to name a few. All of these services let providers outsource elements of their claims and billing processing, and some of them help providers outsource the management of their entire revenue cycle.

One thing is certain: outsourcing options for HME businesses are not going away. Whether it’s billing workflows or clinical evaluations and care, we can expect the range of options available to providers to expand so that they can maintain and prioritize their primary focus: the patient.

This article originally appeared in the Jul/Aug 2022 issue of HME Business.

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