supplies question

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
princessbelle
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Re: supplies question

Post by princessbelle » Wed Mar 25, 2015 1:38 pm

As you can see right here on this forum many people have begun to take control of their very own health care. Part of that includes controlling sleep issues. My sleep doctor gave the go ahead to change my settings and find what works best for me. I have my own fight with my DME like I said, putting me thiurd behind them and the insurance. I had no idea until November 2014 that if your insurance policy is not based in the state you live, you may get reduced benefits because of it. Replacement machine could have been covered and I my cost would have been 20% deductible had been met or a 3 month rental then purchase. Nope DME says I have to rent the machine for 10 months, new year new deductible. $73.45 for the machine rental and 21.08 for the humidifier, which that confounds me as I have to pay a separate rental charge for something that is a part of the machine.

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Wulfman...
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Re: supplies question

Post by Wulfman... » Wed Mar 25, 2015 2:50 pm

kcodeblue wrote:
princessbelle wrote:If the doc orders an apap then he feels it is necessary. Last I knew a Respiratory Therapist is not a doctor. I have actually sent DME an email today that if they can not bill per my policy they can come get their machine.
I receive orders all the time that say on the Rx "patient would like an Auto CPAP". I call the Dr. and ask what his recommendation is and he tells me he can only recommend what was clinically proven to effectively treat the patient's OSA which is the fixed pressure determined in the sleep study. So many of these are ordered not because the MD feels it's clinically necessary but because the patient is insisting on it. Either that or the titration process has been bypassed entirely so an Auto CPAP must be used.

It's not about me trying to be the doctor! It's about me trying to get the doctor to be the doctor and determine which patients actually need an Auto CPAP and which ones will do fine on a fixed pressure CPAP. I don't want to sound like a broken record but we loose money on Auto CPAP's in the region I work in. If we give them out to every patient, my branch will close down. And while everyone here seems to understand that HCPC E0601 includes all types of CPAP therapy, what most don't seem to know is that the reimbursement amount is based on what you all call "the brick". E0601 covers your basic CPAP. Insurances don't consider efficacy data to provide any clinical benefit so they don't compensate for it, same for Auto CPAP therapy. Pretty soon they'll all have LCD screens and WiFi and everyone will want one and they'll still be under E0601.

I'm sorry if I sound cynical, it's just that a lot of people I know have lost their jobs, their livelihood, because of Medicare and Auto CPAP's. When the announcement came that there was going to be another round of cuts in reimbursements totaling a 60% reduction to CPAP/BiPAP's, we had no choice but to close down 5 branches in Central California. This was because the primary source of revenue those branches had was Medicare CPAP/BiPAP setups. In order to keep the patient's and the MD's happy and stay competitive they gave Auto CPAP's with every request. When the announcement of the reimbursement cuts came, it was determined that it would be to much of a financial strain on the company to keep the branches open. 109 good people lost their jobs that day. And we have had another wave of layoffs since.

So please forgive me if I seem a little over protective when someone says every patient should get an Auto or my insurance paid for it so I should get it. The fact is Auto CPAP's fall under E0601 because they are capable of being a standard CPAP. The problem is the Insurances won't acknowledge or compensate for any of it's capabilities beyond that mode

On the bright side, I do believe within the next couple of years we will see Auto CPAP become the standard. This will drastically reduce their cost and make all of this a non issue.
In reality, most of the "differences" between the straight-pressure (data-capable) CPAPs and the Auto CPAPs is the internal programming. Been this way for 10 years or more. I knew this before I did it, but.....when I opened up the case on one of my Legacy (2005 vintage) REMstar Pro 2 machines, the PCA board has a label on one of the chips that says "Auto C-Flex Domestic".
So, there is NO valid reason that they couldn't program them all as Autos and cut all those other non-data-capable models out of their production.......and SAVE MONEY.......which then they could pass on those savings to the resellers and users.

The "logic" used by the manufacturers to have so many models is extremely flawed.


Den

.
(5) REMstar Autos w/C-Flex & (6) REMstar Pro 2 CPAPs w/C-Flex - Pressure Setting = 14 cm.
"Passover" Humidification - ResMed Ultra Mirage FF - Encore Pro w/Card Reader & MyEncore software - Chiroflow pillow
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palerider
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Re: supplies question

Post by palerider » Wed Mar 25, 2015 3:25 pm

Wulfman... wrote: The "logic" used by the manufacturers to have so many models is extremely flawed.
the logic is because they're meeting customer demand.

and as long as the cheap ass DMEs are their customers, and they are demanding cheap crap... the manufacturer will produce cheap crap, or the cheap ass DMEs will take their business to some other manufacturer who will.

the production costs of a resmed s9 escape and a resmed s9 vpap adapt are *exactly* the same.

now, the R&D costs are different...

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Wulfman...
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Re: supplies question

Post by Wulfman... » Wed Mar 25, 2015 3:40 pm

palerider wrote:
Wulfman... wrote: The "logic" used by the manufacturers to have so many models is extremely flawed.
the logic is because they're meeting customer demand.

and as long as the cheap ass DMEs are their customers, and they are demanding cheap crap... the manufacturer will produce cheap crap, or the cheap ass DMEs will take their business to some other manufacturer who will.

the production costs of a resmed s9 escape and a resmed s9 vpap adapt are *exactly* the same.

now, the R&D costs are different...
The problem with the "cheap crap" is that it's exactly the same as the "expensive crap".......with the exception of the programming........which they have to do for the "expensive crap" anyway........so, why even bother with the "cheap crap"? Unfortunately, in the world of big business there's the mentality of "That's the way we've always done it, just do what you're told and shut up!" "How can we drop the line of "cheap" models (Plus, Escape, etc.) that we've always made?" In reality, they aren't any cheaper when the production costs are taken into consideration.

ResMed........Philips/Respironics.........ARE YOU READING THIS????????


Den

.
(5) REMstar Autos w/C-Flex & (6) REMstar Pro 2 CPAPs w/C-Flex - Pressure Setting = 14 cm.
"Passover" Humidification - ResMed Ultra Mirage FF - Encore Pro w/Card Reader & MyEncore software - Chiroflow pillow
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Sharrykb
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Re: supplies question

Post by Sharrykb » Wed Mar 25, 2015 4:40 pm

kcodeblue wrote:
You are correct that Medicare reimbursement rates vary by region. In the part of southern California were I am located the rate is $42/month x 13 months. The heated humidifier is a sale item and is not included in the rental. An Auto CPAP (ResMed or Respironic) cost my company over $300
kcodeblue, can you please explain to me how that scenario equals "we loose money on Auto CPAP's in the region I work in" as you say in another comment in this thread? Using the numbers you give, my calculator tells me that Medicare is paying $546 for the machine rental (plus whatever they get paid for the humidifier) for a machine that costs "over $300". Isn't that still a profit? What am I missing?

I completely understand that DMEs make a SMALLER profit on an Auto machine than they do on a straight CPAP. But they idea that they actually lose money on an Auto machine is news to me...

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accurate
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Re: supplies question

Post by accurate » Wed Mar 25, 2015 5:26 pm

Wulfman... wrote:
The problem with the "cheap crap" is that it's exactly the same as the "expensive crap".......with the exception of the programming........which they have to do for the "expensive crap" anyway........so, why even bother with the "cheap crap"? Unfortunately, in the world of big business there's the mentality of "That's the way we've always done it, just do what you're told and shut up!" "How can we drop the line of "cheap" models (Plus, Escape, etc.) that we've always made?" In reality, they aren't any cheaper when the production costs are taken into consideration.

ResMed........Philips/Respironics.........ARE YOU READING THIS????????


Den

.
There's so much more to this issue then this argument. It's so easy to blame the manufacturers. It's also easy to blame the DME's (although I have less of an argument). The fact of the matter (and these are the facts) is that CMS (and Medicare) is compelled to cut costs. They were mandated by the House to reduce reimbursement to company's that supply products and services to patients. In 2008 they passed laws to force DME's to bid for services supplied to Medicare patients. In doing so they stratified diagnoses to the point where manufacturers and DME's were forced to make decisions whereby patients were divided by strict definitions of diagnosis. For example; A patient has cataracts. If the right eye can't see within a strict definition of sight, but the left eye can, then the right is covered but the left eye isn't, no matter how much of a sight deficit that left eye may suffer. If you have SA within certain limits (as determined by sleep studies) you get this machine, not the next level up. The DME is left with little choice. The manufacturers react to the market, not to there base greed. They are going to sell levels of products that their customers (the DME's) demand. In other words; they react to the market with which they are presented. There is a cost to program complicated algorithms and to manufacture sophisticated machines. It isn't a matter of slam a board, blower and case together and then set the capabilities. There is also the added liability of patient safety, FDA, and international regulations. Is there not more liability in a BiPAP ASV then there is for a CPAP? It's dealing with a lot more sophisticated condition and therefore a lot more responsibility in its successful treatment.

I'm not defending nor am I an advocate for the DME/ manufacturer industry. There are companies that exist that I feel make an inordinate amount of profit from the products they supply (I'll be more than happy to discuss hospital beds and alternating pressure mattresses). But let's stand back and look at the driving market forces, including government intervention, before we start advancing red herrings.

Now let's talk about insurance companies....

.
Ian McCullough
Accurate Biomed Services Inc.
http://www.acbio.com

kcodeblue
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Re: supplies question

Post by kcodeblue » Wed Mar 25, 2015 6:25 pm

Sharrykb wrote:
kcodeblue wrote:
You are correct that Medicare reimbursement rates vary by region. In the part of southern California were I am located the rate is $42/month x 13 months. The heated humidifier is a sale item and is not included in the rental. An Auto CPAP (ResMed or Respironic) cost my company over $300
kcodeblue, can you please explain to me how that scenario equals "we loose money on Auto CPAP's in the region I work in" as you say in another comment in this thread?
I explained it in detail in this thread back on March 20th at 9:31pm. Just go back to the place where you quoted me from and keep reading this time.

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Re: supplies question

Post by kcodeblue » Wed Mar 25, 2015 7:10 pm

accurate wrote:The fact of the matter (and these are the facts) is that CMS (and Medicare) is compelled to cut costs. They were mandated by the House to reduce reimbursement to company's that supply products and services to patients. In 2008 they passed laws to force DME's to bid for services supplied to Medicare patients.
2013 saw "Rd 2" of Medicare's competitive biding.

Here is a link to some testimonies to the negative affect it has had on our industry

https://www.google.com/url?sa=t&rct=j&q ... lYoEvz0UCw

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palerider
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Re: supplies question

Post by palerider » Wed Mar 25, 2015 7:42 pm

kcodeblue wrote:Just go back to the place where you quoted me from and keep reading this time.
rawr, hissss *claw*

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accurate
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Re: supplies question

Post by accurate » Wed Mar 25, 2015 8:05 pm

kcodeblue wrote:
2013 saw "Rd 2" of Medicare's competitive biding.

Here is a link to some testimonies to the negative affect it has had on our industry

https://www.google.com/url?sa=t&rct=j&q ... lYoEvz0UCw
I don't know what the relevance of this is. You are quoting a lobbyist for the DME industry. I know this because they solicit my company. The competitive bidding act was passed in 2008. There was a lot of legislative baloney before they started enacting the bid process in 2009. The reference in your post I happen to mostly agree with. The competitive bidding act made an expectation of historical levels of service from DME's difficult if not unattainable. However, I do believe that if you are a business owner and faced with challenging competitive obstacles you over come those obstacles or go away. You do not cut services to the determent of the market you serve.
Ian McCullough
Accurate Biomed Services Inc.
http://www.acbio.com

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Sharrykb
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Re: supplies question

Post by Sharrykb » Wed Mar 25, 2015 9:41 pm

kcodeblue wrote:
Sharrykb wrote:
kcodeblue wrote:
You are correct that Medicare reimbursement rates vary by region. In the part of southern California were I am located the rate is $42/month x 13 months. The heated humidifier is a sale item and is not included in the rental. An Auto CPAP (ResMed or Respironic) cost my company over $300
kcodeblue, can you please explain to me how that scenario equals "we loose money on Auto CPAP's in the region I work in" as you say in another comment in this thread?
I explained it in detail in this thread back on March 20th at 9:31pm. Just go back to the place where you quoted me from and keep reading this time.
Either this forum is playing games with me or someone has deleted your comment from March 20th at 9:31pm. I can't even find the comment I quoted. But I did read your entire post at the time and it still doesn't make any sense to me how this is "losing money". Decrease in profit, yes. But "losing money" no. They are still getting more for the Auto Cpap than what they paid for it, right?

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Re: supplies question

Post by chunkyfrog » Wed Mar 25, 2015 9:42 pm

I am looking at my Medicare Part B statement for February. The Medicare allowable monthly payment for my pretty
white and gray Airsense is $63.90; times 13 equals $830.70; $54.30 less than today's price at our fave online supplier.
Two sets of P10 pillows are $54.36; a bit more than $19 each online.
Two hypoallergenic filters are two for $10.34; as opposed to about $1.99 each online.
Just an observation, but I really love knowing all this stuff.
When I was working, my S9 Elite plus one mask, made my then DME about $1500.
Everything else was extra. That first year, I was SO clueless. That was then; this is now.
Network suppliers claim paperwork expenses, but most of the paperwork is done, regardless of who pays.
If insurance forms were so expensive, why are cash discounts not more common?

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Sharrykb
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Re: supplies question

Post by Sharrykb » Wed Mar 25, 2015 9:54 pm

Sharrykb wrote:
kcodeblue wrote:
Sharrykb wrote:
kcodeblue wrote:
You are correct that Medicare reimbursement rates vary by region. In the part of southern California were I am located the rate is $42/month x 13 months. The heated humidifier is a sale item and is not included in the rental. An Auto CPAP (ResMed or Respironic) cost my company over $300
kcodeblue, can you please explain to me how that scenario equals "we loose money on Auto CPAP's in the region I work in" as you say in another comment in this thread?
I explained it in detail in this thread back on March 20th at 9:31pm. Just go back to the place where you quoted me from and keep reading this time.
Either this forum is playing games with me or someone has deleted your comment from March 20th at 9:31pm. I can't even find the comment I quoted. But I did read your entire post at the time and it still doesn't make any sense to me how this is "losing money". Decrease in profit, yes. But "losing money" no. They are still getting more for the Auto Cpap than what they paid for it, right?
Okay, I've gone back and reread all of your posts (and I did finally find the one I quoted but on a different day and time than you said) and I think I finally get what you are saying. The DME you work for doesn't actually lose money on the sale (they are still collecting more money than the machine itself cost) but it is the LABOR involved that makes it work out to loss. Am I understanding correctly now?

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rdfry
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Re: supplies question

Post by rdfry » Wed Mar 25, 2015 11:12 pm

Sorry, but it's not up to the DME provider to decide what equipment I need. If you can't make money providing the equipment the patient wants that has been diagnosed with sleep apnea then you need to find another way to make a living. I have been using xpap for 15 years and wouldn't settle for anything less than a top of the line Apap machine.
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Re: supplies question

Post by kcodeblue » Thu Mar 26, 2015 1:25 am

Sharrykb wrote:Okay, I've gone back and reread all of your posts (and I did finally find the one I quoted but on a different day and time than you said) and I think I finally get what you are saying. The DME you work for doesn't actually lose money on the sale (they are still collecting more money than the machine itself cost) but it is the LABOR involved that makes it work out to loss. Am I understanding correctly now?
Yes, that is correct. It's like any other business, you purchase a product at a wholesale price and sell it for retail (or in this case, whatever the insurance allowable will pay). The difference between the two should cover your operating expenses specific to the delivery of that product including labor and have some free cash flow left over.Your free cash flow is your profit. Unfortunately, the $200 plus dollars that we are left with (difference between wholesale price of device and allowable from Medicare) rarely covers the labor needed to jump through all of Medicare's hoops when pre-qualifying, delivering, and then qualifying again for continued coverage beyond the first 3 months as I outlined in my previous post you just read. The result is usually a financial loss. And it's all because of hours of mandated information gathering. Multiple calls to MD offices because we don't have ALL of the documents up front required by Medicare. Or they are sending them but they're not signed or they're signed but not by an MD who's qualified to sign them. Then once it's set up, we need to make sure the patient provides us with a compliant download from the device. This can take multiple attempts. Once we have that we need to make sure the patient goes in to see their MD and has him send us a signed and dated progress note that states the patient is clinically benefiting from the CPAP. Getting these progress notes can be like pulling teeth. We often times have to send someone out to the MD's office to pick it up. If we don't receive a compliant download and MD progress notes within the first 90 days of delivery, Medicare will deny coverage of the remaining 10 months as medically unnecessary. Unfortunately, 30% of our patients do not meet Medicare's compliance criteria within the first 90 days of delivery and we are forced to offer them a cash pay price or return the CPAP. Most return the CPAP. This means that for 30% of the Medicare CPAP orders we receive, we purchase a CPAP at wholesale (between $300-400) go through that entire process I just described ($200 plus in labor) and only get 3 months rental from Medicare ($126). That comes out to about a $450-$500 loss on 30% of our Medicare CPAP requests. That also needs to be considered when assessing the profitability of Medicare CPAP's in the region where I work .