supplies question

[winnie]

Looks like this is another thing my DME lied to me about. They told me my insurance would only pay for the bottom of the line machine unless there was some reason I needed a better one. I got the approval letter from Manulife (my extended health plan here in Canada) and it said they approved cpap/APAP, as if there was no difference.

The Canadian system is a little different than what we have in the US and from what I hear can vary among the provinces as to what is or is not covered.
99.9% of the insurance companies out there don't pay by model or features or brand name...they pay by that billing code and in the US E0601 covers both cpap and apap capable machines.
Not sure what the Canadian system uses but here in the US I always tell people to go directly to the insurance company to find out how they pay for this stuff...never rely on what the DME says as to what the insurance company pays for or how they even do the paying. Not all plans are the same and it would be impossible for a DME to have ALL plan specs in front of them.

Big surprise though ...DMEs in Canada aren't known for their honesty or even if we give them the benefit of the doubt...what every plan in Canada might do.

I'm at the point now where I don't believe anything they say.

[kcodeblue]

So you work for a DME...

Yes. I am a Registered Respiratory Therapist of 18 years and have been in home care for 14 of them.

It's sure odd that other DMEs can supply APAPs as standard protocol to Medicare patients routinely so if done routinely I would think they are making money.
Medicare reimbursement rates vary by region so it's a bit difficult to figure out exactly what the rates are but from a ball park average of the cap rental allowable schedule rates I have seen...roughly $100 a month for 13 months and that's just for the blower.

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

If profit cannot be made....I am scratching my head as to why not unless there is a lot of extra overhead or whatever.

The reason why anything other than a standard CPAP under E0601 is not profitable is because of all of the labor involved to make sure Medicare guidelines are being followed. We have a Medicare Intake Team that does nothing but review and approve Medicare requests prior to processing the order. This is because Medicare is very strict about acquiring specific documentation prior to dispensing equipment. Some examples are face to face progress notes from the ordering MD documenting specific symptoms, a qualifying sleep study, and a written order from a PECOS verified MD that must meet no less than 7 specific criteria. Once the order is approved and processed, unlike other DME companies, we only use RT's to set up CPAP/BiPAP. We dedicate an 1 hr per setup. Not only does the RT instruct on the use of the device and accessories, he/she also reviews both the diagnostic and titration portion of the patient's PSG with the patient. I let my RT's be RT's. Once the device goes home, Medicare only guarantees payment for the first 3 months of the 13 month rental period. The patient must provide us with a download from the device that meets Medicare's adherence criteria and they must have another face to face visit with their MD and provide us with a progress note from that visit stating the CPAP is clinically benefiting the patient. If we don't receive both within the first 3 month "grace period", Medicare will deny continued coverage of the remaining 10 months as "not medically necessary". We have another team that is dedicated to retrieving these downloads and MD progress notes. Only 70% of our Medicare patients who have received a CPAP or a BiPAP are billable. And last, Medicare is now auditing over 50% of our CPAP setups to see if they can find one "i" not dotted or one "t" not crossed somewhere in the entire process. If they do, we pay all of the money back! Usually, it's because the MD didn't include his NPI number on the order or something petty like that.

As a clinician, I have no problem giving Auto CPAP, I understand the benefits and I want patients to get the most out of their PAP therapy. I also know that a standard CPAP can be 100% effective in treating OSA and many patients do wonderful on them. Because Auto CPAP's truly are a losing endeavor where I am at, I need to be responsible a make sure there is some clinical justification for taking that loss. Do we know a standard CPAP won't work in this case? If the doc says Auto CPAP and states why, I have no problem with that. If a patient says I want an Auto CPAP because my friend has one or because I saw one on the internet, to me that does not justify the financial loss. I want to treat the patient's clinical needs, not his need to have the latest and greatest. The insurances simply don't give us the liberty.

[kcodeblue]

what, do you work for crapria?

Absolutely not! Never have, never will. I despise Apria and everything they stand for. They seem to have forgotten that there is a human being at the other end of all of there policies and process. Not to mention, about 2 years ago, they decided that firing all of their Respiratory Managers was a good way to save money. Some of whom had been there for over 20 years. Oh, and they did this right before Christmas. They truly are evil.

[palerider]

what, do you work for crapria?

Absolutely not! Never have, never will. ... They truly are evil.

good to see something we can agree on

[Sonnyboy]

Re:

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.

I have a question.
Are you in a competitive bidding region?
If so, why would a business place a bid that would not in the end be profitable?

What am I not understanding?

Thank you

[kcodeblue]

I have a question.
Are you in a competitive bidding region?
If so, why would a business place a bid that would not in the end be profitable?

What am I not understanding?

Thank you

Yes, I am actually in the original "experimental" competitive bid region. We have recently went through round 2.
It can be profitable with anything other than an Auto CPAP. I believe companies are afraid of losing the relationships they have developed with their referrals so they bid low to try and keep the business. The referrals that send them CPAP also send them orders for Oxygen, beds and all other DME. I am in a very competitive area so low bidding and low reimbursement is the result. It's exactly what the government wanted from this, less spending. The problem is it makes it very difficult to meet the demands of the patient which is often viewed as being difficult or giving poor service.

[Pugsy]

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

I know Medicare sucks...I used to do the Medicare filing for a walk in clinic that was a non participating provider.
They finally got to the point that all lab was sent outside because reimbursement didn't cover costs.

I wasn't aware that in your region the reimbursement was so low. Sounds like a competitive bid thing.
I also am quite aware of the rules and regulations and the overhead...so I feel your pain but I also see things from the patient's standpoint and the fact of the matter is...suppliers can supply an apap with cpap RX legally anyway....and too many times patients are lied to and that just irritates me to no end. I would rather a supplier be up front and say they lose money and that's why they won't do it. I would appreciate honesty and understand.
My DME wouldn't supply me a mask that I wanted no matter how much I tried to get them to because it wasn't something they could buy in bulk and get a discount and get reimbursed by Medicare (I have Medicare now) to have them make much profit. He was honest and I knew what the masks cost to buy just one and I know the reimbursement rates and he wouldn't have netted much profit...so I really didn't blame him or push the matter.

I do think that if a patient wants an apap for whatever reason....then they should get an apap and if a DME is unwilling to dispense that machine because of the lack of profit margin then the patient needs to be told the truth and the patient given the choice as to what they wish to do...get a full data CPAP or go elsewhere to get their machine from a supplier that will give them what they want. Be honest and up front with people and they will understand....but when patients are flat out lied to...that is something that will make or break a business deal with me. I fired my first DME because I was lied to....and kept my current DME because they were honest with me.

Does everyone who thinks that they want an apap really need an apap...of course not but the mind is a powerful drug and when patients start "what iffing I would feel better with apap" it can potentially impact the perception of the effectiveness of their therapy.
And of course there are people like me who actually found that apap mode was better suited for their needs.
In REM sleep my pressure needs are substantially higher than it is in non REM...
Let's see...I can use APAP with minimum of 9 and maximum of 20 and maybe see 18 cm during REM sleep or I could use CPAP mode with fixed pressure of 18 cm to cover my REM based pressure needs but I would have to use 18 cm all night. Not something that is high on my want list.

Oh...dispensing non data machines...I just imagine you already know what my feelings about that will be so I won't get on that soap box.

BTW, welcome to the forum.

I am sorry that where you live that you can't make money on apaps...I really am because I know that places need to make money to stay in business but if that loss can't be recouped elsewhere...then either tell the patient the truth and offer them a choice as to how they want to proceed if you are unwilling/unable to supply what they want.

Edit...I see that you mention you are in a competitive bidding area...that's tough I know. Not one of Medicare's finest moments but it's all about saving Medicare dollars and the government never has been known to have any common sense.

[Sonnyboy]

Hi,

I live in California in a competitive bidding region.

My doctor specifically ordered a data capable machine, the s9 or the Airsense 10 for Her, my choice.
My doctor chose the machine, I'm new, so I did not know one machine from another.
I got lucky, I discovered this forum on my own, did some reading, and decided on the Airsense 10.
I went to the DME referred to me by my doctor and when the DME would not provide me with the Airsense 10, I moved on to the next DME on the list, and then the next one. My doctor did not care which DME I used.

In my opinion the client really is the patient and not the doctor, hospital, home care agency, or insurance company that may have made the referral. [Even the HMO insurance company can be changed by the patient, though unfortunately only once a year.] Medicare is paying and it is not the job of the DME or the RT to choose the machine. Just my opinion.

[Wulfman...]

As a clinician, I have no problem giving Auto CPAP, I understand the benefits and I want patients to get the most out of their PAP therapy. I also know that a standard CPAP can be 100% effective in treating OSA and many patients do wonderful on them. Because Auto CPAP's truly are a losing endeavor where I am at, I need to be responsible a make sure there is some clinical justification for taking that loss. Do we know a standard CPAP won't work in this case? If the doc says Auto CPAP and states why, I have no problem with that. If a patient says I want an Auto CPAP because my friend has one or because I saw one on the internet, to me that does not justify the financial loss. I want to treat the patient's clinical needs, not his need to have the latest and greatest. The insurances simply don't give us the liberty.

One way or the other (insurance provider, insurance premiums, co-pays, out-of-pocket or whatever) the user is paying for that machine. If they want an APAP, then they should GET an APAP........PERIOD! They're paying for it and they should get what they want. Just because you get an APAP doesn't mean it has to be run in a range of pressures. It would be like a person going to an automobile dealership and paying for a Buick and having to drive off in a Yugo. And, in my opinion, the manufacturers should only make ONE CPAP machine.......a fully data-capable APAP......it's a multi-mode machine and can be set to straight pressure. The manufacturers could cut their overhead and offer the APAPs for much less if they would cut out the data-less ("brick") machines. And, yes, we've known for years that the E0601 code applies to ALL CPAP machines.

In my area, there's at least one DME which ONLY dispenses APAPs for a CPAP prescription.
I'm not sure how they are otherwise as I've never used them, but found out quite a bit visiting with them a couple of years ago (killing some time while my wife had a doctor's appointment). They seemed to be very well stocked with a wide variety of masks and other supplies. And, they told me they will keep working with the user until they get the right mask that works for them.


Den

.

[kcodeblue]

I do think that if a patient wants an apap for whatever reason....then they should get an apap and if a DME is unwilling to dispense that machine because of the lack of profit margin then the patient needs to be told the truth and the patient given the choice as to what they wish to do...get a full data CPAP or go elsewhere to get their machine from a supplier that will give them what they want. Be honest and up front with people and they will understand....but when patients are flat out lied to...that is something that will make or break a business deal with me.

With all due respect, I have to say that being open and honest, which I always am with my patients, does not usually result in them being understanding when it comes to this subject. You are one of the exceptions. I was completely honest about the financial challenges my company faces when providing Auto CPAP's on my original post here and this was one of the responses I received:

Cry me a river! A Lot of DME's screw you over and line their pockets because they are the DEVIL

Not very understanding.

Usually when I tell a patient that we cannot provide an Auto CPAP because it is going to result in a financial loss for our company, they tell me I'm legally obligated to provide it and I will be putting their life in jeopardy if I don't. Then they go lean on their doctor to put pressure on us to provide it.

The only way to do good business is to be completely honest about everything involved. I won't do it any other way. People have the right to make informed decisions. The problem is nobody want's to hear that they can't have something that they believe they are entitled to.

[chunkyfrog]

. . . when it comes to Auto CPAP's, it's not always a case of "wont" do it, it could very well be '"afraid to go out of business" if we continue to do this.

Funny, my DME ONLY dispenses the Autoset for the same reason--repeat business!
My sleep doc only prescribes the Autoset for the benefit of his patients.
I'm fully aware that many companies have gone belly-up due to their business myopia.
---(only the current month is relevant).
Of course, unless you are the boss, you have no control, and are only told what THEY WANT YOU TO BELIEVE.

[kcodeblue]

BTW, welcome to the forum.

Thank you! I can tell the you have earned the trust and respect of those here on the forum. From what I have seen in the short time I've been here, I'd say it's very well deserved! Not that you need me to tell you. Thanks again!

[princessbelle]

Do we know a standard CPAP won't work in this case? If the doc says Auto CPAP and states why, I have no problem with that. If a patient says I want an Auto CPAP because my friend has one or because I saw one on the internet, to me that does not justify the financial loss. I want to treat the patient's clinical needs, not his need to have the latest and greatest. The insurances simply don't give us the liberty.[/quote]

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.

[kcodeblue]

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.

[Sonnyboy]

I do not believe one test, one study, one treatment shows "clinical proof".
I believe the term "clinically proven" is an advertising gimmick.