Quantcast

Bookmark and Share
General Discussion on any topic relating to CPAP and/or Sleep Apnea.
User avatar
Okie bipap
 
Posts: 1147
Joined: Thu Oct 15, 2015 4:14 pm
Location: Central Oklahoma
Gender: Male

Re: Surviving DME with Medicare

Postby Okie bipap on Wed Apr 12, 2017 11:46 am

Guest wrote:I had to pick up mine too. It wasn't until I filed a complaint that I found out and you know the face-to-face is required every 6 months now too?
Maybe call Medicare yourself and put this to rest but that is what they told me. They haven't been to my house since either. I think the idea is to make sure it is set up correctly and you have what is needed to meet compliance.


I have not been able to find the 6 month requirement in the Medicare rules, but I have seen it in the Afordable Care Act rules, and Medicare follows the ACA guidelines. I can't find the reference right now, but my doctor has gone to the 6 month rule. It's really not that much of a problem since it only takes a few minutes for them to read my SD card to verify I have been using the machine and then talk to the nurse practitioner for two or three minutes and pick up a script on the way out.

_________________
Machine: AirCurve™ 10 VAuto BiLevel Machine with HumidAir™ Heated Humidifier
Mask: AirFit™ F20 Full Face CPAP Mask with Headgear
Additional Comments: IPAP 12-22, ps 4, Sleepyhead software

User avatar
LSAT
 
Posts: 9062
Joined: Sun Nov 16, 2008 10:11 am
Location: SE Wisconsin
Gender: Male

Re: Surviving DME with Medicare

Postby LSAT on Wed Apr 12, 2017 11:53 am

Okie bipap wrote:
Guest wrote:I had to pick up mine too. It wasn't until I filed a complaint that I found out and you know the face-to-face is required every 6 months now too?
Maybe call Medicare yourself and put this to rest but that is what they told me. They haven't been to my house since either. I think the idea is to make sure it is set up correctly and you have what is needed to meet compliance.


I have not been able to find the 6 month requirement in the Medicare rules, but I have seen it in the Afordable Care Act rules, and Medicare follows the ACA guidelines. I can't find the reference right now, but my doctor has gone to the 6 month rule. It's really not that much of a problem since it only takes a few minutes for them to read my SD card to verify I have been using the machine and then talk to the nurse practitioner for two or three minutes and pick up a script on the way out.


If you are a current CPAP user, why would you need a new prescription?
https://www.cms.gov/Outreach-and-Educat ... 905064.pdf

_________________
Machine: S9 AutoSet™ CPAP Machine
Mask: Mirage Quattro™ Full Face CPAP Mask with Headgear
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control
Additional Comments: S9 Autoset...APAP Settings 11-15

Back up mask is another Quattro FF and an F20
Buckwheat Hull Pillow (CPAPfit) from http://www.pur-sleep.com/

Lucyhere
 
Posts: 1349
Joined: Sun Oct 18, 2015 2:45 pm
Gender: None specified

Re: Surviving DME with Medicare

Postby Lucyhere on Wed Apr 12, 2017 1:32 pm

Okie bipap wrote:I have not been able to find the 6 month requirement in the Medicare rules, but I have seen it in the Afordable Care Act rules, and Medicare follows the ACA guidelines. I can't find the reference right now, but my doctor has gone to the 6 month rule. It's really not that much of a problem since it only takes a few minutes for them to read my SD card to verify I have been using the machine and then talk to the nurse practitioner for two or three minutes and pick up a script on the way out.


I've seen the 6 month rule mentioned here before, several times, and I still can't figure it out. Is it possible it's different from state to state? The last face to face appointment with my sleep doctor was in October, 2015. I recently called Versus Health Care and asked for the Brevida Mask. No problems, no questions and I received the mask about a week and a half later. Doesn't make sense to me.
Resmed Vpap Auto - 7/11
Airfit P10

Guest
Also Posted As:
(Snowleopard1901)
(traveler12)
 

Re: Surviving DME with Medicare

Postby Guest on Wed Apr 12, 2017 1:47 pm

Okie bipap wrote:I have not been able to find the 6 month requirement in the Medicare rules, but...my doctor has gone to the 6 month rule
Ask your doc "why am I here?"

User avatar
Pugsy
 
Posts: 41221
Joined: Thu May 14, 2009 9:31 am
Location: Missouri, USA
Gender: Female

Re: Surviving DME with Medicare

Postby Pugsy on Wed Apr 12, 2017 2:13 pm

Lucyhere wrote:I've seen the 6 month rule mentioned here before, several times, and I still can't figure it out. Is it possible it's different from state to state? The last face to face appointment with my sleep doctor was in October, 2015. I recently called Versus Health Care and asked for the Brevida Mask. No problems, no questions and I received the mask about a week and a half later. Doesn't make sense to me.


I have seen it mentioned too...along with "Medicare requires a 1 year follow up face to face" which I haven't seen that documentation either at the official Medicare website.

I think that what is happening is some DMEs and doctors are coming up with their own "in house" rules and blaming Medicare.
They are certainly within their rights to do that but until someone can show me at the Medicare website...just because "my doc says...." or "my DME says..." doesn't make it a Medicare change in regulations.

Last time I saw my sleep doc was Aug 2009....I have Medicare...and I still get my masks every 6 months and they still try to offer something else when I pick up the mask. No one has ever said I needed anything new from from my doc to get my masks or whatever I am picking up at the time.

I am still waiting to see proof in writing at Medicare website.....or if someone doesn't have Medicare and has other insurance to see confirmation at the insurance website or written evidence of coverage.
Just because a DME or doctor says something doesn't mean it's anything other than the DME and doctor making up their own rules. Now there is a notice at my DME office about a particular Blue Cross plan that requires annual compliance proof but that's a specific Blue Cross plan and isn't necessarily a reflection of all Blue Cross plans.

_________________
Machine: AirSense™ 10 AutoSet™ For Her CPAP Machine with HumidAir™ Heated Humidifier
Mask: AirFit™ P10 For Her Nasal Pillow CPAP Mask with Headgear
Additional Comments: Backups..AirCurve 10 ST, S9 Adapt, PR S1 Bipap #760

User avatar
klm49
 
Posts: 122
Joined: Sat May 28, 2016 4:24 pm
Location: Texas
Gender: Male

Re: Surviving DME with Medicare

Postby klm49 on Wed Apr 12, 2017 6:13 pm

Pugsy wrote:I have Medicare and I can only get a new complete mask once per 6 months because the 3 month Medicare allowance for a new mask doesn't include headgear...and my DME won't just let the headgear cost slide. Some DMEs will let it slide but mine doesn't.
So sometimes I have wanted to try a different mask that cpap.com has...usually brand new to the market and the DME doesn't have it anyway. So I use my RX to try a new mask....happy to pay for it myself and not involve insurance because sometimes I just don't want to wait. :lol:


That's curious Pugsy, I have medicare and my DME will give me a complete mask and extra cushions every 3 months. The mask and head gear are billed separate but it all comes in one package. I am sure Medicare is apying there billing as I have checked.

_________________
Machine: DreamStation Auto CPAP Machine
Mask: Amara View Full Face CPAP Mask with Headgear
Humidifier: DreamStation Heated Humidifier
Additional Comments: Setting: APAP, 17 - 20 CFLEX=2, Humidifer & Heated Hose

User avatar
Pugsy
 
Posts: 41221
Joined: Thu May 14, 2009 9:31 am
Location: Missouri, USA
Gender: Female

Re: Surviving DME with Medicare

Postby Pugsy on Wed Apr 12, 2017 6:26 pm

klm49 wrote:That's curious Pugsy, I have medicare and my DME will give me a complete mask and extra cushions every 3 months. The mask and head gear are billed separate but it all comes in one package. I am sure Medicare is apying there billing as I have checked.


Medicare will pay for a mask every 3 months but they only pay for the headgear once ever 6 months.
Some DMEs will let the headgear that isn't covered at the 3 month mark to just slide and be happy with what Medicare pays minus the headgear. Some DMEs aren't happy and they won't let it slide. Mine isn't happy not getting paid for the headgear so they won't let me have a mask (and have Medicare be billed) but once every 6 months.

I always thought it was kinda stupid on Medicare's part to allow a new mask at 3 months but not the headgear but I guess maybe that is for people who already have the headgear and getting the same mask as they got before and supposedly won't need new headgear.

Mine won't give extra cushions/nasal pillows at the time of the 6 month mask purchase either...I have to wait a month and then I can get 2 each month...won't let me get 5 months of cushions/nasal pillows in one trip. I have to do the once a month thing....but it really isn't that big of a deal for me because my nasal pillows will last for months and months and months.
Right now I am working on 13 months on one nasal pillow.

Different DMEs can do different things depending on their own in house rules.
Your DME would rather sell 2 masks in 6 months and doesn't care that the headgear isn't covered on one of those mask packages. They still make more money selling the 2 masks minus one headgear than just selling one mask every 6 months.

I suspect they just adjust off the headgear portion of your bill when Medicare doesn't pay.

_________________
Machine: AirSense™ 10 AutoSet™ For Her CPAP Machine with HumidAir™ Heated Humidifier
Mask: AirFit™ P10 For Her Nasal Pillow CPAP Mask with Headgear
Additional Comments: Backups..AirCurve 10 ST, S9 Adapt, PR S1 Bipap #760

User avatar
chunkyfrog
 
Posts: 23227
Joined: Mon Jul 12, 2010 5:10 pm
Location: The middle--yet nowhere.
Gender: Female

Re: Surviving DME with Medicare

Postby chunkyfrog on Wed Apr 12, 2017 7:21 pm

My DME has absorbed the cost of a headgear.
I guess they want me happy. :mrgreen:

_________________
Machine: AirSense™ 10 AutoSet™ For Her CPAP Machine with HumidAir™ Heated Humidifier
Mask: AirFit™ P10 For Her Nasal Pillow CPAP Mask with Headgear
Additional Comments: Backup: Devillbiss Intellipap Autoadjust
I once was lost in apnea; but now I'm found--breathing easily all night long.

User avatar
LSAT
 
Posts: 9062
Joined: Sun Nov 16, 2008 10:11 am
Location: SE Wisconsin
Gender: Male

Re: Surviving DME with Medicare

Postby LSAT on Wed Apr 12, 2017 7:28 pm

I have not seen a "sleep doctor" since I was first diagnosed and got my first CPAP When I needed a prescription for a new CPAP my PCP wrote it for me....that was 3 years ago. I have been getting my supplies as I need them and no one has asked me whether I saw my sleep doctor.

_________________
Machine: S9 AutoSet™ CPAP Machine
Mask: Mirage Quattro™ Full Face CPAP Mask with Headgear
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control
Additional Comments: S9 Autoset...APAP Settings 11-15

Back up mask is another Quattro FF and an F20
Buckwheat Hull Pillow (CPAPfit) from http://www.pur-sleep.com/

User avatar
klm49
 
Posts: 122
Joined: Sat May 28, 2016 4:24 pm
Location: Texas
Gender: Male

Re: Surviving DME with Medicare

Postby klm49 on Thu Apr 13, 2017 1:44 pm

LSAT wrote:I have not seen a "sleep doctor" since I was first diagnosed and got my first CPAP When I needed a prescription for a new CPAP my PCP wrote it for me....that was 3 years ago. I have been getting my supplies as I need them and no one has asked me whether I saw my sleep doctor.


Lsat, When I called for supplies 2 months ago which was 9 mos. for me they said I needed to get my RX reissued from a sleep Dr. They agreed with me that the prescription was "forever" but it is their policy. They went ahead and gave me my 9 mos. supplies but insisted on me getting a new prescrip. so I am. I suppose I could have changed DME's but it was such a hassle getting them going I decided not to attempt it. The bad thing is my Sleep Dr. quit taking Medicare so I am having to go to s new Sleep clinic and who knows what they will want to do, probably milk all the can from Medicare. My DME said my PCP could issue a new prescrip. but he was unwilling to do that.

Pugsy was right, they arent getting paid for the headgear every time.

_________________
Machine: DreamStation Auto CPAP Machine
Mask: Amara View Full Face CPAP Mask with Headgear
Humidifier: DreamStation Heated Humidifier
Additional Comments: Setting: APAP, 17 - 20 CFLEX=2, Humidifer & Heated Hose

User avatar
LSAT
 
Posts: 9062
Joined: Sun Nov 16, 2008 10:11 am
Location: SE Wisconsin
Gender: Male

Re: Surviving DME with Medicare

Postby LSAT on Thu Apr 13, 2017 2:12 pm

klm49 wrote:
LSAT wrote:I have not seen a "sleep doctor" since I was first diagnosed and got my first CPAP When I needed a prescription for a new CPAP my PCP wrote it for me....that was 3 years ago. I have been getting my supplies as I need them and no one has asked me whether I saw my sleep doctor.


Lsat, When I called for supplies 2 months ago which was 9 mos. for me they said I needed to get my RX reissued from a sleep Dr. They agreed with me that the prescription was "forever" but it is their policy. They went ahead and gave me my 9 mos. supplies but insisted on me getting a new prescrip. so I am. I suppose I could have changed DME's but it was such a hassle getting them going I decided not to attempt it. The bad thing is my Sleep Dr. quit taking Medicare so I am having to go to s new Sleep clinic and who knows what they will want to do, probably milk all the can from Medicare. My DME said my PCP could issue a new prescrip. but he was unwilling to do that.

Pugsy was right, they arent getting paid for the headgear every time.


Why do you need a sleep clinic/sleep doctor? Any of your doctors can write a prescription.....Primary Care, specialist, Physicians Assistant, Nurse Practitioner, Dentist..etc

_________________
Machine: S9 AutoSet™ CPAP Machine
Mask: Mirage Quattro™ Full Face CPAP Mask with Headgear
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control
Additional Comments: S9 Autoset...APAP Settings 11-15

Back up mask is another Quattro FF and an F20
Buckwheat Hull Pillow (CPAPfit) from http://www.pur-sleep.com/

Guest
Also Posted As:
(Snowleopard1901)
(traveler12)
 

Re: Surviving DME with Medicare

Postby Guest on Thu Apr 13, 2017 2:25 pm

LSAT wrote:
klm49 wrote:
LSAT wrote:I have not seen a "sleep doctor" since I was first diagnosed and got my first CPAP When I needed a prescription for a new CPAP my PCP wrote it for me....that was 3 years ago. I have been getting my supplies as I need them and no one has asked me whether I saw my sleep doctor.


Lsat, When I called for supplies 2 months ago which was 9 mos. for me they said I needed to get my RX reissued from a sleep Dr. They agreed with me that the prescription was "forever" but it is their policy. They went ahead and gave me my 9 mos. supplies but insisted on me getting a new prescrip. so I am. I suppose I could have changed DME's but it was such a hassle getting them going I decided not to attempt it. The bad thing is my Sleep Dr. quit taking Medicare so I am having to go to s new Sleep clinic and who knows what they will want to do, probably milk all the can from Medicare. My DME said my PCP could issue a new prescrip. but he was unwilling to do that.

Pugsy was right, they arent getting paid for the headgear every time.


Why do you need a sleep clinic/sleep doctor? Any of your doctors can write a prescription.....Primary Care, specialist, Physicians Assistant, Nurse Practitioner, Dentist..etc

User avatar
Comfortably Numb
 
Posts: 126
Joined: Fri Mar 31, 2017 8:49 am
Gender: Male

Re: Surviving DME with Medicare

Postby Comfortably Numb on Sat Apr 15, 2017 6:15 am

I was about to post an update concerning my journey when I saw this post on another thread:
Postby alexsmom on Fri Apr 14, 2017 1:14 pm
I don't post often but have used this site for almost 5 years to gain a better understanding of my CPAP stuff and it has been extremely helpful. I purchased my first machine myself (Resmed S-9 auto) and have now received my first replacement under Medicare. I thought it was going to be a long hassle to get the machine I wanted. My DME (American Home Patient) handled everything with Medicare, my supplemental insurance and my doctor. Today I picked up a new Resmed 10 Autoset with all the fixings :-) and no co-pay. Couldn't have been easier. I'm sure it helped that AHP only carries the Resmed 10 and the Respironics high end machines.


I would have to agree that my ability under Medicare to get the exact equipment that I want "appears" at this point to be a non-issue. Both DME's I have spoken with have quickly confirmed that I will be getting the exact equipment that I want ("top of the line, our best seller, etc."). The problems I'm encountering are different than expected. The first DME I selected was affiliated with the same practice that did my sleep study (SleepMed). When they attempted to process my information through Medicare, the request was rejected because SleepMed had already performed my "at home" study and my subsequent titration study. Apparently "triple dipping" is not allowed.

The SleepMed DME called to report this problem and asked where I would like for them to send my paperwork. I selected the next DME on my list that did not start with A or L. Shortly after that, a very pleasant lady contacted me and confirmed that I would be getting the exact equipment requested. She said there is a 3 week backlog of cases and they will contact me as soon as possible. She encouraged me to check with other DMEs to see if anyone could process my request in a more timely manner, and only asked that I let her know if I find someone else. I asked her what was causing this problem and she explained that very few DME's in my area are currently handling Medicare patients. My doctor indicated the same thing when he told me that there has been a tremendous reduction in Medicare contract DMEs in the recent past.

Based upon alexsmom's favorable Medicare experience with American Home Patient, I'm going to give them a call and see how far they are backed up and if they are willing to give me the exact equipment I want.

Guest
Also Posted As:
(MrGrumpy)
 

Re: Surviving DME with Medicare

Postby Guest on Sat Apr 15, 2017 7:04 am

Comfortably Numb wrote:Based upon alexsmom's favorable Medicare experience with American Home Patient, I'm going to give them a call and see how far they are backed up and if they are willing to give me the exact equipment I want.
By all means give them all a go - just keep both eyes and ears wide open and keep notes of who you talked to and what they said. So when you get to the point you think you are going crazy you can find out what has happened.

Hopefully, your AHP won't make promises they won't keep like mine did. I do find the one who told you there was a 3 weeks delay refreshing, I can deal with honesty and would keep them in mind for future business.

The other option would be to check Craiglist (under Health & Beauty) in your area for what you want then won't be stressed by delays and you will also have a backup when the DME of your choice comes thru. AND you will have yourself a backup. Keep in mind the cpap purchased by insurance or Medicare is the cpap you should use until compliance is over.

User avatar
bwexler
 
Posts: 1192
Joined: Mon Nov 08, 2010 11:52 pm
Location: San Marcos, Ca. USA
Gender: Male

Re: Surviving DME with Medicare

Postby bwexler on Sat Apr 15, 2017 3:55 pm

I have found the squeaky wheel gets the grease.
I have seldom been known to call more than 3 or 4 times a day.
Just this past week I got an approval just 2 hours after they told me it would take a year.
If I chose to deal with the provider who quoted 3 weeks lead time, they would hear from me several times a day until they realized it takes more time to tell me not yet, then to say come in this afternoon.

_________________
Mask: SleepWeaver 3D Soft Cloth Nasal CPAP Mask with Headgear
Humidifier: PR System One 60 Series Heated Tube Humidifier with Heated Tube
Additional Comments: Also using Sleaplyhead 0.9.53, Pro 2.12 and CMS50i PR 960 ASV

PreviousNext

Return to CPAP and Sleep Apnea (CLICK HERE TO READ POSTS)

Who is online

Users browsing this forum: No registered users and 31 guests