Here we go again or the saga continues

[lilly747]

Well my doctor put in for a replacement bilevel, I have Medicare. He said it would be no problem. Well it is a big problem. It seems the DME did not charge Medicare for my S9 AVPAP BiLevel back in 2012. It seems they were in some kind of trouble with Medicare at the time I got my machine. So now I have to redo the sleep study and fail the CPAP machine before I can get a BiLevel. Back in 2012 I was a newbee and ended up with a BRICK. At the end of my 90 days the DME still did not want to verify my 4+ hr per night usage even though I was doing 6+ hours a night of usage, now I know tge real reason.. Story short, after some heavy arm twisting, I ended uo with the S9 VAUTO BiLevel....and they did not even charge Medicare. But now I have to start all over...ugh.

[Okie bipap]

If they do another sleep study, you will not need to "fail" CPAP prior to getting a BIPAP machine. I have never had a CPAP. My doctor simply put "Patient did not tolerate CPAP" on my prescription and was issued a BIPAP machine. If your doctor can say you have been using a machine and it is treating your condition, Medicare may not require a new prescription. Since your DME never billed Medicare for your machine, Medicare probably doesn't know what you have. It likes you paid for your current machine your self.

[Pugsy]

Who says the sleep study has to be repeated?

[lilly747]

If they do another sleep study, you will not need to "fail" CPAP prior to getting a BIPAP machine. I have never had a CPAP. My doctor simply put "Patient did not tolerate CPAP" on my prescription and was issued a BIPAP machine. If your doctor can say you have been using a machine and it is treating your condition, Medicare may not require a new prescription. Since your DME never billed Medicare for your machine, Medicare probably doesn't know what you have. It likes you paid for your current machine your self.

Okie I am about to pull my hair out already. My doctor's nurces don't seem to know what to do, and they said they would see what could be done and "check into it." Still waiting, and I can't seem to get through to my doctor. I called for an appointment and they gave me a Jan 15th appointment.

Who says the sleep study has to be repeated?

I called the DME where I got my Machine (Pacific Pulmonary Services) and they said my doctor had faxed over an order for a replacement machine, but because there is no record of Medicare paying for the one I have, I would have to have another sleepstudy. Get this tho, I am receiving supplies from another DME (LIncare) for my machine and Medicare is paying for them.

So then I called the Sleep Center where I had my last study done in 2012 and they said I had to have another study and would have to fail the CPAP to get a BiLevel.

So now what.......

[Pugsy]

So now what.......

How about contacting Medicare directly and cutting these yahoos out of the discussion?
You shouldn't need a new sleep study. Medicare will tell you if you do or not...I am betting the yahoos at both places don't know their butt from a hole in the ground and you got the pat answer they give so they get to bill Medicare for another sleep study.
If Medicare has been paying for supplies...they already have what they need in terms of diagnosis and this "you gotta fail cpap crap"...is just that...crap.
All it takes is for a doctor to say "patient couldn't tolerate cpap"...that's all it takes to get a bilevel....now if you were needing the fancy ASV bilevel then more stuff is needed but not for a regular bipap.

[Lucyhere]

All it takes is for a doctor to say "patient couldn't tolerate cpap"...that's all it takes to get a bilevel....

Exactly. That's how I got mine.

[Okie bipap]

If you are getting your supplies from Linn Care, why not have the doctor send your new prescription for the machine to them? They will make a claim with Medicare and will know within a day or two if it is approved or not. As long as you can show you have been using your machine and it is treating your apnea, that should be all you need. Go here and see which DME supplies have current Medicare contracts: https://www.medicare.gov/supplierdirectory/search.html If you are in an area that has competitive bidding, you will see a list of approved suppliers. If you are in an area that is not have the competitive bidding, you can go to any DME that will accept Medicare.

[Madalot]

So now what.......

How about contacting Medicare directly and cutting these yahoos out of the discussion?
You shouldn't need a new sleep study. Medicare will tell you if you do or not...I am betting the yahoos at both places don't know their butt from a hole in the ground and you got the pat answer they give so they get to bill Medicare for another sleep study.
If Medicare has been paying for supplies...they already have what they need in terms of diagnosis and this "you gotta fail cpap crap"...is just that...crap.
All it takes is for a doctor to say "patient couldn't tolerate cpap"...that's all it takes to get a bilevel....now if you were needing the fancy ASV bilevel then more stuff is needed but not for a regular bipap.

I agree with this. Contact Medicare. And if they say you need another sleep study, fight it. I mean, this is not your fault! You shouldn't have to go through all that because the DME screwed up.

[Janknitz]

If you are getting your supplies from Linn Care, why not have the doctor send your new prescription for the machine to them? They will make a claim with Medicare and will know within a day or two if it is approved or not

Perhaps a DME member will chime in here but I’m pretty sure this is NOT how it all works. Claims probably take weeks or months to send their way through the system and even if they slide in through the usual process to get paid later a claim maybe flagged in an audit—requiring the provider to repay Medicare. And too many flags in an audit can cause fines or loss of provider status. That’s why DMEs are cautious about these situations. They assume all the risk.

[Pugsy]

Claims probably take weeks or months to send their way through the system and even if they slide in through the usual process to get paid later a claim maybe flagged in an audit—requiring the provider to repay Medicare. And too many flags in an audit can cause fines or loss of provider status. That’s why DMEs are cautious about these situations. They assume all the risk.

I think what they were referring to was the claim for the machine itself.
I got Medicare approval for the machine probably within 2 hours of the time the DME got the paper work and sent the stuff to Medicare.
It does take more than the RX from the doctor initially though.
Medicare can work fast if they really want to.

Now when Medicare has already received the needed documentation and has been paying for supplies for 5 years and that documentation is already on file then the OP being told by the DME that "Medicare requires..." is a load of BS. Medicare already has what they need or they wouldn't have been paying for stuff for 5 years. Either that or the DME has been sending out stuff for free all these years and I seriously doubt they did that.

As usual...DME's don't always tell the truth and like to blame Medicare or insurance for their screw ups and people buy it because they get away with it all the time.

[lilly747]

I want to thank each and every one of you for responding and giving me this much needed support. I really don't what i would do without this community. This community was a life saver 5 yrs ago and now again. There are good things in the world, and this community is at the top....thanks.

Pacific Pulmonary Services called my doctor and told him that Medicare required another sleep study because it had been too long since my last one and the doctor bought it

So I had to fight with the nurse to get her to send my machine order to Lincare. She kept saying PPS called Medicare and they said I needed a sleep study. I kept saying, no I don't please send order to Lincare. Finally sha said if Lincare is going to try to get you a machine, ok fine I will fax order. I talked to Lincare, the DME who give me my supplies and bills Medicare, and they are going to help me with this mess. So we will see what happens. I have to take my sleep study to them and may be my org Rx which (thanks to Pugsy) I have. Will keep you posted. I hope I don;t need a new study.

[Okie bipap]

I just found a document on line titled "Positive Airway Pressure (PAP) Devices: Complying With Documentation & Coverage Requirements" and page 6 addresses getting a new machine if you got your old pmahine prior to enrolling in Medicare. Since there is no record of Medicare ever buying your old machine, this should apply to you. In part, the document reads:

For patients who received a PAP device prior to enrollment in FFS Medicare and are seeking Medicare coverage of either rental of the device, a replacement PAP device, and/or accessories, both of the following coverage requirements must be met: 1. The patient had a documented sleep test prior to FFS Medicare enrollment that meets the Medicare AHI/RDI coverage criteria in effect at the time that the patient seeks Medicare coverage of a replacement PAP device and/or accessories; and 2. The patient had a face-to-face clinical evaluation following FFS Medicare enrollment by the treating physician who documented in the patient’s medical record that: a. The patient has a diagnosis of OSA, and b. The patient continues to use the PAP device. If either criteria 1 or 2 above are not met, the claim will be denied as not medically necessary. In these situations, there is no requirement for a clinical reevaluation or for objective documentation of adherence to use of the device.

Your doctor can attest to the fact you have been using your old machine and it was effective in treating your apnea.

[lilly747]

I just found a document on line titled "Positive Airway Pressure (PAP) Devices: Complying With Documentation & Coverage Requirements" and page 6 addresses getting a new machine if you got your old pmahine prior to enrolling in Medicare. Since there is no record of Medicare ever buying your old machine, this should apply to you. In part, the document reads:

Okie thanknyou for this. I printed it out and am giving a copy to NURSE S who has done everything she can to stop my paper work from being sent to Lincare. However this has now been taken care of, I think....

I kinda lost it and had a show down at DR office/clinic friday. Here's what happened: On Thur Nurse S told me I needed a sleep study. I told her no I did not and to please fax info to Lincare, she said ok she would. Then later that day NURSE J called me and said NURSE S had been gone the last 2 weeks and did not really know what was going on but she (NURSE J) would fax the info to Lincare. Then Friday Lincare says they did not get anything from the doctor. So I ask Lincare to call doctor which she did. Lincare called me back and said NURSE S told her she could not fax an order to her because "I had to do "something" first, and I know what that "something" is but she (NURSE J) could not tell Lincare what that "something" is because HIPAA.

Well I saw red at that point and called the doctor's office. NURSE S told me that PPC and Lincare both had my order for a New CPAP and THEY said Medicare said I needed a sleep study. I knew this was BS because i just talked to Lincare who said I should be able to get a machine without a new sleep study and that they HAD NOT gotten any ORDER FROM MY DR FOR A REPLACEMENT CPAP.

So I told NURSE S I was on my way to their office to find out why every time I have communications with them it is a different story. And I told her that Lincare DID NOT say I needed a sleep study.

When I got there I had Lincare on the phone, and I told the front office I wanted to speak to the NURSE S's supervisor and NURSE J and NURSE S. Well we all had a meeting, all 5 of us. The short of it was, after Lincare and the NURSE Supervisor was finished talking, I was told by the NURSE Supervisor that every thing Lincare wanted would be FAXED to them and yes I should not need a new sleep study.

Incompetence does not even come close to describing this mess. I told them if Lincare did not have my paper work MONDAY I would be back and would hand carry it to Lincare myself.

Thanks to all for giving me the support to fight this and confront NURSE S.

[chunkyfrog]

Good fight!
Congratulations.

[Okie bipap]

Your Nurse S sounds like some of the people I have worked with in the past. "Don't confuse me with the facts, my mind is already made up."