Medicare changes--can't get mask--Youre next

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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LSAT
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Re: Medicare changes--can't get mask--Youre next

Post by LSAT » Tue Feb 18, 2014 8:05 pm

I have had a medicare advantage plan for several years. The competitive bidding does not apply to these plans. I can go to any DME that is in network for my plan. I have my choice of 6 or 7 in my city. I currently use a small mom & pop facility that will give me anything I want. I pay 20% of the Medicare allowable amount.

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star444
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Re: Medicare changes--can't get mask--Youre next

Post by star444 » Tue Feb 18, 2014 10:46 pm

Sir NoddinOff wrote: I'm starting to get the feeling that some DMEs will use the ruse of "Medicare sez" or "Your insurance company sez" as a tool to steer their hapless clients into whatever product line, whether PR or ResMed, that tends to yield the most profit. With Obamacare thrown into the mix, the system is in a crazy flux pattern anyway... that opens the door to profit grabbing, just like when there's a natural disaster and local stores ream out the victims for weeks afterwards. Maybe I'm too cynical???.
I don't think it is cynical, I think it is a spot on observation! I agree, as well, that the added veil of confusion created by the Obamacare roll-out leaves the door wide open for the "snake oil salesmen". Furthermore, I fear this may be but the tip of the iceberg.

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Re: Medicare changes--can't get mask--Youre next

Post by Janknitz » Wed Feb 19, 2014 12:32 am

Medicare competitive bidding dates back to the Bush years, it was not implemented until recently, but it's not Obama's idea. ACA has nothing to do with competitive bidding.
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Denial Dave
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Re: Medicare changes--can't get mask--Youre next

Post by Denial Dave » Wed Feb 19, 2014 6:01 am

DME's are like used car salesmen.... they are going to try to sell you whatever makes the most profit for them.

It is our job as the customer to know what our medical plans cover and insist on making the DME's comply.


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star444
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Re: Medicare changes--can't get mask--Youre next

Post by star444 » Wed Feb 19, 2014 1:19 pm

Denial Dave wrote:DME's are like used car salesmen.... they are going to try to sell you whatever makes the most profit for them.

It is our job as the customer to know what our medical plans cover and insist on making the DME's comply.
EXACTLY!

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Wulfman...

Re: Medicare changes--can't get mask--Youre next

Post by Wulfman... » Wed Feb 19, 2014 2:48 pm

Denial Dave wrote:DME's are like used car salesmen.... they are going to try to sell you whatever makes the most profit for them.

It is our job as the customer to know what our medical plans cover and insist on making the DME's comply.
I think in some ways they're worse. But, the problem is that the buyers of the flow generators don't do their homework.
In the case of the car salesman, the buyers generally know the difference between a Yugo and a BMW.
With many of the disreputable DMEs, they'll try to claim that THEIR "Yugo" is a full-featured top-of-the-line "BMW".


Den

.

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Allyson
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Re: Medicare changes--can't get mask--Youre next

Post by Allyson » Thu Dec 18, 2014 9:01 am

RE sleeplessinaz: Which mask are you looking for? Many of us have storage boxes loaded with masks and mask parts so you may find one on here! Let us know! Carrie:

I just read your posts about how difficult it is to get certain masks. My Medicare provider in Massachusetts can't/won't do business with the company that has the Aloha nasal cushion mask, I have also tried other providers in my area and came up with the same negativity. I was given it as a sample an year ago, and with the added complication of severe screeching 24/7 tinnitus it is the only mask I have ever used that I am able to actually sleep through the night with. Is there anyone who has one that they don't use?

I appreciate so very much that this forum exists, thanks. -- Allyson

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SleepyEyes21
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Re: Medicare changes--can't get mask--Youre next

Post by SleepyEyes21 » Thu Dec 18, 2014 12:21 pm

Catnapper wrote:I have experienced this in KY where I live. How can they fit a mask long distance?

Another change that really irritates me is the generic for my blood pressure medicine which cost $3 last year has become a Tire 4 drug and now costs $80 for a month's supply. Not only that, but it requires a medical exception. I said that if I have to pay the same for the generic as the name brand I should get the name brand. They replied that the insurance would not go for that because then they would have to pay a higher amount for their part.

Nice.

Catnapper-Joanie
Hi Joanie - as for your meds, check out the prices at your local Walmart. My store will let me choose between the store's price and going through insurance. Some vast differences - its' generally much cheaper to go with Walmart generics.

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Re: Medicare changes--can't get mask--Youre next

Post by chunkyfrog » Thu Dec 18, 2014 1:27 pm

The fact that nobody will tell me how much it will cost until they actually fill the prescription . . .
FROSTS MY LILY PAD!

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Re: Medicare changes--can't get mask--Youre next

Post by Krelvin » Thu Dec 18, 2014 2:06 pm

chunkyfrog wrote:The fact that nobody will tell me how much it will cost until they actually fill the prescription . . .
FROSTS MY LILY PAD!
Don't know of any pharmacy that won't give you a quote after they get your medical insurance info. they need that to know what rates they are bound to for the quote.
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mike1953
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Re: Medicare changes--can't get mask--Youre next

Post by mike1953 » Thu Dec 18, 2014 2:18 pm

wardmiller wrote:
andorra3 wrote: Medicare has allowed the suppliers to severely restrict the type of masks they will supply.
Can you cite a reference in a Medicare publication or their web site? I'm in NY and have not encountered that restriction. A lot of unwarranted blame is placed on Medicare's doorstep, often generated by DME's. I'd lean on the DME and ask management to cite the Medicate source of that action.

Getting a DME you trust and can work with can be worth the effort to change, in my experience.
http://www.medicare.gov/supplierdirectory/search.html

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Re: Medicare changes--can't get mask--Youre next

Post by mike1953 » Thu Dec 18, 2014 2:32 pm

KarenK wrote:I am in western New York and I have a Medicare Advantage plan, so I don't have to go to someone on *the list.* I use a Pilairo nasal cushion mask. My main place told me a few months ago that they would no longer carry the "old" Pilairo, so I bought a new one at a DME nearer my home. I went back to the original place yesterday to get a new hose and they had both the Pilairo and new Pilairo. BUT he said they are not supplying as many F&P masks as they used to.
The Competitive Bidding Program applies to Original Medicare only. If you’re enrolled in a Medicare Advantage Plan (like an HMO or PPO), your plan will let you know if your supplier is changing. If you’re not sure, contact your plan.

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Re: Medicare changes--can't get mask--Youre next

Post by jwerley » Thu Dec 18, 2014 4:09 pm

Allyson:

I have a new Aloha Mask and a used one with various nasal pillows . You are welcome to them.....(no cost). Please PM me with your info.

Janice

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Re: Medicare changes--can't get mask--Youre next

Post by PAPgirl2017 » Fri Apr 14, 2017 12:28 pm

The biggest piece of the puzzle here is crappy insurance reimbursement.

I hear so much complaining about DME companies. But really, do you think they want to constantly have the negativity of unhappy customers and telling people NO? OF COURSE NOT!!!!

They WANT to say yes. But when it comes to CPAP stuff, saying yes to Resmed can mean bankruptcy.

Unfortunately, as with all branches of medical equipment, not just CPAPs/BPAPs/supplies, the insurance companies have made the rules so difficult to comply with, and reimbursement so low, DME's simply can't afford to help everyone get everything they want. Consumers are already suffering the consequences of this, and if you'll notice, very few local providers still exist. Most are being forced to go through a national mail-order chain or big companies like Apria or Lincare. Tons of local, smaller, family owned, and mom & pop shops have had to close because they simply can't stay afloat in an industry with such low reimbursement rates. For those of you mentioning that the suppliers need to complain to Medicare? Lots of complaining has already happened. Lots of lobbying has been done and letters sent. But the point of the competitive bid has been to find the companies that can provide services at the lowest rate possible and save the insurance companies and Medicare money. And so Medicare's response--if you don't want to accept our competitive bid pricing, then step aside. And so, the industry will continue to be dominated by the Aprias. And your smaller local offices will continue to refuse to supply you with Resmed. And for the record, this is legal. When a supplier on Medicare's competitive bid accepts a contract, they write to Medicare with what they will supply. And most leave the big, expensive brands off the list. They tell Medicare, "We will accept this contract at these rates, but the only brands we will supply are 3B and Roscoe and whatever else they can afford"

Now what do I mean by crappy reimbursement? You work and pay into insurance or you worked 45 years and paid into Medicare, and dangit, you deserve that Resmed mask! It should be covered in full and all companies should have to provide you with whatever you want!
WRONG.

Lets talk hypothetically here for a minute:

If you were running a CPAP supply business, could you stay afloat if everytime you filled a mask supply order, you had to give the recipient a mask and $20 to go with it? No WAY! This is the problem with Resmed. They do have nice masks. Their masks are like Mercedes. Fisher & Paykels and Phillips Respironics are also nice, more like Acuras. And everything else is like a Kia. Medicare wants to pay for a Kia--an economy mask, not a luxuriant Resmed. And Blue Cross--they want to pay even less. Blue Cross utterly sucks.

Now, take for example a Resmed Quattro Full Face Mask. Maybe a big supplier like Apria or Verus orders such high volume they can get the Quattros (which realistically only cost Resmed $5 to manufacture) at a cost of $50-70. For a smaller DME, that same mask can cost $99+. Medicare reimbursement is only $84. Now why would they want to LOSE money just to give you what you want? And so this is why your DME doesn't want to give you that cushy Resmed mask you've gotten so used to. You're insurance doesn't cover the cost. You can throw a fit and refuse to go to the national chain, but the national chain is the only company who can afford that nice of a mask. Your local company can afford to give you a $55-65 mask from Roscoe or 3B or maybe even a $70-80 mask from PR or F&P, but the Resmed is simply too expensive. And Resmed isn't coming down on their prices anytime soon, because of the consumers! The consumers LOVE Resmed. They like to work out deals with sleep labs to get you hooked on their products too.

And for the record, people are under the misconception that the machines are what makes money. But this is soooo wrong. The machines are mostly rentals. In order to make like $100 on a new unit, give or take, the supplier is waiting for a year of rental to go by and they are having to ensure the user stays compliant. If not, they end up NOT making money and then having a USED machine that most other people would not be happy about getting so it ends up being a loaner-type device that sits on a shelf until an occasional out of towner needs to rent a loaner or until someone brings in a broken unit.

And it will only get worse. as Medicare considers flat-rate monthly fees to cover the cpap rental and all supplies. This will be yet another cost-cutting practice for them, and you'll have to kiss all of your excess supplies good-bye.

Hopefully you have a stockpile.

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Re: Medicare changes--can't get mask--Youre next

Post by nanwilson » Fri Apr 14, 2017 1:28 pm

PAPgirl2017 wrote:The biggest piece of the puzzle here is crappy insurance reimbursement.

I hear so much complaining about DME companies. But really, do you think they want to constantly have the negativity of unhappy customers and telling people NO? OF COURSE NOT!!!!

They WANT to say yes. But when it comes to CPAP stuff, saying yes to Resmed can mean bankruptcy.

Unfortunately, as with all branches of medical equipment, not just CPAPs/BPAPs/supplies, the insurance companies have made the rules so difficult to comply with, and reimbursement so low, DME's simply can't afford to help everyone get everything they want. Consumers are already suffering the consequences of this, and if you'll notice, very few local providers still exist. Most are being forced to go through a national mail-order chain or big companies like Apria or Lincare. Tons of local, smaller, family owned, and mom & pop shops have had to close because they simply can't stay afloat in an industry with such low reimbursement rates. For those of you mentioning that the suppliers need to complain to Medicare? Lots of complaining has already happened. Lots of lobbying has been done and letters sent. But the point of the competitive bid has been to find the companies that can provide services at the lowest rate possible and save the insurance companies and Medicare money. And so Medicare's response--if you don't want to accept our competitive bid pricing, then step aside. And so, the industry will continue to be dominated by the Aprias. And your smaller local offices will continue to refuse to supply you with Resmed. And for the record, this is legal. When a supplier on Medicare's competitive bid accepts a contract, they write to Medicare with what they will supply. And most leave the big, expensive brands off the list. They tell Medicare, "We will accept this contract at these rates, but the only brands we will supply are 3B and Roscoe and whatever else they can afford"

Now what do I mean by crappy reimbursement? You work and pay into insurance or you worked 45 years and paid into Medicare, and dangit, you deserve that Resmed mask! It should be covered in full and all companies should have to provide you with whatever you want!
WRONG.

Lets talk hypothetically here for a minute:

If you were running a CPAP supply business, could you stay afloat if everytime you filled a mask supply order, you had to give the recipient a mask and $20 to go with it? No WAY! This is the problem with Resmed. They do have nice masks. Their masks are like Mercedes. Fisher & Paykels and Phillips Respironics are also nice, more like Acuras. And everything else is like a Kia. Medicare wants to pay for a Kia--an economy mask, not a luxuriant Resmed. And Blue Cross--they want to pay even less. Blue Cross utterly sucks.

Now, take for example a Resmed Quattro Full Face Mask. Maybe a big supplier like Apria or Verus orders such high volume they can get the Quattros (which realistically only cost Resmed $5 to manufacture) at a cost of $50-70. For a smaller DME, that same mask can cost $99+. Medicare reimbursement is only $84. Now why would they want to LOSE money just to give you what you want? And so this is why your DME doesn't want to give you that cushy Resmed mask you've gotten so used to. You're insurance doesn't cover the cost. You can throw a fit and refuse to go to the national chain, but the national chain is the only company who can afford that nice of a mask. Your local company can afford to give you a $55-65 mask from Roscoe or 3B or maybe even a $70-80 mask from PR or F&P, but the Resmed is simply too expensive. And Resmed isn't coming down on their prices anytime soon, because of the consumers! The consumers LOVE Resmed. They like to work out deals with sleep labs to get you hooked on their products too.

And for the record, people are under the misconception that the machines are what makes money. But this is soooo wrong. The machines are mostly rentals. In order to make like $100 on a new unit, give or take, the supplier is waiting for a year of rental to go by and they are having to ensure the user stays compliant. If not, they end up NOT making money and then having a USED machine that most other people would not be happy about getting so it ends up being a loaner-type device that sits on a shelf until an occasional out of towner needs to rent a loaner or until someone brings in a broken unit.

And it will only get worse. as Medicare considers flat-rate monthly fees to cover the cpap rental and all supplies. This will be yet another cost-cutting practice for them, and you'll have to kiss all of your excess supplies good-bye.

Hopefully you have a stockpile.
Words of wisdom ? out of the mouth of the DME employee
Started cpap in 2010.. still at it with great results.