Medicare Capped Bidding Explanation of Benefits

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Sonnyboy
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Medicare Capped Bidding Explanation of Benefits

Post by Sonnyboy » Fri Apr 17, 2015 1:43 pm

Today I reviewed my first Medicare Capped Bidding Explanation of Benefits.

I have the Airsense 10.

The billed rental fee is $350/month, allowed amount 47.75. Service Code E0601.
A humidifier purchase is billed separately using E0562. The billed amount is $2500, allowed amount 139.44.

I have two questions:

1. Can the Airsense 10 humidifier be billed as a separate unit? My understanding from reading this forum is that the whole unit is covered under E0601.

2. I am searching for Capped Bidding Reimbursement amounts for the 95071 area code [Santa Clara County, California].
Any suggestions where I can locate this information?

Thank you

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Deep Sleep
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Re: Medicare Capped Bidding Explanation of Benefits

Post by Deep Sleep » Fri Apr 17, 2015 2:19 pm

Can't help you with that, but offer this.

library lady
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Re: Medicare Capped Bidding Explanation of Benefits

Post by library lady » Fri Apr 17, 2015 2:31 pm

I can't help you with your question about capped billing in California, I live in Minnesota, but I do know that the machine and humidifier are billed separately... humidifiers sometimes need to be replaced before machine is in need of replacing... so since they are separate pieces that's the way they do it. Also, the machine is usually a rental until totally paid (think car payments that end when you've paid it off), but the humidifier is not considered a rental.. I don't know what the logic to that is, but that's the way Medicare does it, and most insurance companies follow Medicare guidelines for durable medical equipment.

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LSAT
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Re: Medicare Capped Bidding Explanation of Benefits

Post by LSAT » Fri Apr 17, 2015 3:01 pm

I think that even with the Airsense 10 with built in humidifier, the unit and humidifier are billed separately under the Medicare codes. E601 could be any CPAP....Medicare doesn't care which one it is.

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Deep Sleep
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Re: Medicare Capped Bidding Explanation of Benefits

Post by Deep Sleep » Fri Apr 17, 2015 3:29 pm

In retrospect...

Just looking at the allowed amounts, $47.75 x 13 is only $620.75. Add to that the allowed amount of $139.44 for the built-in humidifier is only $760.19 if I did the math right.

That's $120 less than the typical $883 online price for the AutoSet/AutoSet for Her and the gov't got a pretty good deal.

Sonnyboy
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Re: Medicare Capped Bidding Explanation of Benefits

Post by Sonnyboy » Fri Apr 17, 2015 3:44 pm

The Airsense 10 and humidifier are one unit.

I called my DME and they say Resmed gives Medicare the two codes [E0562 and E0601] for Airsense 10 billing.
I called cpap.com to check on this and see what they provide their customers without success.

The medicare allowed amounts are correct for my area. Quite a cut from pre capped bidding amounts.

If you want to go online, the DMEPOS Competitive Bidding Program website shows single payer amounts for various geographic locations.

My DME could not account for the $2500 other than they said it did not matter since medicare has fixed amounts they are willing to pay.

Very confusing

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Deep Sleep
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Re: Medicare Capped Bidding Explanation of Benefits

Post by Deep Sleep » Fri Apr 17, 2015 4:34 pm

Thanks for following up on this for us, Sonnyboy. And thanks for the website referral.

SewTired
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Re: Medicare Capped Bidding Explanation of Benefits

Post by SewTired » Fri Apr 17, 2015 4:54 pm

This is all very interesting since I will be ordering my first CPAP in June through one of these competitive bidding places. So, do you pay up front for the humidifier or is that billed later?

I've had a frustrating afternoon trying to arrange for my handicapped brother to get a replacement BiPap. At the Medicare site, it lists the various winning competitive bidders and they list what they have. However, is this a partial or a complete list? When I call them, you cannot get them to give you any information if it is a complete or a partial listing. In fact, can't get any information at all and I just became so annoyed, I had to just stay off the phone. I get that the first liner on the phone doesn't know, but I can't get them to transfer me to someone who DOES know. What they want me to do is fax the prescription and his information to them and then they will make an appointment. I don't want an appointment if they don't accept assignment for the higher end Resperonics auto bipap (which is what he has now, but it's 6 years old). That's the whole point. On their website at Medicare, they only offer a handful of C-pap machines (this is the place that my bro's doctor's office told him to go) and no bipaps. I appreciate that Medicare is saving a lot of money, but those who make those decisions have never had to shlep a severely handicapped person in a wheelchair around. Ok, end of rant.

ANYWAY, I do appreciate this discussion because I was unaware that the humidifier is considered a separate unit.

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Deep Sleep
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Re: Medicare Capped Bidding Explanation of Benefits

Post by Deep Sleep » Fri Apr 17, 2015 5:28 pm

Well, here's an example of a high end PR BiPAP:

Phillips Respironics DS760TS
auto-titrating BiPAP machine with
Heated Tube Humidifier and
Integrated Heated Tube

Here's the codes they'll probably bill
HCPCS Name
E0470 BiPAP Machine first month rent (13 month capped rental)

E0562 CPAP Heated Humidifier (purchase up front)
A4604 Integrated Heated CPAP Tube (purchase up front)

Does this help?

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Re: Medicare Capped Bidding Explanation of Benefits

Post by chunkyfrog » Fri Apr 17, 2015 5:45 pm

The paperwork lags behind blower and mask technology. Tweaks are allowed, when "needed".
If you expect a government agency to be current, you will be disappointed.

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Re: Medicare Capped Bidding Explanation of Benefits

Post by Janknitz » Fri Apr 17, 2015 6:11 pm

The billed rental fee is $350/month, allowed amount 47.75. Service Code E0601.
A humidifier purchase is billed separately using E0562. The billed amount is $2500, allowed amount 139.44.

I have two questions:

1. Can the Airsense 10 humidifier be billed as a separate unit? My understanding from reading this forum is that the whole unit is covered under E0601.
$350 per month for the blower unit and $2500 for the purchase of the humidifier is pure FANTASY on the part of the DME. They get exactly what Medicare says they get, and you can see it's just a fraction of what they WISH they could get. That's like 1000% mark up!

Yes, the humidifier can be billed separately even if it's built in to the PAP unit. Wait until you see how they part out masks to bill them when all they are really doing is providing you with a complete mask in a package sealed by the manufacturer! It's all games. It's going to take Medicare a good, long while to figure out that the humidifier can't be separated from the blower unit. I'm waiting for someone to say they don't WANT the humidifier and see what happens
What they want me to do is fax the prescription and his information to them and then they will make an appointment. I don't want an appointment if they don't accept assignment for the higher end Resperonics auto bipap (which is what he has now, but it's 6 years old). That's the whole point. On their website at Medicare, they only offer a handful of C-pap machines (this is the place that my bro's doctor's office told him to go) and no bipaps. I appreciate that Medicare is saving a lot of money, but those who make those decisions have never had to shlep a severely handicapped person in a wheelchair around. Ok, end of rant
CPC codes for CPAP equipment are NOT limited to the particular makes and models your DME wants to provide you. They have figured out what items do the best for their bottom lines, and may not be willing to provide more expensive models. Nothing says they have to UNLESS your doctor's order specifies, in which case (I think) they have to provide what your doctor's order calls for even if they don't normally carry it, and can't bill extra for it. I think there's no longer such a thing as "accepting Medicare Assignment". The whole idea behind competitive bidding is exclusivity of contract. That means that other DME's who didn't win competitive bidding contracts may be prohibited BY LAW from providing DME to Medicare recipients regardless of what they charge. See http://www.thecre.com/blog/2011/02/new- ... r-choices/
In mid-January, she accidentally tore the face mask, which pumps oxygen into her lungs. Graham called her provider but was told the business couldn’t help her anymore because it didn’t win a Medicare competitive bidding contract for CPAP machines.
(Ignore the "pumps oxygen into her lungs" part ).

The only thing I can suggest there is ask the doctor to write the script specifically for the machine you want and write "Dispense as Written" on it. That MAY work. You don't have to use the DME your doctor recommended, but if you want Medicare to pay, you do have to use a provider who has a competitive bid contract.

If this was for CPAP it would be easy enough to get one on Craigslist or Secondwind.com, but BiPAP's are a lot more expensive and difficult to source. It's still worth trying, but hard to beat the Medicare coverage.
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Krelvin
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Re: Medicare Capped Bidding Explanation of Benefits

Post by Krelvin » Fri Apr 17, 2015 6:13 pm

Wonder if you tell them you don't want the humidifier?
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Sonnyboy
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Re: Medicare Capped Bidding Explanation of Benefits

Post by Sonnyboy » Fri Apr 17, 2015 6:55 pm

chunkyfrog wrote:The paperwork lags behind blower and mask technology. Tweaks are allowed, when "needed".
If you expect a government agency to be current, you will be disappointed.
Thank you chunky frog. I see what you are saying.
Krelvin wrote:Wonder if you tell them you don't want the humidifier?
Good point Krelvin. Also, Sleeprider on the Apnea Board says you cannot bill for something that does not exist.

Janknitz and Deep Sleep, Thank you for the good information.

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Re: Medicare Capped Bidding Explanation of Benefits

Post by SewTired » Fri Apr 17, 2015 8:16 pm

The whole idea behind competitive bidding is exclusivity of contract. That means that other DME's who didn't win competitive bidding contracts may be prohibited BY LAW from providing DME to Medicare recipients regardless of what they charge

Bidding contracts mean that other companies cannot provide equipment that is PAID FOR by Medicare. It does not exclude Medicare recipients from going to other places and buying it themselves. However, they will not be reimbursed. The problem with the contracts is that if they give the contract to a company that provides bad service, all the Medicare recipients in the area suffer for it. Apria has a terrible reputation, yet that is what many are stuck with. Frankly, their business practices are fraudulent, so why did they win the contract? I'm rather anxious about getting my machine and supplies, but I know if I have problems with getting supplies, I have MANY options that probably would cost less than getting through Medicare. It's just the machine I really need to get paid for by Medicare. It's quite a chunk of change.

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Re: Medicare Capped Bidding Explanation of Benefits

Post by Janknitz » Fri Apr 17, 2015 8:46 pm

SewTired wrote:
The whole idea behind competitive bidding is exclusivity of contract. That means that other DME's who didn't win competitive bidding contracts may be prohibited BY LAW from providing DME to Medicare recipients regardless of what they charge

Bidding contracts mean that other companies cannot provide equipment that is PAID FOR by Medicare. It does not exclude Medicare recipients from going to other places and buying it themselves. However, they will not be reimbursed. The problem with the contracts is that if they give the contract to a company that provides bad service, all the Medicare recipients in the area suffer for it. Apria has a terrible reputation, yet that is what many are stuck with. Frankly, their business practices are fraudulent, so why did they win the contract? I'm rather anxious about getting my machine and supplies, but I know if I have problems with getting supplies, I have MANY options that probably would cost less than getting through Medicare. It's just the machine I really need to get paid for by Medicare. It's quite a chunk of change.
Medicare went with the lowest bidders who lowballed because they make up in volume and cost cutting what they lost in margin. They put the squeeze on manufacturers to lower their prices and also to produce lower quality supplies. I stopped getting white filters from Crapria because they are junk. Thin and cheap, so they get pulled up into the air inlet and make a bunch of noise. And the water chambers are junky, too.
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