DMEs & Government; WalMart & The Free Market to the Rescue

Guest · Post by **Guest** » Fri Feb 10, 2012 6:21 pm

Remember the good old days when news media did not print complete BS and actually checked things out first?

The product noted above costs, at a mimumum, $10 thousand dollars - many cost more than $20 thousand dollars. You couldn't buy the tubing the device requires for $39.95 let alone the device itself.

The highest reimbursement for it in the United States is $1500 per month - nowhere near $4500 a month. The insurance will not pay unless it is applied and documented by a Registered Nurse or better, who must also be paid (at least in reality world).

Here are the coverage criteria and details on what the nurse and physician must document in order for the claim to be paid:

A Negative Pressure Wound Therapy pump (E2402) and supplies (A6550, A7000) are covered when either criterion A or B is met:

A. Ulcers and Wounds in the Home Setting:

The patient has a chronic Stage III or IV pressure ulcer (see Appendices Section), neuropathic (for example, diabetic) ulcer, venous or arterial insufficiency ulcer, or a chronic (being present for at least 30 days) ulcer of mixed etiology. A complete wound therapy program described by criterion 1 and criteria 2, 3, or 4, as applicable depending on the type of wound, must have been tried or considered and ruled out prior to application of NPWT.

1. For all ulcers or wounds, the following components of a wound therapy program must include a minimum of all of the following general measures, which should either be addressed, applied, or considered and ruled out prior to application of NPWT:

a. Documentation in the patient’s medical record of evaluation, care, and wound measurements by a licensed medical professional, and

b. Application of dressings to maintain a moist wound environment, and

c. Debridement of necrotic tissue if present, and

d. Evaluation of and provision for adequate nutritional status.

2. For Stage III or IV pressure ulcers:

a. The patient has been appropriately turned and positioned, and

b. The patient has used a group 2 or 3 support surface for pressure ulcers on the posterior trunk or pelvis (see LCD on support surfaces),

c. The patient’s moisture and incontinence have been appropriately managed.

3. For neuropathic (for example, diabetic) ulcers:

a. The patient has been on a comprehensive diabetic management program, and

b. Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities.

4. For venous insufficiency ulcers:

a. Compression bandages and/or garments have been consistently applied, and

b. Leg elevation and ambulation have been encouraged.

Documentation of the history, previous treatment regimens (if applicable), and current wound management for which an NPWT pump is being billed must be present in the patient’s medical record and be available for review upon request. This documentation must include such elements as length of sessions of use, dressing types and frequency of change, and changes in wound conditions, including precise measurements, quantity of exudates, presence of granulation and necrotic tissue and concurrent measures being addressed relevant to wound therapy (debridement, nutritional concerns, support surfaces in use, positioning, incontinence control, etc.).

Documentation of wound evaluation and treatment, recorded in the patient’s medical record, must indicate regular evaluation and treatment of the patient’s wounds, as detailed in the Indications and Limitations of Coverage Section. Documentation of quantitative measurements of wound characteristics including wound length and width (surface area), and depth, and amount of wound exudate (drainage), indicating progress of healing must be entered at least monthly. The supplier of the NPWT equipment and supplies must obtain from the treating clinician, an assessment of wound healing progress, based upon the wound measurement as documented in the patient’s medical record, in order to determine whether the equipment and supplies continue to qualify for Medicare coverage. When billing for NPWT, an ICD-9-CM diagnosis code (specific to the 5th digit or narrative diagnosis), describing the wound being treated by NPWT, must be included on each claim for the equipment and related supplies.

The medical record must include a statement from the treating physician describing the initial condition of the wound (including measurements) and the efforts to address all aspects of wound care (listed in A1 through A4). For each subsequent month, the medical record must include updated wound measurements and what changes are being applied to effect wound healing. Month-to-month comparisons of wound size must compare like measurements ie depth compared to depth or surface area compared to surface area.

If the initiation of NPWT occurs during an inpatient stay, in order to accurately account for the duration of treatment, the initial inpatient date of service must be documented. This date must be available upon request.

When NPWT therapy exceeds 4 months on the most recent wound and reimbursement ends, individual consideration for one additional month at a time may be sought using the appeals process. Information from the treating physician’s medical record, contemporaneous with each requested one-month treatment time period extension, must be submitted with each appeal explaining the special circumstances necessitating the extended month of therapy. Note, this policy provides coverage for the use of NPWT limited to initiating healing of the problem wounds described in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this LCD rather than continuation of therapy to complete healing since there is no published medical literature demonstrating evidence of a clinical benefit for the use of NPWT to complete wound healing. Therefore, general, vague or nonspecific statements in the medical record such as “doing well, want to continue until healed” provide insufficient information to justify the need for extension of treatment. The medical record must provide specific and detailed information to explain the continuing problems with the wound, what additional measures are being undertaken to address those problems and promote healing and why a switch to alternative treatments alone is not possible. "

But hey, why let ignorance stop anyone from sending moronic letters to the equally moronic WSJ, and by all means don't let your ignorance prevent you from posting things you know nothing about on the internet. Seems to be a theme here.

DoriC · Post by **DoriC** » Fri Feb 10, 2012 7:14 pm

roster wrote:My cpaptalk activities have been curtailed due to some business commitments. However, flying home today I saw something in the WSJ that I had to share with you.

IMO, Not such a simple device and definitely needs the services of a wound care nurse in the home setting. Mike was sent home from the hospital one time with a Wound Vac and that was the first time I wasn't being tortured to learn how to do dressing changes myself. Very complicated and you have to really be trained. Only a few RN's in the hospital knew how to care for Wound Vac patients and only a Visiting Nurses were trained. He was doing well and the wound was healing but even with a full staff of wound care specialists, Mike's wound developed a fungus at home and treatment had to be stopped and we went back to wet/dry packing which I then had to learn to do when an RN wasn't available. Wound Vac is a great procedure for healing if there are no complications and it's done right. We weren't so fortunate and our surgeon never recommmended it again with future surgeries.

People outside the CPAP community are taking note of the dreadful problems when medical equipment can only be procured by prescription through a licensed DME. They also understand that if the regulations, prescription requirements, and licensing requirements are stripped away the patient, not to mention the U.S. taxpayer, will see big benefits.

Letter to the Editor
Wall Street Journal, February 10, 2012

As a result of a simple outpatient operation in 2010, I became seriously infected and was readmitted to the hospital for six weeks. I was fitted with a negative pressure wound therapy device. It was a simple device consisting of a vacuum pump, a fluid reservoir and a tube running to my knee, and included some basic electronic controls. I carried it home and used it for two months.

I was appalled that the device was not available to purchase but had to be rented for about $4,500 per month. Dressings and reservoirs were replaced every few days at extra cost, of course.

I can visualize this simple device being sold at Wal-Mart for probably $39.95. No wonder Medicare is going bankrupt.

Charlie Bolles

Wrightsville Beach, N.C.

http://online.wsj.com/public/page/letters.html

NightMonkey · Post by **NightMonkey** » Fri Feb 10, 2012 8:07 pm

This guest may well be LTTS. What this is all about is the pressure Medicare is putting on DMEs to clean up their act.

If you look at HME News, http://www.hmenews.com/ , a newsletter for DMEs you see plenty of evidence for it. Some examples:

Walkers and commodes were just stacked up, with no rhyme or reason," said Ward. "Odds and ends were hanging on the walls and nothing had a price tag."

Enter Ward, who set about turning the full line HME provider's retail business--about 25 of its locations offer retail--into a serious money-maker. In the last year, retail business has doubled.

One key strategy that has worked in getting the word out about the provider's new offerings is enlisting clinicians, therapists and even the company's drivers to hand out coupons that offer 15% off items bought in the store.

"What's exciting is people are coming in off the street, picking up six or seven items and cashing out," said Ward

The newsletter is engaged in sending out price-fixing signals to keep prices up under Medicare's competitive bidding process. Example:

No one will know for sure until this fall, when CMS plans to announce the payment amounts, but HME providers like Doug Crana like to think the increase in education leading up to Round 2, led by The VGM Group, The MED Group and state associations, will result in more rational bidding.

"If we understand the process, and we also understand the lessons from Round 1, we'll bid correctly," said Crana, owner of Consolidated Medical in Newburgh, N.Y. "We'll bid within our limits and not cut ourselves off at the knees. There'll always be wild cards, but hopefully this will be suppressed and limited."

Doug is clearly sending signals to fellow DMEs to keep the bid prices up. He even talks about "suppressing and limiting the wild cards" - this is dangerously close to being prima facie evidence of illegal price fixing.

Has HME News or more likely one of the DME trade associations assigned a person or two to bombard this site with arguments favoring their members? If they did they picked one with a personality like a bucket full of rusty nails.

Guest · Post by **Guest** » Fri Feb 10, 2012 8:09 pm

roster wrote:
Guest wrote:
The product noted above costs, at a mimumum, $10 thousand dollars - many cost more than $20 thousand dollars. You couldn't buy the tubing the device requires for $39.95 let alone the device itself.

The highest reimbursement for it in the United States is $1500 per month - nowhere near $4500 a month.
Well I received a PM warning me that you are a pesky troll that should not be fed. But I think I will take a little time to feed you.

I think you may be lying about some of the facts. This may be because you see that your industry is being exposed as low quality and high price not to mention poorly managed and living off naive government bureaucrats.

According to OIG analysis of supplier documentation, 2008, the purchase price paid by DMEs for these machines ranged from $1085 to $4,970 with the average being $3,604 and the most expensive machine being $4,970 - a long way from your claims of "$10,000 and many more in excess of $20,000". This is not to mention that one-quarter of the machines were acquired by DMEs by leasing, renting, or exchanging them, undoubtedly resulting in an average cost to the DME much lower than $3,604. You lying troll.

So these machines that cost on average something less than $3,604 were reimbursed by Medicare at an average of $13,561 a wonderful gross profit of at least $10,000 per machine.

Furthermore the OIG commented:

On a monthly basis, Medicare reimbursed suppliers $1,716 for these pumps for the first 3 months. At this rate, suppliers recouped the average cost of a new pump model in approximately 2 months. Suppliers generally reported that the new pump models have an estimated lifespan of 3 to 5 years. As one supplier noted, pumps are commonly rented to one beneficiary, sanitized, and then rented to another beneficiary.
Now that is a nice business - a two-month payback and then 3 to 5 years life still remaining on the equipment.

I know why you are crying so loud and spending much time to post in the forum: The game is up for DMEs. Medicare is slowly putting you on competitive bidding and you will have to respond to a real market for the first time in your life.

But your constant crying will yield no fruit for you. Information shared by patients through the internet is making them savvy consumers. Internet suppliers will dig more and more into your game. Medicare which is starting to have bad problems with funding will abandon the lucrative game you have been allowed to play with them.

Don't get caught in a dead end job. Get some education and prepare yourself for a real career in another industry before it is too late. WalMart always needs employees.

That report is from 2004, and the OIG is wrong. Even then. The OIG wouldn't recognize that device if it bit them on the butt. By the way, they also think your fully data capable PAP machines costs less than $200, and the respiratory inhalation drugs costs 5 cents a dose. They often confuse manufacturing costs with the price available to DME providers. I suppose you also believe congressional budget estimates that healthcare reform is going to save $500 billion dollars, too, right?

In addition, the OIG considers the DME improperly paid because the nurse and physician did not write literally pages and pages of documentation as noted in my original post (that language comes straight from Medicare). So guess who they deny payment to? Not the doctor or the nurse, that's for sure. The DME has absolutely no control over the clinical professional's charting, but because they do not chart the chapter and verse the payer requires they do not get paid. 90% of the claims for this product are denied by the insurance payer. That is why most DMEs won't even carry this product, even though it is amazing in its effectiveness. That's how effective products become what we call orphan products.

60% of DME providers will go out of business when anti-competitive bidding reaches 91 more metropolitan areas that include most of the Medicare population of the country in 2013. Other insurance payers will demand a discount off those rates as they always do. That will reduce your choice of provider another 20%. There is not a respiratory therapist to be found in many DMEs that are in the first 10 cities, and when this hits nationwide next year you will find out what I am talking about after it's too late. Enjoy your free upgrades now because they won't be available in 2 years. You will get the lowest care possible because your insurance payer, including Medicare, doesn't care.

Your politicians are stealing your benefits and you don't even know it, because you're currently being shielded from it by DME providers. Only they won't be here to shield you soon. On the bright side most posters here will be getting exactly what they deserve.

ems · Post by **ems** » Fri Feb 10, 2012 8:21 pm

Ooooooh, now I remember her!

chunkyfrog · Post by **chunkyfrog** » Fri Feb 10, 2012 8:33 pm

Roster!
Welcome back!
You always did make my little green toes curl!

Guest · Post by **Guest** » Fri Feb 10, 2012 8:39 pm

NightMonkey wrote:This guest may well be LTTS. What this is all about is the pressure Medicare is putting on DMEs to clean up their act.

If you look at HME News, a newsletter for DMEs you see plenty of evidence for it. Some examples:

Walkers and commodes were just stacked up, with no rhyme or reason," said Ward. "Odds and ends were hanging on the walls and nothing had a price tag."

Enter Ward, who set about turning the full line HME provider's retail business--about 25 of its locations offer retail--into a serious money-maker. In the last year, retail business has doubled.

One key strategy that has worked in getting the word out about the provider's new offerings is enlisting clinicians, therapists and even the company's drivers to hand out coupons that offer 15% off items bought in the store.

"What's exciting is people are coming in off the street, picking up six or seven items and cashing out," said Ward

The newsletter is engaged in sending out price-fixing signals to keep prices up under Medicare's competitive bidding process. Example:

No one will know for sure until this fall, when CMS plans to announce the payment amounts, but HME providers like Doug Crana like to think the increase in education leading up to Round 2, led by The VGM Group, The MED Group and state associations, will result in more rational bidding.

"If we understand the process, and we also understand the lessons from Round 1, we'll bid correctly," said Crana, owner of Consolidated Medical in Newburgh, NY "We'll bid within our limits and not cut ourselves off at the knees. There'll always be wild cards, but hopefully this will be suppressed and limited."
Doug is clearly sending signals to fellow DMEs to keep the bid prices up. He even talks about "suppressing and limiting the wild cards" - this is dangerously close to being prima facie evidence of illegal price fixing.

Has HME News or more likely one of the DME trade associations assigned a person or two to bombard this site with arguments favoring their members? If they did they picked one with a personality like a bucket full of rusty nails.

Oh brother, another instant internet expert, not just on DME, but also the law! What an amazing forum. First, there is a minimum % that DME providers are required to bid below the current fee schedule in order for their bid to be accepted. Second, supressing and limiting the wild cards has nothing to do with the bid amount - it has to do with the rules of the bid program that were not in place in the first round that were beyond crazy (with most of the really crazy stuff surviving, unfortunately -- like you don't even have to have a DME in the area you are bidding in). Thirdly, it's not like industry publications are super secret and not available to be read by CMS. So I guess this guy is expecting to be arrested for "price fixing" any day now.

The Medicare claim denial rate for CPAP is 39%. Do you think that DME providers are knocking on doors and foisting CPAP devices on patients that don't need them? Do you think DME providers come and reposses the machine when Medicare finds a reason not to pay (mostly associated with poor physician documentation)? Do you think the doctor cares if the DME gets paid?

I looked at 13 claims to United HealthCare today. They denied because they wanted a special 2 letter modifier on the claim. The provider refiled the claims with the corrected modifier. They came back denied because they didn't want ANY modifier on the claim. The provider billed them a third time without the modifier (as he had the first time). Then they denied because oops, times up. Timely filing denial. That was over $6000 in cost of product to the provider. No pay. Can he appeal? Sure, he can fill out a big long appeal form and wait 4 months, only to have them say, sorry denied.

Good lord, the arrogance combined with ignorance here is simply unparalled. Is there anything you folks know nothing about that you aren't willing to pretend you are experts on?

-tim · Post by **-tim** » Fri Feb 10, 2012 8:45 pm

Lots of medical equipment can be made much cheaper. Doctors in poor countries are now using endoscopes like the ones they sell at the local hardware store for $100. They do it because they simply can't afford the medical grade ones and they do what they can. The interesting thing is now there is a growing market in disposable medical grade endoscopes.

chunkyfrog · Post by **chunkyfrog** » Fri Feb 10, 2012 8:47 pm

One thing will not change--cheaters will get busted.
Aww, sugar!

Guest · Post by **Guest** » Fri Feb 10, 2012 9:11 pm

-tim wrote:Lots of medical equipment can be made much cheaper. Doctors in poor countries are now using endoscopes like the ones they sell at the local hardware store for $100. They do it because they simply can't afford the medical grade ones and they do what they can. The interesting thing is now there is a growing market in disposable medical grade endoscopes.

In Russia they reuse IV needles. Buy your plane ticket now before the prices go up

Guest · Post by **Guest** » Fri Feb 10, 2012 9:24 pm

chunkyfrog wrote:One thing will not change--cheaters will get busted.
Aww, sugar!

Here are the top reasons for the denial AS REPORTED BY MEDICARE AND THEIR BELOVED OIG. Which of these is related to the DME provider "cheating" or even related to the DME provider AT ALL???

- No initial face-to-face evaluation prior to sleep study or no face-to-face evaluations after 31st day (nope not that one - that's the irresponsible patient not showing up for the appointment, or the physician to lazy to document why they sent the patient for a sleep study)

- No signature and/or date on sleep study (nope, that's the doctor's job)

- No polysomnogram report (this one doesn't actually mean there was no sleep study - it just means the sleep lab wouldn't give it to the DME provider - DME provider is cheating because the lab wouldn't send the sleep study? Ah, no)

- Prescription illegible, poor copy quality (this is my favorite one, and is actually related to the physician signature on the prescription - when they absolutely, positively can't find another way to rip off the DME provider this is the one they use -- as if ANY physician signs their name legibly)

- Incorrect diagnosis (the DME doesn't diagnose you, the doctor does. If s/he doesn't use the right code the DME does not get paid)

So, Chunky, which one of these is the DME cheating anyone? Do tell.

chunkyfrog · Post by **chunkyfrog** » Fri Feb 10, 2012 9:24 pm

Better study up on prison etiquette, 'guest',
because the truth will prevail.

ChicagoGranny · Post by **ChicagoGranny** » Fri Feb 10, 2012 9:29 pm

Guest wrote: On the bright side most posters here will be getting exactly what they deserve.

I learned the forum owners are very liberal with what may be said. But I am still shocked that a nonregistered is allowed to post such wishes on the members.

Someone who has the attitude of Guest and spends the time and effort to make long posts to people whom he wishes the worst on is surely a social deviant.

Guest · Post by **Guest** » Fri Feb 10, 2012 9:39 pm

chunkyfrog wrote:Better study up on prison etiquette, 'guest',
because the truth will prevail.

Well I'm not a DME provider, and none of the 1200 clients I have assisted have gone to jail. Not a one in 25 years. So I'm not too concerned about it. The reality is that actual Medicare cheaters don't provide any product at all. They slip a poor person 25 bucks for their Medicare number, and find a crooked physician to split the profits with. And they don't actually give the fictional patient any product at all.

What you are witnessing now with Medicare and other payers is a bald faced attempt to rip off legitmate DME providers as a way to maximize profits or decrease costs. Because if they raise your premiums or decrease your benefits to accomplish that you will raise hell and get in the news, and they don't want that. So instead they invest time and effort convincing you that there are hoards of providers out there busting their butts everyday just to rip you off. And frankly, most of you are so gullible you buy it.

It's been proven that the American public is stupid and gullible. I mean after all, most of you bought the whole WMD and Iraq war thing, didn't you? I knew that was BS from day one, did you? Never underestimate a gullible public.

Guest · Post by **Guest** » Fri Feb 10, 2012 9:48 pm

ChicagoGranny wrote:
Guest wrote: On the bright side most posters here will be getting exactly what they deserve.

I learned the forum owners are very liberal with what may be said. But I am still shocked that a nonregistered is allowed to post such wishes on the members.

Someone who has the attitude of Guest and spends the time and effort to make long posts to people whom he wishes the worst on is surely a social deviant.

OR just sick of people posting absolutely untrue comments about hard working DME providers. I would LOVE LOVE LOVE for this forum to require actual names to be posted. I'd be the first one in line to track the names and make sure DME providers knew them so they could refuse your business.

Cold hard data shows that greater than 90% of DME patients would recommend their DME to family and friends. This forum is just filled with nasty people that DME providers should not have to service.

DMEs & Government; WalMart & The Free Market to the Rescue

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Re: DMEs & Government; WalMart & The Free Market to the Rescue

Re: DMEs & Government; WalMart & The Free Market to the Rescue

Re: DMEs & Government; WalMart & The Free Market to the Rescue

Re: DMEs & Government; WalMart & The Free Market to the Rescue

Re: DMEs & Government; WalMart & The Free Market to the Rescue

Re: DMEs & Government; WalMart & The Free Market to the Rescue

Re: DMEs & Government; WalMart & The Free Market to the Rescue

Re: DMEs & Government; WalMart & The Free Market to the Rescue

Re: DMEs & Government; WalMart & The Free Market to the Rescue

Re: DMEs & Government; WalMart & The Free Market to the Rescue

Re: DMEs & Government; WalMart & The Free Market to the Rescue