Let's clear up some misinformation

[HoseCrusher]

As I see it...

The actual problem begins with the sleep doctor. If the doctor took time to educate the patient on the importance of what the sleep study revealed, rather than just summarizing the summary sheet, the patient would come away from the meeting with an understanding of the importance of AHI and the other data that made up the diagnosis.

Many people will still not be interested in monitoring their progress, but some will. With education the demand for full data machines will rise, and there may be pressure put on the insurance companies to review their policies on machine reimbursement.

The problem with this approach is that the doctors don't put any value in the machine scored data. If they are going to make adjustments, they need another sleep study to get what they determine as "reliable" data. This is a problem that the xPAP machine manufactures need to address. There are some studies correlating the data from a home machine and the sleep study data, but they are too few to be conclusive.

I will also point out that with all technological advancement, expectations change...

Just so you know, I live in a "deluxe" house that has both hot and cold running water, and flush toilets. In addition, my computer has a built in hard drive...

[portiemom]

I would like a simple answer to a simple ?. My insurance company told me that I am responsible for and will be billed for ten percent of the dollar amount that they, the insurance company is going to be paying the DME for my equipment. Then they told me that they have a set amount that they pay for the equipment regardless of the type of machine the DME delivers to me. I asked what that amount was so that I would know how much out of pocket I was expected to pay. They told me that they didn't know and no-one there could tell me. I responded is that how you would purchase say, a house, a car, a diamond ring etc. I couldn't get an answer no matter how I tried. So I called the DME and asked how much they charge for the machine I was getting, and was told I would know that when it was brought to my home. Wow, what bunch of hooey. Well the delivered price for the S9 Autoset, with heated humidifier, and heated hose was $1,544.00, and in the total it said ZERO to be paid by customer. So, I know my insurance company is NOT going to pay that 1,544.00 to the DME so at most my part would be 10 percent of that price. What a crappy way to do business, and I believe no matter where the responsibility lies for the lousey treatment of the customer, BOTH the Insurance Company and the DME are at fault. The insurance company knows darn well how much they'll pay the DME, which is where my 10 percent payment is derived from and the DME inflates the purchase price in the invoice, which in my case doesn't really matter because my portion isn't based on that so end of rant, The simple question is: WHY ALL THIS EVASIVE MESS FOR A CUSTOMER ALREADY STRESSED WITH THIS HEALTH ISSUE?
Thanks

[Elle]

My DME asked my insurer (Blue Cross) for $2900. for a machine and $375. for a mask. They gave them $2205. for the machine and $175. for the mask. I got the machine I wanted but if I hadn't been specific I would have got a compliance only machine for the same price...just as I did before I knew the difference.

[NateS]

I've been cruising posts here for awhile, and I have to say I am literally astounded by how much disinformation is posted by certain members here and on a particular person's blog that seems to post here frequently. I don't know where people that post these things got their education about the difference between online suppliers, DMEs and how insurance pays for PAP devices and supplies, but in many cases it is incorrect.

…
But under no circumstances is a patient entitled to a deluxe machine. …

Insurance payers do recognize that some physicians and some patients want these deluxe features, and that is why nearly all of them allow the patient to be charged an upgrade fee. In fact Medicare has a very specific process for this called an Upgrade ABN, which is a form you sign that acknowledges that you will pay the difference between the basic machine covered by Medicare and the deluxe machine you desire. The DME is permitted to give you a free upgrade if they so desire, but again, under absolutely no obligation to do so, and is not trying to rip you off if they refuse to do so. They are trying to stay in business in a highly regulated environment with plummeting reimbursement rates. …

TO: LTTS

Are you unaware of the Balance Billing Prohibition Law in force in the overwhelming majority of states? It generally provides approximately as follows:

“Balance billing” means charging or collecting from a medicare beneficiary an amount in excess of the medicare reimbursement rate for medicare-covered services or supplies provided to a medicare beneficiary, except when medicare is the secondary insurer. When medicare is the secondary insurer, the health care practitioner may pursue full reimbursement under the terms and conditions of the primary coverage and, if applicable, the charge allowed under the terms and conditions of the appropriate provider contract, from the primary insurer, but the medicare beneficiary cannot be balance billed above the medicare reimbursement rate for a medicare-covered service or supply. “Balance billing” does not include charging or collecting deductibles or coinsurance required by the program.

The law also generally includes a complaint process, investigation of the provider, financial penalties as well as the enforcement powers of the state to bring the provider into court to recover repayment from the provider of any balance amount the patient was pursuaded or compelled to pay.

Are you contending that these laws do not apply to durable medical equipment providers? If so, I will be glad to supply you with plenty of rulings holding that DMEs are held to compliance with these laws.

Please answer this question.

[chunkyfrog]

Looking at what passes for paperwork at a DME,
no wonder their "profit" margin is so high.
They seem to be counting any amount disallowed by insurance or Medicare as a LOSS!
Hey, anyone from IRS on this forum?
Please tell me how this is not tax fraud.

[ltts]

I think 6% profit is a bit low.
Wireless Modem Billed amt. $750.00 Allowed amt. $450.00 Paid by Ins. $382.50 I'm 15% co-pay

Here's where it gets even better: SD Card Billed amt $750.00 Allowed amt. $450.00 Paid by Ins. $382.50!!!!!!!
These two items have same billing code.

Yes, I know how to read my EOB's and I called both my insurance Co. and DME to confirm this. As per my 15% co-pay, my insurance Co. showed me to be responsible for the $67.50
each for these two items on my EOB's. When I received my bill from DME, wireless modem and SD card were on there without the 15% co-pay due. 99% of patients wouldn't look twice at this bill as seeing no charged amounts for these two items. I am a "have to know why" type of guy. These are the reasons why our insurance rates skyrocket. If a9279 billing code can fetch $450.00 for an at maximum $12.00 SD 2 Gigabyte Card I know why the DME provided these two items to me at no charge. They collected $382.50 for the $12.00 item, I paid no co-pay, supposedly insurance co. and patient are none the wiser and everybody is happy.

The wireless modems costs the providers about $180 dollars, plus $10 per month in wireless charge (like a phone, each wireless modem requires a data plan). So if you have it for 3 months the cost to the provider is $230 before adding in the costs of the RT that has to monitor the data.

And the reason 99% of patients wouldn't look twice at the bill is because literally 99 times out of 100 the insurance payer refuses to pay ANYTHING for the A9279, or an SD card for that matter, claiming it is already bundled into the cost of the device. See Resmed's guidance on this code below. It is almost never covered by insurance payers (even though DME providers incurr the costs on a rountine basis).

HCPCS code A9279
Description: Monitoring feature/device, stand-alone or
integrated, any type, includes all accessories, components and
electronics not otherwise classified
What DME suppliers need to know: This code applies to
ResMed equipment including the ResTraxx, S9 Wireless
module, ResLink™ and ResScan products as well as the
S9 SD card. Suppliers should bill A9279 when providing the
equipment to the patient, including the ResScan/S9 card at
setup or when providing and using the ResTraxx device to
remotely transfer compliance data. Since there is no payment
attached to the HCPCS code A9279 at this time, suppliers can
bill commercial payors and payment will be at their discretion,
or consider negotiating payment with payors directly.

[ltts]

I've been cruising posts here for awhile, and I have to say I am literally astounded by how much disinformation is posted by certain members here and on a particular person's blog that seems to post here frequently. I don't know where people that post these things got their education about the difference between online suppliers, DMEs and how insurance pays for PAP devices and supplies, but in many cases it is incorrect.

…
But under no circumstances is a patient entitled to a deluxe machine. …

Insurance payers do recognize that some physicians and some patients want these deluxe features, and that is why nearly all of them allow the patient to be charged an upgrade fee. In fact Medicare has a very specific process for this called an Upgrade ABN, which is a form you sign that acknowledges that you will pay the difference between the basic machine covered by Medicare and the deluxe machine you desire. The DME is permitted to give you a free upgrade if they so desire, but again, under absolutely no obligation to do so, and is not trying to rip you off if they refuse to do so. They are trying to stay in business in a highly regulated environment with plummeting reimbursement rates. …

TO: LTTS

Are you unaware of the Balance Billing Prohibition Law in force in the overwhelming majority of states? It generally provides approximately as follows:

“Balance billing” means charging or collecting from a medicare beneficiary an amount in excess of the medicare reimbursement rate for medicare-covered services or supplies provided to a medicare beneficiary, except when medicare is the secondary insurer. When medicare is the secondary insurer, the health care practitioner may pursue full reimbursement under the terms and conditions of the primary coverage and, if applicable, the charge allowed under the terms and conditions of the appropriate provider contract, from the primary insurer, but the medicare beneficiary cannot be balance billed above the medicare reimbursement rate for a medicare-covered service or supply. “Balance billing” does not include charging or collecting deductibles or coinsurance required by the program.

The law also generally includes a complaint process, investigation of the provider, financial penalties as well as the enforcement powers of the state to bring the provider into court to recover repayment from the provider of any balance amount the patient was pursuaded or compelled to pay.

Are you contending that these laws do not apply to durable medical equipment providers? If so, I will be glad to supply you with plenty of rulings holding that DMEs are held to compliance with these laws.

Please answer this question.

Upgrade charges are NOT balance billing. Here is information from Medicare that you may find helpful - (most other insurances have similar mechinsims for billing upgrade charges to the patient). Again, there is no need to take my word for it. Simply call your insurance payer and try to get a knowledgable person on the phone, which would much preferable to folks posting hysterical accusations that their DME provider is "lying" to them.

From the Medicare manaul-

The following instructions apply to situations where the ABN is being used for upgrades and applies to
both assigned and unassigned claims.

An upgrade is an item with features that go beyond what is medically necessary. The Centers for
Medicare & Medicaid Services defines an upgrade as an item that is more expensive, contains more
components or features, or is greater in quantity than what is medically necessary under Medicare’s
coverage requirements. When a DMEPOS supplier knows or believes that the DMEPOS item does not
or may not meet Medicare’s reasonable and necessary rules under specific circumstances, it is the
responsibility of the supplier to notify the beneficiary in writing via an ABN if the supplier wants to collect Jurisdiction B DME MAC Supplier Manual

Chapter 10: Advance Beneficiary Notice of Noncoverage

money from a beneficiary if an item is denied. When a beneficiary prefers an item with features or
upgrades that are not medically necessary, a supplier may collect the difference between the charges
for the upgraded item and the charges for the nonupgraded item, if the beneficiary agrees to be
financially liable by signing an ABN.

[ltts]

I would like a simple answer to a simple ?. My insurance company told me that I am responsible for and will be billed for ten percent of the dollar amount that they, the insurance company is going to be paying the DME for my equipment. Then they told me that they have a set amount that they pay for the equipment regardless of the type of machine the DME delivers to me. I asked what that amount was so that I would know how much out of pocket I was expected to pay. They told me that they didn't know and no-one there could tell me. I responded is that how you would purchase say, a house, a car, a diamond ring etc. I couldn't get an answer no matter how I tried. So I called the DME and asked how much they charge for the machine I was getting, and was told I would know that when it was brought to my home. Wow, what bunch of hooey. Well the delivered price for the S9 Autoset, with heated humidifier, and heated hose was $1,544.00, and in the total it said ZERO to be paid by customer. So, I know my insurance company is NOT going to pay that 1,544.00 to the DME so at most my part would be 10 percent of that price. What a crappy way to do business, and I believe no matter where the responsibility lies for the lousey treatment of the customer, BOTH the Insurance Company and the DME are at fault. The insurance company knows darn well how much they'll pay the DME, which is where my 10 percent payment is derived from and the DME inflates the purchase price in the invoice, which in my case doesn't really matter because my portion isn't based on that so end of rant, The simple question is: WHY ALL THIS EVASIVE MESS FOR A CUSTOMER ALREADY STRESSED WITH THIS HEALTH ISSUE?
Thanks

Your insurance sets the rules, not your DME provider. They just have to abide by them. Your insurance company wouldn't give you amount because you might take that as a promise to pay, and they want to reserve their right to say you don't qualify. They haven't seen your sleep study, don't know if there is a valid physician's order in place, if you will be compliant with the use, etc. All those things factor into whether they will pay.

But you did get the answer that I have been saying a patient would get if they called their insurance company. They pay one price for an E601, and they do not obilgate the provider to give you one with features like autoset. Looks like your DME provider gave you a free upgrade. Very nice of them.

As to how much you will pay the DME -- if your insurance plan says you pay 10% then it will be 10% based on the insurance fee schedule. The DME may have no idea what that fee schedule is (either because the insurance payer won't disclose it, or because they are not contracted with that payer, but are allowed to bill claims out of network), so they cannot tell you your amount until the insurance company pays them.

[chunkyfrog]

Shouldn't you be watching somebody sleep?
Your boss is watching.

[ltts]

s

As I see it...

The actual problem begins with the sleep doctor. If the doctor took time to educate the patient on the importance of what the sleep study revealed, rather than just summarizing the summary sheet, the patient would come away from the meeting with an understanding of the importance of AHI and the other data that made up the diagnosis.

Many people will still not be interested in monitoring their progress, but some will. With education the demand for full data machines will rise, and there may be pressure put on the insurance companies to review their policies on machine reimbursement.

The problem with this approach is that the doctors don't put any value in the machine scored data. If they are going to make adjustments, they need another sleep study to get what they determine as "reliable" data. This is a problem that the xPAP machine manufactures need to address. There are some studies correlating the data from a home machine and the sleep study data, but they are too few to be conclusive.

I will also point out that with all technological advancement, expectations change...

Just so you know, I live in a "deluxe" house that has both hot and cold running water, and flush toilets. In addition, my computer has a built in hard drive...

No question that deluxe (as it is called by the insurance payers - not me) is in the eye of the beholder. A few months ago I came across the case of a patient in KY that needed a power wheelchair. He hunted a lot, so for him the custom camo patient offered by Invacare was a "must have" feature because it would improve his quality of life (not unlike why people want Autoset machines). He was not a happy camper to find that the DME was not willing to absorb the extra $300 cost.

[ltts]

Shouldn't you be watching somebody sleep?
Your boss is watching.

LOL! I'm the boss.

[NateS]

From the Medicare manaul-

The following instructions apply to situations where the ABN is being used for upgrades and applies to
both assigned and unassigned claims.

An upgrade is an item with features that go beyond what is medically necessary. The Centers for
Medicare & Medicaid Services defines an upgrade as an item that is more expensive, contains more
components or features, or is greater in quantity than what is medically necessary under Medicare’s
coverage requirements. When a DMEPOS supplier knows or believes that the DMEPOS item does not
or may not meet Medicare’s reasonable and necessary rules under specific circumstances, it is the
responsibility of the supplier to notify the beneficiary in writing via an ABN if the supplier wants to collect Jurisdiction B DME MAC Supplier Manual

Chapter 10: Advance Beneficiary Notice of Noncoverage

money from a beneficiary if an item is denied. When a beneficiary prefers an item with features or
upgrades that are not medically necessary, a supplier may collect the difference between the charges
for the upgraded item and the charges for the nonupgraded item, if the beneficiary agrees to be
financially liable by signing an ABN.

Medicare.gov
https://questions.medicare.gov/app/answ ... 22-mean%3F

What does "medically necessary" mean?
Services or supplies are considered medically necessary if they:

Are proper and needed for diagnosis, or treatment of your medical condition.
Are provided for the diagnosis, direct care, and treatment of your medical condition.
Meet the standards of good medical practice in the medical community of your local area.
Are not mainly for the convenience of you or your doctor.

[ems]

OMG... I finally got to the end of this thread... the end for now anyway. I woke with head/neck/shoulder pain again this morning... seems it's getting worse instead of better. I'm starting to entertain throwing in the towel with BPAP... then I start to read this thread and now feel even worse. Not sick enough to call my doctor and the DME isn't in or won't answer anyway. Trying to understand what the point is... what is the OP trying to tell us anyway? Why does he/she feel she needs to protect the DME's? Why are so many of you getting so pi**ed at her? Who cares?

I would just like to feel better! It was promised that I would... but aside from being less fatigued during the day, I don't feel any better. Headaches are worse (and no, no brain tumor) than before I started with this therapy. All my numbers are good (Pugsy said so ), so why don't I feel better? BP is low, blood work in the acceptable range. Why aren't there real answers to real questions? So much of this is guess work. So few clinical studies that produce real results. That's what we should be talking about. The $$$ that DME's make should be the least of our concerns - why they know so little, yet sell these machines, is what we should be angry about. Getting the help we need and having our questions answered should be what the discussion is here. Using this therapy is like living in the dark ages. I feel as tho I'm using a machine that no one really knows anything about - it's all guess work - and they are guessing on me! I feel like a guinea pig.

[ltts]

I am new here, and won't have my titration study done until tomorrow, so please excuse some of my ignorance. I find this thread very educational. I have been a sponge absorbing all of the information I could find since my first sleep study about a month ago, and, for the most part, all of my readings had me convinced that almost all DMEs were basic slime. Aetna is my insurance and it will be interesting to see, of the 26 DMEs within network and within 15 miles of my home, just what the span of equipment will be that they are willing to provide based on what my insurance agrees to.

Well here are some questions to ask:

1. If you and/or your doctor decide you need an autoset will they provide that at no extra cost to you?

2. Do they have a mask replacement program? Will they proactively contact you when your insurance allows for replacement supplies?

3. Do they have a mask trial program, meaning can you try a mask for up to 30 days to ensure it works well for you? If they don't and you otherwise want to use them try talking to the owner/manager and see if they have contacted their manufacturers reps about this program. Some manufacturer's reps simply haven't done the job to make these programs available to DME providers.

If you can find one that is fairly close to you (instead of 15 miles away) that would be a plus. It will make it easier for you to take the machine to schedule free checks, switch masks until you find the right one, etc. I think those are the most important points.

Good luck!

[ltts]

OMG... I finally got to the end of this thread... the end for now anyway. I woke with head/neck/shoulder pain again this morning... seems it's getting worse instead of better. I'm starting to entertain throwing in the towel with BPAP... then I start to read this thread and now feel even worse. Not sick enough to call my doctor and the DME isn't in or won't answer anyway. Trying to understand what the point is... what is the OP trying to tell us anyway? Why does he/she feel she needs to protect the DME's? Why are so many of you getting so pi**ed at her? Who cares?

I would just like to feel better! It was promised that I would... but aside from being less fatigued during the day, I don't feel any better. Headaches are worse (and no, no brain tumor) than before I started with this therapy. All my numbers are good (Pugsy said so ), so why don't I feel better? BP is low, blood work in the acceptable range. Why aren't there real answers to real questions? So much of this is guess work. So few clinical studies that produce real results. That's what we should be talking about. The $$$ that DME's make should be the least of our concerns - why they know so little, yet sell these machines, is what we should be angry about. Getting the help we need and having our questions answered should be what the discussion is here. Using this therapy is like living in the dark ages. I feel as tho I'm using a machine that no one really knows anything about - it's all guess work - and they are guessing on me! I feel like a guinea pig.

I'm not implying that any patient should be concerned about whether their DME makes money. But I do think it's important for you to realize how much they do for free and fully understand what your insurance payer covers and does not cover as far as features. Many DME providers WILL provide free upgrades over and beyond what is covered. But I don't think the best approach to getting them is calling the DME a liar (particularly when they aren't lying at all) when they explain to you what the reality is regarding insurance payment.

If you feel that your pressures are set appropriately and you're still not feeling better you should make another appointment with your physician. And bring your current data with you to the appointment. Did you have many central apneas in your initial or titration studies? I don't think I would ask a person on the internet to read your data and tell you whether your numbers are good or not.