DME Malpractice - How you can save top dollars!

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
chalasani
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DME Malpractice - How you can save top dollars!

Post by chalasani » Thu Jul 24, 2014 12:55 pm

If you or one of your near /dear ones ever need to procure a medical device against a prescription, you need to be aware of the underlying malpractice that is known to, but ignored by, Insurance carriers, . . . is rampant - in fact, entrenched - in the industry, and, . . . how to protect yourself from it while saving precious, hard earned, and - your very own - dollars!

Before I proceed, I list here some typical DME covered by Insurers (not a complete list!)
home oxygen equipment
infusion pumps
wheelchairs
walkers
hospital beds
seat lifts
prosthetic equipment (like cardiac pacemakers, enteral nutrition pumps, and prosthetic lenses)
orthotic items (like leg, neck, and back braces)
prostheses (like artificial legs, arms, and eyes)
respirators (APAP, CPAP, BiPAP etc)

Here is how it starts: the patient goes to a physician for a condition that requires a DME. The physician refers the patient to a study professional who assesses the need, gravity, intensity, frequency of whatever that needs to be "assessed".

The study professional communicates the study results and then advises the referring physician for next steps. Results are communicated to the patient too, but after a "very" slight delay of about two days.

Meanwhile, the referring physician "routinely" issues a certificate of medical necessity to the study professional without any consultation with the patient. (The patient knows this after the fact!)

More often than not, the study professionals, who seem to be independent in the beginning, are tied up with a "sister" concern who happen to provide the very same device the patient needs.

The study center then schedules a professional, "educational" appointment with the patient and walks through the process of using "a" (the most fitting, so to speak) medical device and trains (the mind) on how the equipment best suits the medical need.

Did I mention that the patient's Insurance coverage, deductible - the patient's ability to cover the deductible has already been taken care of by the study professional? No? Ooops!

During the education session, a word is also casually thrown in as to the Insurance carrier being strict in following up on usage data while providing equipment that is likely to be unused, and hence there is a need for the study center to evaluate the progress of the patient and the level of comfort and benefit in "about three months" (read "forever").

Once the patient's mind is "happily" associated with the equipment, the technician walks the patient across the floor to his sister company that now takes over the transaction.

This is the dreaded "Durable Medical Equipment provider" (DME) that I want to warn you about.

The vendor's technical rep rapidly gets the paperwork signed and has the deal closed - before the patient wakes up from his/her stupor.

What you need to be aware before you even enter the DME's office is that you need to know the make, model and specs of the equipment that you would be assigned (more often than not, you will be given a make model spec of an equipment that is typically not returnable by google)

Anyway, coming back to the paperwork: The patient will notice that s/he is signing insurance paperwork for the "purchase" of equipment. Do I need to mention that you will never be able to extract an itemized list of the equipment, make /model, accessories etc., from the vendor?

Now imagine you are the patient . . . Fast forward, . . . go home, . . . don't open the equipment yet!

Go online and browse through your insurance referrals and authorizations - you will find that there is an authorization, issued the very same day, for an equipment rental for three months+, for which you are about to be billed - unknown to you - for equipment rental!

If you want to have some fun, call the vendor's office and the first respondent will direct you back to the study center who will then try to deflect the call back to the vendor - they are experienced, and hence, pretty good at this.

You need to remember all along is that you have the right to have the CMN (Certificate of Medical Necessity) (you should have taken this from your physician directly in the first place!)

Now go ahead, return the equipment - while notifying your insurance company of a cancelled transaction with all possible documentation and dates on it. Don't forget to get the CMN from the DME (even if you do, you can still get it from your physician, but that could mean turnaround time lost, especially when you need the equipment badly - remember it is a "Medical necessity")

Now, why would you want to go through the entire process of being educated when you don't intend to buy the medical equipment from the DME provider? Remember, you need to have hands-on experience with the equipment you will be using going forward, and you will not get a better opportunity than the one being provided by your very own study specialist!

Go ahead, get the CMN, leave the DME, go online and start your research (you may not find the model your study center offered you, but hey, there are a lot of other genuine products that provide equally good warranties!).

Don't lose sleep over the extra forty percent a DME is going to pile on your insurance as claim for rental on an equipment that you have already purchased.

Please note - this article is written for patients whose deductibles are not yet maxed out, hence the factor of compliance is not addressed in context.

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Drowsy Dancer
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Re: DME Malpractice - How you can save top dollars!

Post by Drowsy Dancer » Thu Jul 24, 2014 1:01 pm

I think your definition of "malpractice" must be different from mine. Where did you go to law school?

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Re: DME Malpractice - How you can save top dollars!

Post by sc0ttt » Thu Jul 24, 2014 1:47 pm

That's the longest post by a first-time poster I've ever seen on any forum.

I'm guessing he posted it on a bunch of other forums as well, ones dealing with:
home oxygen equipment
infusion pumps
wheelchairs
walkers
hospital beds
seat lifts
prosthetic equipment (like cardiac pacemakers, enteral nutrition pumps, and prosthetic lenses)
orthotic items (like leg, neck, and back braces)
prostheses (like artificial legs, arms, and eyes)
respirators (APAP, CPAP, BiPAP etc)

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Re: DME Malpractice - How you can save top dollars!

Post by palerider » Thu Jul 24, 2014 1:49 pm

sc0ttt wrote:That's the longest post by a first-time poster I've ever seen on any forum.

I'm guessing he posted it on a bunch of other forums as well, ones dealing with:
home oxygen equipment
infusion pumps
wheelchairs
walkers
hospital beds
seat lifts
prosthetic equipment (like cardiac pacemakers, enteral nutrition pumps, and prosthetic lenses)
orthotic items (like leg, neck, and back braces)
prostheses (like artificial legs, arms, and eyes)
respirators (APAP, CPAP, BiPAP etc)
I got lost about half way through, is there a tl;fa (too long, fell asleep) version? *lol*

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library lady
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Re: DME Malpractice - How you can save top dollars!

Post by library lady » Thu Jul 24, 2014 2:20 pm

In some places, that is probably an accurate assessment, but it doesn't happen where I am (see my avatar if you haven't already).

I neglected to do research prior to getting my machine so I went into this blind. My sleep center called me to say my prescription was ready and asked where I'd like to have it sent. I said I didn't know, could they send it to me so I could take it in when I decided? They sent it to me, and after looking around for a few days I decided to use the Sleep Apnea Store that is in my clinic complex as it is not affiliated with any of the national or chain DMEs, also because it's easy to get to from my home. I took my Rx in, and they showed me three machines. I picked one, later found out that all three of them have full data efficacy, apparently that is all they have in-house. The tech showed me how everything worked, pulled the SD card out and said "this records the data for compliance along with other data about your sleep efficiency."

I was not asked to sign anything until after tech had shown me the paperwork and explained to me the 13-month rent-to-own policy that Medicare has, along with the compliancy rules and that I would be billed each month after my Medicare Advantage had paid its share, which of course includes the Medicare portion. That turned out to be exactly what happens. The clinic staff takes care of the data compliancy, so I don't deal with the DME at all for that part. The sleep center calls me to make an appointment and I pack up the machine and take it down there. DME and sleep center are not located in the same office, but they are on the same floor with independent billing operations. I did not have to ask for a copy of the Rx I gave them, it was given to me once I'd signed the paperwork.

So, you should all go into this with questions on how they operate and get compliance taken care of, etc. Also know that while there are unreliable DMEs, there are also reliable DMEs.

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Re: DME Malpractice - How you can save top dollars!

Post by Janknitz » Thu Jul 24, 2014 4:17 pm

OP is giving a pretty accurate portrayal of how most people experience the CPAP mill. Substitute the word "prescription" for "Certificate of Medical Necessity" and it makes a little more sense (yes, some insurers do require a CMN, but it's the RX which the DME "fills", just as a pharmacist fills your medication RX).

This is how it is for most people. They go in for a sleep study, most don't expect a diagnosis and have no clue what's next in store. And because people ARE so clueless ,the system is set up to serve them while keeping them clueless. Even if you do go through the fiction of being asked to choose a DME rather than having one chosen for you, as a brand spanking newbie, what do you know about it all? How can you possibly choose as a wise consumer? That's how this wheel turns, over and over again.

Occasionally someone is smart enough to think "I'll do some research" and winds up here, where there is a STEEP learning curve--what is OSA, how is it measured, how bad is it, do I really need treatment, what treatment is best, but I don't like that option!, what's a DME, what's a CPAP or APAP, how is it determined which machine and mask I will get, do I have any say in all this????? Most people don't ask these questions. They do exactly what the do for the medication prescription--my doctor says I have to take this medication, please fill the prescription and I'll take it as long as I don't hate the side effects, what do you mean it costs me $1,200 out of pocket?"

So I take it that the OP was venting because he/she didn't like the process much, feels cheated and angry. Welcome to the club--we are all here because we are members. So even though it feels kind of late, climb that steep learning curve, educate yourself and learn to be your own advocate. We're here to help if you want it.
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Re: DME Malpractice - How you can save top dollars!

Post by Drowsy Dancer » Thu Jul 24, 2014 5:25 pm

Not all exploitative business practices are "malpractice," however, which is a word with a real meaning.

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Re: DME Malpractice - How you can save top dollars!

Post by library lady » Thu Jul 24, 2014 5:29 pm

Janknitz, you're right that the OP's experience is the norm, I just wanted to point out that not all DMEs are alike, but to go into it asking questions regardless. Like everybody else here, I went into it blind, didn't find this forum until after my first two rotten nights. The DMEs and the docs don't tell us much of anything about what to expect. I'm not certain 'malpractice' was the term to use though.

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Re: DME Malpractice - How you can save top dollars!

Post by Drowsy Dancer » Fri Jul 25, 2014 9:14 am

I would consider that medical malpractice occurs when a health-care provider deviates from the recognized “standard of care” in the treatment of a patient. The “standard of care” is defined as what a reasonably prudent medical provider would or would not have done under the same or similar circumstances. In essence, it boils down to whether the provider was negligent.

I look forward to the day when prescribing data-capable machines to a patient with apnea is considered the "standard of care" and the provision of a brick to be malpractice. We're not there yet.

There's also a leap of logic in asserting that a DME is committing "malpractice" in their pricing practices. Are DMEs "treating" a patient when they sell equipment? Are DMEs "medical providers"?

I am no friend or defender of the system, let's just be clear about who's doing what that is wrong.

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Re: DME Malpractice - How you can save top dollars!

Post by chunkyfrog » Fri Jul 25, 2014 9:32 am

The DME is engaging in marketing--this is his job.
Our own healthcare involves shopping; we can't afford to pretend it doesn't.

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chalasani
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Re: DME Malpractice - How you can save top dollars!

Post by chalasani » Sun Jul 27, 2014 8:56 am

If you are belong to the "tl;fa" class, here is another opportunity to fall asleep again . . .

A patient's pressure needs change day by day, - more so hour by hour during sleep - and differ within the night depending upon the sleep stage.

The pressure needs to address OSA are also affected by what the patient eats /drinks, body weight, drugs (read medicine) relied upon to address other issues, the sleeping environment, sleeping position, and whether sick etc, but not limited to these alone.

A one-time titration in a sleep lab in a second stage study in the second half of one night cannot account for all these parameters.

The first CPAP assigned (rented?) issued immediately after the study is set an initial pressure recommended in the titration - which usually has a tremendous scope for improvement. The clinic is well aware the pressure settings are subject to change eventually - not to talk about the initial adjustments and comfort levels associated with the mask itself!

Patient continues to rely on the clinic to address each and every increment or other adjustment that only a "Clinician" can perform. (BTW, . . I know there will be a lot of flames on this, but here it goes anyway . . . if one is tech-savvy, clinical adjustments to the A/CPAP device could be carried out home with a little caution - it is not a rocket science!)

Eventually, a couple of painful visits, and possibly a thinner wallet later, there will be a recommendation of a more advanced device to suit the specific needs of the patient - an APAP!

So, the CPAP was a brick was it not? (FYI - the sleep study which gave me the initial reading in one night, billed my insurance for $1700. I just found out that there is a less than $300, at-home, three night study (needs prescription, though) - which gives a better average.)

These trips to the clinic could be avoided if patients (many, if not all), are educated about the process and assigned an APAP to begin with instead of a CPAP.

I do believe, any person who has an email and could set up an account in this forum is intelligent enough to use SleepyHead software and read parametric figures and make corrections over a period of time.

I did my own monitoring to find my initial pressure recommendation (based on a study during the wee hours of the morning) of 6 stands corrected to 8.5 which is based on a three day average on an APAP and spikes reported in reports recorded during the initial sleep.

My turnaround time to better sleep? Three days . . . intensive research and self study, and not relying on the first brick offered to me that cost $340 (and, respectfully, the masks) that would have ended up with a deductible of $1010.95.

I chose to invent my own little wheel within the parameters of the prescription and ended up buying an APAP with mask for under $700. So I not only saved over $300, I do not have to rely on a clinic for tweaks for something that I could on my own.

I know this post will once again be subjected to flames, but heck . . who is the loser?

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chunkyfrog
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Re: DME Malpractice - How you can save top dollars!

Post by chunkyfrog » Sun Jul 27, 2014 9:10 am

@chalisani: We are NOT "that other" forum. --we are mostly friendly.
What you say is one of the primary principles we live by here. (and well said, at that)
You are "preaching to the choir" here. You are saying nothing we do not already know.
We are all working to spread the word, and educate other patients and even providers wherever possible.
Some have mentioned your use of the term, "malpractice"--which might be debatable, in a legal sense,
however, many of the unscrupulous practices used by DME's might actually be prosecutable--
--IF the plaintiff has piles of money!

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Re: DME Malpractice - How you can save top dollars!

Post by photonic » Sun Jul 27, 2014 12:05 pm

Just as an interesting point of interest, the term malpractice has a two part requirement as far as medical malpractice is concerned.

1. Must deviate from community standards of practice

AND

2. If must cause harm

Kind of interesting to know that non standard care that doesn't harm you is not malpractice. who knew.
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Re: DME Malpractice - How you can save top dollars!

Post by englandsf » Sun Jul 27, 2014 12:18 pm

There seems to be very poor delineation of who does what between the sleep doctor and the DME and no-one is really there to support the patient through the process.

The money is in the margin on the hardware, but should be in the consulting that needs to be done to help get a new user up and running. There lies the biggest issue IMHO.

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Re: DME Malpractice - How you can save top dollars!

Post by Janknitz » Sun Jul 27, 2014 3:27 pm

Kind of interesting to know that non standard care that doesn't harm you is not malpractice. who knew.
You say that as if it was a bad thing. Sometimes the standard of care is what's harmful and it requires a practitioner who thinks outside the box to try something different that might be better. Case in point, huge numbers of women died from childbed fever because it was not standard of practice for doctors and midwives to wash their hands before delivering babies.

I pray my doctors think outside the box and buck the standard of care by NOT prescribing statins. IMHO, a good deal of the dementia, heart failure, and diabetes are a result of this "standard of care" routinely prescribed for individuals who are healthy in the first place. Likewise, standard of care routinely prescribes high carb diets for diabetics who have a severe glucose tolerance. It takes a doctor bucking the standard of care, like Richard Bernstein, to prescribe a low carbohydrate diet.

Imagine if these practitioners were liable for prescribing treatment outside the standard of care.
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