Not a fan of DME rants, but...

[kteague]

In view of recent discussions on Medicare cuts, I guess I shouldn't be surprised, though it's really nothing new, but I had a frustrating phone encounter with an employee of Allstate Medical today. I've been in L.A. for a while now and selected to this company from a list provided by a new doc I'd seen here who gave me a script for equipment and supplies. When asked which model of the System One they planned to provide, it was the Plus. Told him I would need the Pro and was not interested in the Plus model. His reply - do you even know the difference? Well, if I didn't know the difference, why would I have even asked?! When I said the Plus doesn't provide data, he said that yes it does provide data. I countered that I already know how much I use it, that compliance data is not what I'm interested in. He said Medicare will only provide the Plus model because it provides the data THEY need. Period. Had the whole discussion about billing numbers, etc. He didn't budge and got irritated with me. Explained to him I have other sleep disorders and having treatment data enables me to narrow down the source of any sleep problems rather than keep getting studies. Still didn't budge. I asked him what if the doctor wrote the script for a specific model, would they provide it then? No - not through Medicare. I could only get the Pro if I private paid for it. He said Medicare says I should get the Plus model, so it doesn't matter if I WANT the other machine or THINK it MIGHT be beneficial to me. Told him I'd take my business elsewhere. When I placed the call I was planning to order a new mask, hose, and filters. Oh well, moving right along...

[Janknitz]

Ugh! At least you have a list of options to choose from.

I think we should all get in the habit of stating we want a "machine with EFFICACY data", rather than saying we want a "machine with data". It puts the DME on notice that we know what we are talking about and to think twice about playing games.

Won't necessarily stop the games, especially with clueless newbies, but at least they can't the "it does have data" game once we have specified what type of data we mean.

[ems]

I just sent back a mask that didn't work for me, well within the 30 day trial period. I don't expect a problem but you never know. If I do I'll plaster their name all over the forum. I did ask for another mask so we'll see what happens.

[DreamStalker]

There are a couple of other threads on how DMEs are taking a 47% cut on Medicare reimbursements ... so that is why they are likely refusing your request. Your request cuts even more into the 47% cut they are now facing.

The problem with our healthcare system is the same as the economy and our standard of living ... it's unsustainable.

[DoriC]

. Still didn't budge. I asked him what if the doctor wrote the script for a specific model, would they provide it then? No - not through Medicare. I could only get the Pro if I private paid for it. He said Medicare says I should get the Plus model, so it doesn't matter if I WANT the other machine or THINK it MIGHT be beneficial to me. ...

I'm not sure of this but I think that if a DME is a contracted Medicare provider they have to dispense a Dr's RX as written. The codes are the same for Plus or Auto and Medicare pays the same so they don't care which one the patient gets. With the higher end machines it may be a different documentation. How about a call to Medicare? K, I have faith in you, keep us posted!

[chunkyfrog]

What Dori says; +1
I would also get the Rx from my doctor for the EXACT machine--DAW!
Can you get a TV news crew to come along?

[jnk]

Sounds to me like the way things are heading is that docs will be limited in what they can prescribe if they want to stay in the Medicare game. And soon, the insurance game. The docs will either have to play by the payers' new money-saving rules or not see patients of those payers who have contracted with suppliers who agree to supply only certain machines in certain circumstancs. The payers and DMEs will then have power over the docs to keep the docs from doing what the doc may want to do as best for the patient but what the patient's payer doesn't want to pay for. The payers dictate the medicine being practiced.

In other words, if Medicare forces you to use one particular DME, and a doc prescribes something that DME believes it can't be forced to supply, the DME can then refuse to fill any Rx that does not meet the criteria of what the DME believes it contracted with Medicare to supply. And then the DME can simply wait for Medicare to smack the doc into line with the program so that the doc will then write an Rx that the DME is willing to fill. The patient then has no rights to go anywhere else unless the patient pays out of pocket. Payer and DME win. Doc and patient loses. It's the new normal.

But I may be wrong. I don't have any actual firsthand knowledge about such matters. I'm just saying what it all smells like from a distance.

[bjcyorkiemom]

The Doctors are never limited to what they can prescribe, but the DME / HME companies are limited to what they can provide by finances, and soon to be even more limited with the newest round of Competitive Bidding, which is anything but...

If your finanaces allow, find a DME that is "Non Partipating". A "Participating" DME has to file with Medicare an can not charge you anything more than your 20% co-pay, which either you or your secondary insurance are responsible. A "Non-Participating" DME can bill Medicare for a standard machine and bill you a deluxe charge for something more than that. I work for this kind of DME dealer. Basically we can pick and choose what we bill direct to Medicare and what we bill a deluxe up charge for or even take "non-assigned", which means you would pay up front and Medicare would reimburse you 80% of what their "allowed amount" is. A good number of people in my state have a second insurance that picks up the balance, plus whatever Medicare doesn't allow, bascally paying the customer back 100%.

[DreamStalker]

Sounds to me like the way things are heading is that docs will be limited in what they can prescribe if they want to stay in the Medicare game. And soon, the insurance game. The docs will either have to play by the payers' new money-saving rules or not see patients of those payers who have contracted with suppliers who agree to supply only certain machines in certain circumstancs. The payers and DMEs will then have power over the docs to keep the docs from doing what the doc may want to do as best for the patient but what the patient's payer doesn't want to pay for. The payers dictate the medicine being practiced.

In other words, if Medicare forces you to use one particular DME, and a doc prescribes something that DME believes it can't be forced to supply, the DME can then refuse to fill any Rx that does not meet the criteria of what the DME believes it contracted with Medicare to supply. And then the DME can simply wait for Medicare to smack the doc into line with the program so that the doc will then write an Rx that the DME is willing to fill. The patient then has no rights to go anywhere else unless the patient pays out of pocket. Payer and DME win. Doc and patient loses. It's the new normal.

But I may be wrong. I don't have any actual firsthand knowledge about such matters. I'm just saying what it all smells like from a distance.

I think you have it fairly correct ... except it's not called the new normal ... it's called fascism, a government system of the corporations, by the corporations, and for the corporations.

[Sheriff Buford]

The next time you go... I'll go with ya'. You can introduce me and tell them I'm carrying a weapon...I also carry my taser, pepper spray and my night stick (my ole wooden one and the new fangle-ones).

Sheriff

[archangle]

If you have a cooperative doctor, get him to write a prescription specifying a pressure range. Then he'll have to dispense an Auto CPAP machine, which you can set to CPAP mode later if necessary. Of course, they could try to dispense an S9 Escape Auto, but that doesn't seem to happen that often.