ABN Question--Is this common?

[Janknitz]

I just heard about someone who was given an ABN to sign on the date of delivery of her CPAP equipment. (ABN for those who don't know is an "Advance Beneficiary Notice" a Medicare provider must issue to let the Medicare recipient know when a goods or services may not be covered by Medicare). The ABN stated that the patient would be responsible for the entire cost of the machine rental if she didn't meet the compliance requirements.

Is that a standard ABN? Do they always issue an ABN at the beginning warning people that they will have to pay out of pocket for lack of compliance? Do they issue these to everyone with CPAP???

This site http://www.medicareinteractive.org/page ... ipt_id=191 says:

You might not be responsible for charges if the ABN:
•Is difficult to read or hard to understand.
•Is given by the provider (except a lab) to every patient with no reason to believe claims may be denied.
•Does not list the actual service provided or is signed after the date the service was provided.
•Is given to you during an emergency or is given to you just prior to receiving a service (i.e. on the way into the MRI machine).

They required her to sign the ABN as they were delivering the machine.

The DME is using this ABN she signed to claim that because she didn't meet the compliance requirements (long story with significant extenuating circumstances) she owes the entire $300/month (!!!) rental for the machine in perpetuity--they sued her for an incredible amount of money.

Since I don't have Medicare I've never seen any ABN related to CPAP, but I was curious if it is standard to get an ABN warning of compliance issues before the machine has even been delivered???

[grayghost4]

When my wife received her machine a year ago she was asked to sign the same thing. It was never enforced when Medicare refused to pay for the machine, not because of compliance ... but because the DME was not the the same county as us and had not won the bid for our county ... so we returned the cpap and purchased one on craigslist .... much less trouble ... no rental ... no compliance.

[MarylandCPAPer]

I got a new A10 machine June 30 and don't recall signing such a form, but will look through my paperwork when I find it and let you know.. I was told that the A10 would send compliance data to the DME remotely and that Medicare would not pay for the machine if I wasn't compliant for the first 30 or 90 days, can't remember which, since I am 100% compliant.

The DME said most people starting on CPAP aren't compliant during the 30 or 90 day period, so Medicare gets out of paying for the machine (and presumably the DME takes back the machine). The DME said Medicare doesn't really want people to be compliant, because they don't want to pay for CPAP machines. I wouldn't take anything the DME said as being accurate, but it was an interesting perspective.

[Janknitz]

Bumping this in case people didn't see it last night.

This lady really needs help!

[MarylandCPAPer]

I just checked the paperwork I got with my A10 machine on June 30, 2015, using Medicare coverage. I am diligent in asking for a copy of every document I sign and the DME was very willing to provide copies. I do NOT have an ABN document. Perhaps my 100% compliance rate on my prior CPAP machine indicated to them it was not necessary, as I was very diligent in my pursuit of the machine, with the complaint that my existing machine of 5.5 year was non-functional and I cannot sleep without CPAP.

I DID, however, receive an ABN when I went for blood tests. There was an ABN that Medicare may not cover the costs of B12, lipids panel, and HBA1C tests. I was a little shocked to be presented with an ABN when I got the blood tests done, a few weeks before I got the new CPAP machine, so I was aware of what an ABN is.

I am curious, what DME is involved, so I can avoid them? I cannot imagine that the contract could force the person to pay a monthly rental in perpetuity. The machine won't last more than 5 years, if my well used PR System One is any indication. It is now effectively only a leaf blower.

[Pugsy]

It's been a few years so rules may have changed but back when I was working our clinic was not a Medicare participating facility...so when we saw Medicare patients we asked them to pay up front and essentially the patients signed an ABN each time they were seen. Now we did go ahead and file to Medicare and Medicare would send them the check if it was covered and maybe explain why no check if the office visit was denied...BUT we still were bound by the rules/regs for how much we could charge Medicare patients.
Every Jan we got new allowable charges fee schedules....almost always less than the prior year for the common stuff and increases only in the stuff we rarely ever did. That's Medicare's way of saving money.

What does Medicare say about all this?
Is a Medicare Advantage plan involved? Mine is a perpetual machine rental now and for that reason alone I wouldn't ever be using them for a machine.

Is this a local mom and pop DME store? Are they participating providers?

[MarylandCPAPer]

If it matters as to the ABN, my DME is a nationwide, in-network provider with Medicare.

I had to switch DMEs when I got on Medicare because my prior DME was discontinued as an in-network provider with Medicare.

Prior to Medicare and the switch in DMEs, I was on a Carefirst (BCBS) insurance plan. I was not even given the option to stay with my prior DME and pay out-of-pocket. The prior DME had been an in-network provider with Medicare prior to me going on Medicare and was very astute on how insurance and Medicare works, and very efficient at getting insurance payment for everything I got from them.

[Krelvin]

The DME is using this ABN she signed to claim that because she didn't meet the compliance requirements (long story with significant extenuating circumstances) she owes the entire $300/month (!!!) rental for the machine in perpetuity--they sued her for an incredible amount of money.

I they were sued, they need legal advice.

If they have been threatened with a suit, they need legal advice.

Both would be from an attorney with relevant experience in that local matter.

[Cpapappy]

You cannot have a pt sign an Abn until day 60 of the initial 90 day trial if the patient is showing noncompliance.

[chunkyfrog]

My first EX-DME had me sign one before they would hand over equipment.
At the time, I knew no better. But I learned, and fired their miserable company.

[Janknitz]

You cannot have a pt sign an Abn until day 60 of the initial 90 day trial if the patient is showing noncompliance.

Is there a written rule that says that?

[Cpappappy]

Blanket abn on Cms(dot)gov.

[Baja]

CpapPappy is correct. Medicare prohibits generic ABNs.

See Routine, Generic or Blanket ABNs (40.3.6.1 to 40.3.6.4):
https://www.cms.gov/Regulations-and-Gui ... 104c30.pdf

[Cpappappy]

That's the link! Couldn't post 'cause I'm not registered. (And I can't)

[Janknitz]

Thanks, everyone. I passed the info along and I'm waiting to hear how it came out. The DME took her to small claims court with a threat that they would keep taking her to small claims every 6 months instead of suing for the 12K (!) in superior court. The woman couldn't find a lawyer because this individual case is small (small claims is limited to $2,500) and lawyers around her don't know Medicare law or DME issues.

In the course of their case, they found out this DME was doing the same thing to several other people as well--they are taking advantage because the court knows nothing about Medicare/DME either. I don't know if this practice has stopped because it was a small, local DME that did not get a competitive bidding contract for Medicare. Her issues arose from a CPAP that was supplied in 2012, before competitive bidding.

This is a real scumbag of a DME, though. It would be nice if Medicare would go after them for fraud or someone would be willing to do a class action suit, but it may be moot at this point.