Is this Medicare Fraud?

[hootenanny]

I don't understand Medicare billing and have been told it can be complex but this strains credulity.

At my setup, the therapist determined my size was a medium nose pillow but he took back the small and large ones included in the package. I asked him what he was doing with them and I didn't get a straight answer. A couple of days later they send 5 more mediums in the mail.

I noticed my 20% copay for nose pillow(s) at the initial visit was $14.63 and the subsequent five at $17.67. I believe this is fraud. I did not receive the other two nose pillows, but judging from a per unit cost perspective it looks like I paid for them.

They DME company says they can only give me six pillows (for a three month period). But the logic just isn't there for me. It seems like I paid for 8 to get 6 mediums I can use rather than pay for 6, get 6, but could only use four mediums. Is this the way it works?!?

I launched an investigation via Humana and they reached out to the company and the DME said I only paid for one at the initial setup. I don't believe it. The office woman at the DME does not return my calls. What happens to the two extra nose pillows from setup? Are they sold for profit?

Humana is supposed to be the expert on the medical billing not me. But their response letter to me about the grievance is simply a statement from the DME company that I paid for one pillow at setup. They don't seem to be offering any expert advice on medical billing. The letter is ambiguous about whether there is an actual decision. It says they take matters seriously and that I have a right to an appeal for a denial of service. But this isn't a denial. It's ambiguous about whether their Provider Relations Department is doing any further investigation or decision making.

Maybe I'll learn more when I call Humana?

This isn't the hill I'm going to die on for what seems to be a $10 error. But imagine this amount accumulated across every user who does an initial setup? I think it should be a big deal to Humana and Medicare.

[Pugsy]

What happens to the two extra nose pillows from setup? Are they sold for profit?

There is a very real chance that the 5 mediums you got were taken out of someone else's package that maybe ended up needing the size small. Someone else will likely get the other sizes you didn't get.

Mask packages are broken down into individual components for billing even if they all came in one package.
The DME bills out for the
headgear
the mask frame
the nasal pillow or mask cushion
all under individual HCPCS billing codes for the item.

Technically they billed for one nasal pillow....but morally they are abusing the system IMHO.
It's done all the time...doesn't make it right but a lot of DMEs do it this way so that they can sell the 2 pirated pillows to someone else.

[Rubicon]

At my setup, the therapist determined my size was a medium nose pillow but he took back the small and large ones included in the package. I asked him what he was doing with them and I didn't get a straight answer. A couple of days later they send 5 more mediums in the mail.

I noticed my 20% copay for nose pillow(s) at the initial visit was $14.63 and the subsequent five at $17.67. I believe this is fraud. I did not receive the other two nose pillows, but judging from a per unit cost perspective it looks like I paid for them.

They DME company says they can only give me six pillows (for a three month period). But the logic just isn't there for me. It seems like I paid for 8 to get 6 mediums I can use rather than pay for 6, get 6, but could only use four mediums. Is this the way it works?!?

I am not understanding your math.

They should have used HCPS A7034 (edited) which is one pair of pillows. If at initial visit they gave you one pair, and charged you for one pair, then what they did with S and L is academic.

Did you pay $17.67 for the 5 units? Or $17.67 each for the 5 units?

Please explain

judging from a per unit cost perspective it looks like I paid for them.

better.

[southerndoc]

I think the OP is trying to say they are getting a 3-pack (S/M/L), selling the OP mediums, and then selling the other 2 to other patients.

[hootenanny]

I paid $17.67 total for 5. How could one be $14.63?

[Pugsy]

I paid $17.67 total for 5. How could one be $14.63?

Was the 14.63 the total for the entire package added up together? That is more in line with the 20% of the approved amount for the entire package and not just one pillow.
Did you see other items listed like headgear and frame with additional amounts that you owe?

3.53 (17.67 divided by 5) each pillow is more in line with what medicare would say the 20% of the approved amount might be.

Finally....Humana is an HMO and a medicare advantage plan...and while they follow Medicare guidelines very closely...they don't always go exactly with how Medicare does things. When you have Humana Medicare Advantage plan then you don't have Medicare...you have Humana HMO and HMOs of any kind get to set a lot of their own rules.

[chunkyfrog]

Masks are often packaged with multiple size cushions/pillows, but not always.
Cpap.com sells these packs in their entirety. (Hence the pillow exchange thread)
Insurance/Medicare breaks the price down piecemeal;
but dealers may get a better deal buying masks this way than by the piece.
If you want all the sizes, you can pay yourself.
Insurance is slow updating their bookkeeping, thus, my Airsense 10 machines
had separate charges for the heated humidifier--even though that part is integrated.

[ChicagoGranny]

At my setup, the therapist determined my size was a medium nose pillow but he took back the small and large ones included in the package. I asked him what he was doing with them and I didn't get a straight answer. A couple of days later they send 5 more mediums in the mail.

The DME buys the three sizes in one package from the manufacturer (or the distributor) Assuming the medium size is the only one that works for you, what would you have the DME do with the other two sizes?

Unless you wanted the other two sizes to experiment with, I don't see anything to be upset about.

A couple of days later they send 5 more mediums in the mail.

Your DME should be given instructions NOT to send you anything without an email order from you. Many DMEs want their patients on auto-reorder, and you get supplies regularly per the Medicare schedule. If I did that, I would be flowing over with masks, headgear, cushions and hoses. My equipment lasts much longer than the scheduled lifetime.

[dataq1]

Is this Medicare Fraud?

If you have a Medicare Advantage policy through Humana (it sounds like that is the case), then any questionable billing practices ( fraud ) is NOT Medicare fraud, it would be garden variety insurance fraud. Once you elect to abandon traditional Medicare (in favor of an medicare advantage plan), then "Medicare" is out of the picture.

To your other issue, is the DME breaking a "kit" that contains multiple sizes, charging you for the full kit, and diverting the unused sizes to other clients and charging them? Highly likely. In doing so, are they charging those other clients for items that (you) have already paid? Again, highly likely (at least that has been my experience over the past 20 years).

Does your insurance company care to investigate -- most likely they think it's not worth the effort.

[Rubicon]

I paid $17.67 total for 5. How could one be $14.63?

Was the 14.63 the total for the entire package added up together? That is more in line with the 20% of the approved amount for the entire package and not just one pillow.
Did you see other items listed like headgear and frame with additional amounts that you owe?

And probably the tubing. So pillows, headgear and tubing and you're pretty much on target for 73 bucks, so 14.63 should be about right.

[Rubicon]

To your other issue, is the DME breaking a "kit" that contains multiple sizes, charging you for the full kit, and diverting the unused sizes to other clients and charging them? Highly likely. In doing so, are they charging those other clients for items that (you) have already paid? Again, highly likely (at least that has been my experience over the past 20 years).

What does that mean "highly likely"? Do you have proof?

Or is palerider's sig correct?

[Rubicon]

I don't understand Medicare billing and have been told it can be complex but this strains credulity

It's not complicated at all. Look at this:

https://document.resmed.com/documents/a ... S_Card.pdf

And then research your state to find the exact amount.

[Rubicon]

... he took back the small and large ones included in the package. I asked him what he was doing with them and I didn't get a straight answer.

He could also be taking them to give someone with no insurance.

***I know a guy*** who used to give boxfuls of CPAP stuff away to deserving patients.

[Pugsy]

... he took back the small and large ones included in the package. I asked him what he was doing with them and I didn't get a straight answer.

He could also be taking them to give someone with no insurance.

***I know a guy*** who used to give boxfuls of CPAP stuff away to deserving patients.

Yep. I know that guy as well. He helped a LOT more people than he probably realized.

But the skeptic in me has to assume that a DME isn't giving away the pillows he pirates out of a package.
After all the OP here did get a bill for those 5 other nasal pillows he/she got.
According to the DME that I used to use....once a package is opened the contents all belong to the patient...even if the sizes might not be used. They won't pirate items for resale. It's a fit pack for a reason...so the patient "can" try other sizes if they wish. Here's a news flash...the DMEs don't always get the sizing right the first time.

Now I do realize that this practice has been done by DMEs since time began and while technically "legal" I suppose (since only one pillow is billed for and since insurance always breaks down the contents)....I don't think it is morally right to pirate items out of a fit pack for resale.
DMEs stock the fit packs to save space and money....if they really wanted to sell the frame/tubing/headgear with one pillow in the package they should buy that package from the manufacturer instead of the fit pack. That packaging is available.

Some DMEs aren't as nice as the guy you knew who gave away tons of stuff. They are money grubbing little SOBs who would lie when the truth would fit better.

[Janknitz]

This is a long-standing and legal practice with the DME's.

Here's an example of a "fit pack" our hosts at CPAP.com sell for $88: https://www.cpap.com/productpage/resmed ... XUQAvD_BwE
-The mask with short tube assembly
-The Headgear
-The soft wraps
-3 nasal pillows of different sizes so you can try them on and decide which size is best.

Your local DME buys the same fit pack, but is allowed to charge separately for the items inside (even if they never open it)--which bumps up the reimbursement they get by a significant percentage. You will be charged separately for each of the above items, except that you will only get ONE nasal pillow, not three. The sum cost of all these parted out IS higher than you can buy the fit pack for from cpap.com, but Medicare will pay the DME for 80% of the amount set by Medicare (whatever it is in your region) and your Humana may take care of the rest.

If you want to pay out of pocket for a fit pack from our hosts, you will get to keep all three nasal pillows and the overall cost would be lower, but 100% out of your pocket instead of Medicare and Humana's pocket.

I don't like it either, I think it sucks that insurers and Medicare pay more than the retail price for these things. In a sense it's a fraud on all of us who pay Social Security taxes and insurance costs. But it's legal and standard practice.

I don't have DME coverage for CPAP anymore, so I pay out of pocket for everything (despite paying a lot for health insurance!). I shop around and get my money's worth. It's often cheaper to buy a fit pack than the individual items, but at the same time, I rarely need everything. The best part of not having DME coverage is no hassles with billing and insurance. I get what I want, when I want it without stress.