Have any trouble with DME claims to Medicare?

[dllfo]

EDIT: This thread should have been called DME Double-Talk.

On my fourth call to talk to claims, I find, for the fourth time, I am not getting to claims. WHY? I average almost 32 minutes on hold each time, I told the young lady I have 9023 characters typed in on my congressional complaint to get Medicare to quit lying to me. Yeah, I was frosted. She gave me her supervisor, who saved a Congressional Complaint. She said to please file one, Congress needs to know how bad things are. Honest Lady.

If you call medicare, they will say it will be a 20 minute wait. That recording was made when Nixon was President. Then you ask for Claims, like you were told to do and you get the General Area.

HERE IS THE SCOOP, as I was told by a nice person up there.

1. IF you want claims, get up at 4am in California and be ready to call them
at 5am, when they open on the East Coast. Obviously, your time may be
different. Your wait time is usually under 5 minutes.

2. Ask for English, say billing, next say other billing questions, then say
durable medical equipment, then ask for the state & I say California.
THEN you ask for a DME supervisor when someone gets on the phone.
Obviously this is if you speak english.

3. DME claims in my area go to Noridian. I was told every state is different.
Here is the fun part. One of my 2 DMEs gives me oxygen, the other
gives me Heliox, for Vocal Cord Dysfunction. The Heliox DME has not
been paid in several months, so they billed me for almost $600. Heliox
is expensive. BUT we can't call Noridian, who is bouncing any claims
from the DME back. Medicare shows NO claims from this DME, that pretty
much means the intermediary is kicking the claim back. BUT you cannot
call Noridian. The culprit here. They don't understand two "gas" billings
and think they probably think they are preventing fraud (Just a guess).

4. IF your DME says the claims are not going through, be careful. I was told
they have had cases where the DME PREFERS BILLING THE INDIVIDUAL
BECAUSE YOU AND I DON'T KNOW WHAT THE GOING RATE IS. NOT THAT
THE DME IS CROOKED NECESSARILY, BUT THE INDIVIDUAL IS ONLY
SUPPOSED TO PAY THE MEDICARE RATE. The lady emphasized my
situation may or may not be like this.

5. In the next year or two, in order to save money, Medicare is going to a
---uh --- one DME per area type scenario. Whoever the lowest bidder is,
gets the Medicare contract. Yummy.

Anyway, if you have a claims problem, that is how to handle it. If you have some general problem, expect a 30-40 minute wait when you are put on hold and don't bet the "Phone Tree" will send you where you want to go.
One last thing, Claims closes around 6-7pm, East Coast Time.

Good Luck.





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[Slinky]

Oh, m'God!!!!! Medicare going w/ONLY ONE local DME supplier per area???? Now THERE is something to start writing to CONGRESS about RIGHT NOW. To heck w/at home testing, to be victimized by only one DME supplier per area???? THIS deserves a CONCERTED WRITE-IN CAMPAIGN!!!

[6PtStar]

You did not mention the problem I run into. I call Medicare after going through the push this for that routine and after waiting the 40 minutes I get a person who says "you need the **** department" I will transfer you. After ringing for 2 minutes the recording comes on that says "all the people are busy please call back" CLICK. Start the 40 minutes over and they won't give yout the direct number of the transfer.

Jerry

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[dllfo]

Sorry Jerry, forgot about that trick. You are right. As I told Senator Feinstein, Medicare starts with a lie and keeps it up.

I asked for Claims and don't get it, and the ONLY way you know where your call is going is to wait to see who answers. Grrrrrrrrrrrrrrrrr

When I told this supervisor I was filing a Congressional Complaint, she has two ways to go. If she really is low on people, she can thank me for pointing it out to Congress. If he/she is a bad manager, they know they have enough people to do the job, but due to their incompetence, the job is NOT getting done so they usually tell you to wait, they can help you. This lady thanked me for telling Congress about their problems. I gave her an A.

This program on only having one dme will not be in my area initially, but if I remember correctly, all of the USA will be getting screwed equally. I told the small, local - but pretty good DME about the changes. The asst Mgr said she had heard about it and it would mean a lot of layoffs.

She said if their company doesn't have Medicare, they are going to downsize big time. I hope not. These are nice people who try hard, YET she admitted they don't have nation wide connections. Sad. The lady at Medicare was not happy about this, she has been around long enough to KNOW what is coming. The reason behind it is fraud control, among other things.

Luckily, I have Tricare for Life,which covers many things Medicare doesn't. And my third insurance (I pay $$$$ for this one, but it pays 100% of what Tricare does not cover). I am about 5 years ahead on this deal after my weeks at National Jewish Hospital, testing me 1-3 times most days. $$$$.

Well, now that I have cheered you guys up, have a nice day

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[dllfo]

One more thing. If I understand the lady at Medicare correctly, she said we should NOT have to pay any more than Medicare would pay for an item. I have heard something like this before, but wasn't sure I understood it correctly.

Anyone able to confirm it?

[dllfo]

For any of you with Medicare Claim snafu's --- I was told Noridian is the middle man in California and I was not supposed to call them. Fine, I am now on their email list for any DME changes with Medicare.

I didn't call them, I emailed them. Anyone can do this sort of thing. You have to find out from your DME or call Medicare to see who handles your state.

NOW I AM IN THE LOOP. NO MORE SURPRISES (I HOPE). One of my local DMEs says Medicare won't pay for my Heliox. They sent me a bill for $576, saying Medicare refused to pay for it.

When I am through with the billing department of the DME, they will be better educated on how to file a claim. I honestly feel like they filed it, when rejected they just let it go.

IF you want to be proactive, you can sure help your care from Medicare.

[Guest]

Yes you heard right. DME's can only charge what they charge Medicare. If you are purchasing out right. They can charge you no more and are not supposed to charge you less. If Medicare found out that a DME was charing you less than what they charge them the DME can be in big trouble. But a few do charge you less anyways. I mean it is only fair to try and help people out.

[6PtStar]

My understanding is that they have to take what medicare sets the price if they are a Medicare Contractor. All but one in this town are Medicare Provider which as I understand take money from Medicare but can still charge the patient up to 15% over what medicare sets. I had one on my machine that took the medicare amount then BC/BS paid the 20% that medicare did not cover and I still got a bill for $19.95 a month on my rental.

Jerry

[dllfo]

This just keeps getting better.........

I spoke to a claims person with Medicare and Tricare For Life today. BOTH of them said they have NO RECORD of ANY CLAIM by the small DME who has billed me. Both ladies said to make sure any claim was actually filed.
They said they have had cases where the DME wants the patient to pay and do not actually file the paperwork, but tell the patient it was rejected. I passed that info along to the mgt at this DME. I am not saying they did or did not file, but no one seems to find any record. I also got a fax number told the DME who to send it to.

BOTH Medicare and Tricare said they should bill the Heliox as E1399 Misc.
THEN include the letter or support showing medical necessity. As I told them, it is a life threatening situation if I pass out due to my vocal cords closing off air. It is proven that I don't always start breathing again, and I gave them two examples with medical personnel working on me. Our vocal cords are supposed to open up eventually, but since it has been demonstrated that I do not always breathe on my own, there is a good chance I might not live.

I also pointed out, to Tricare for Life, that I passed out Sept 13, 2006 and it cost them major bucks for the ambulance and me spending a day in Critical Care. I got the rescue agent, Heliox, two days later and have not had to use the ambulance since. Based on my usage of Heliox, I might go 2 or 3 weeks without using it, then I might use it 3 or4 times in a few days. I cannot predict it, but if you computer the cost of an ambulance ride 3 or 4 times and the cost of Critical Care -- the heliox saves Tricare dollars and might save my life.

When I explained that to Tricare, the claims lady said they would pay it.

SO, when your DME says the claim was rejected, it pays to call in yourself.

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[krousseau]

Do you get EOB's?

[dllfo]

Yes, I get EOBs, but could not find one to match my heliox, then again, maybe I lost it. Blame it on the morphine.

Here comes the final shots --- this will water your eyes.

Subject: Medicare



Good Morning Mam,
I spent almost 2 hours with Medicare yesterday (think --- Root Canal with no medication) -- I found out several things. ONE of which mgt needs to know. I left this message with "Accounting".

MEDICARE SUPERVISOR TOLD ME:
(1) From 9-1-07 to date, 4 claims from Apria, NO paperwork from YOU.
(2) YOU can only bill Noridian in our area for DME – I cannot call them. Noridian must be kicking it back guessed Medicare.
(3) YOU have never filed with Medicare for anything for me.
(4) Level 2 claims representative can educate them with Provider education. I CAN CALL MEDICARE AT 5AM, DISCUSS THE PROBLEM AND THEY WILL
CALL YOU AND GIVE YOUR PERSONNEL A CLASS I GUESS. DO YOU WANT THIS??????? The lady at Medicare thinks one of two is happening. YOU are not explaining WHY they are billing for "gases" when Apria is also billing for "gases" or they asked me if YOU would claim to have filed a claim and simply did not do it. Since I said I would pay it before I see YOU taking a loss, the lady said that has happened before. I told her YOU are a GOOD company and has a lot of integrity, I would find it very hard to believe that YOU would do that. She sort of apologized, realizing I like YOU and I was sure YOU have more integrity than that.

Do you want the training for your employees? Since it is 4:39am and I have been up all night, I may call Medicare in a few minutes, then give them Miss XXXX's phone number. I don't want to insult xxxx, but she is doing something wrong or (according to the lady at Medicare) they would have paid the claim.

I understand you are not part of the accounting department, but I am very hesitant to schedule YOUR Employees for training without asking you.
Have a nice day, with any luck at all, I will be asleep after my Dr. appointment --- be home about 11:30.

Take Care, Dave

HERE IS THE ANSWER FROM THE HEAD OF ACCOUNTING, YOU REALLY NEED TO DOWNLOAD THIS THREAD AND SAVE IT. BTW, this is NOT Apria doing this to me.


David,

xxxxxxx has not billed Medicare for your heliox. Your account was changed to Private Pay, thus no Medicare or Tricare claims were generated by our computer system. As I stated today in our telephone conversation, I was asked to review your account and discussed my findings with you. I first contacted Noridian Medicare Region D and was informed by customer service that Heliox was not a covered benefit and did not have a specific code. Medicare directed me to contact SADMERC, the entity that codes equipment for CMS. SADMERC stated that if we billed Medicare, we could do so with HCPC A9270, a non-covered code. Our Private Insurance representative xxxxx, contacted Tricare for Life and spoke with xxxxx that stated if we billed with A9270, it would be denied.


xxxxx has forwarded your latest email to me. I will have the Private Insurance department bill Tricare for Life for your Heliox using code E1399, as per your direction. It will be sent with the prescription and statement of Medical Necessity/Life Threatening condition. I will have the account placed on HOLD until we receive an explanation of benefits.


Thank you for your assistance in this matter.

DO YOU BELIEVE THIS????????????????????????????????????????????
I WORKED MY REAR END OF FOR DAYS TRYING TO FIND OUT WHAT HAPPENED TO THEIR INVOICES, THEIR BILLING SLIPS, THEIR ANYTHING.

THEY LIED TO ME WITH STRAIGHT FACES. ONLY WHEN I CALLED THEIR BLUFF DID THE HEAD OF "ACCOUNTING" FINALLY CONFESS.

This company busted their rear to get my heliox to me. They did not even require insurance at first. I was very grateful. I told the manager they would not lose money on it, if my insurance didn't pay, I would. WAIT, it gets better. They billed Tricare for many months, but decided Medicare was a hassle I guess. They moved my account into Private Pay, THEN told me Medicare wasn't paying the bill, I reminded them I have THREE medical plans, have they contacted all of them. Their people, I have a degree in accounting and don't want to insult myself, so I will refer to them as "people".....they called Medicare, asked for a code. What BS is this? As I told their boss, they used A1399 for months on end and got paid. NOW they are trying to tell me they don't know what code to use?????? HELLO!!
Yeah, I am frosted. I had to get the code, write the Medical Necessity Letter, THEN tell them how to do it, even gave them the fax number to Tricare For Life.

This was supposed to be a good, honest company. And most of them are. My doctor is their Medical Director, I am tempted to print this out and hand it to him. I am wondering how many of us have been screwed like that???

I know a couple of you have kidded me about being too rough on DMEs, etc.
But I rest my case. And this was not Apria folks.

COMMENTS?? I took the company name out and substituted "YOU" or "YOUR" or xxxxx. Anyone who really wants to know can PM or email me.

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[6PtStar]

Ain't it fun. If they did not do this we would have nothing to do with our time but post on this board

Of course it might be a way to get us to live a shorter time because they can get our blood pressure way to high. I had pretty good insurance until I HAD to take on Medicare.

Really sad!

Jerry

[dllfo]

Jerry, my mom was born in De Leon, TX, her name was Smith, so I have a few thousand cousins in Texas and the way you think.....we must be kin.

There is more going on than I wanted to put in writing. This thread should be mandatory reading for everyone on the forum, unless they are rich.

I called our Attorney General's office to get an " informal reading" as to the DMEs responsibilities when it comes to filing on our insurance before they come after us. It was sort of a gray area until they sent me a bill for $576. That crossed a line. I have been awake for 43 hours now, my mind is not working too well. Restless Legs Syndrome came back with a vengance. I took 900mg of Neurontin and 45 mg of the Class II they say to use. It stopped the RLS for the moment, but I can't seem to go to sleep, like I forgot how.

I would never have thought this company would be that --- what is the word?
Careless? Negligent? Crooked?
Oh well, I got them the codes to use, the fax number to fax it to, the POC at Tricare for Life and I wrote the Medical Necessity letter. I wrote it, read it to the Tricare Claims lady and she it was perfect, have them send it in. AND I got a new prescription from my Pulmonologist, explaining why I needed the Heliox. I hope they can operate their fax machine without me.