Question about Medicare billing by DME

[Hosehead4ever]

I'm just wondering if anyone knows if there is a cap on what a DME (Apria in this case) is allowed to charge Medicare for equipment or if it's just a free-for-all.

Something seems wrong here. On my sales agreement, they have charged Medicare the following:

$331 - One month rental of PR Systerm One Pro machine (supposedly will only go up to price of machine?)
$835 - PR System One humidifier
$980 - Mirage Quattro FF mask
$164 - Headgear
$125 - Tubing
$33 - Filter

Total was $2469.34 and that's with the machine not being paid off!

I heard from another doctor of mine who uses CPAP that Apria has been involved in fraud before, so I'm just wondering if these kind of charges is legit. Anyone know or can point me in the direction of finding out?

[Mary Z]

If they charged Medicare $980 for a quattro FFM they are definitely overbilling. The rest of the charges fall in line with mine. With my medicare suplement I pay a 20% copay. They (the DME) routinely charge for the mask and the headgear separately even though they come in the same package.

[Hosehead4ever]

$600 more for the humidifier than cash price is not overbilling too? Sorry, but I'm new to this.

[Pugsy]

What they bill Medicare is not what Medicare will allow. There will be a large adjustment write off. Then your portion of payment will be figured from what Medicare allows.

There is a schedule available as to what medicare actually will allow but I don't have it handy so you can see what to expect. Maybe someone else has it handy. I am short on time at the moment.

In general this billing is typical. Over inflated pricing but it will get reduced considerably. Then your deductible will apply (if not met already) and then the 80/20 co pay. If you have a supplement then that will pick up the 20% portion that it normally picks up.

[pap4life]

I think that Pugsy has a handle on the payout system. The DME and/or other health care providers will make rediculous charges only to be reduced by Medicare to the allowable figure. They pay their share or then you and your co-insurance (hopefully you have some) will pick up the remaining 20%.
Pity the poor person with no insurance when it comes to a medical need.

[Hosehead4ever]

Thanks ya'll. I hope to see that on the final statement.

[chunkyfrog]

The uninsured person will go out of network--as there is no network if there is no insurance.
Check the prices on cpap.com, cpapsupply.com, cpapsupplyusa.com, and secondwindcpap.com. and others
If Medicare would reimburse or pay for products bought this way, tens of thousands of dollars could be saved,--PER STATE!
--to say nothing at all of the aggravation the DME's cause.

[Madalot]

I want to chime in here and reiterate what the others have said...don't worry too much because Medicare is NOT going to allow those outrageous charges. You are only responsible for your percentage of the ALLOWED charge.

My last sleep study -- the facility billed Medicare close to $4000 for it - -they allowed around $700. And the facility had to accept the $700 as the payment for it - and they did.

I don't sweat these bills anymore...

[Slinky]

I call the DME providers' billing amounts their "pipe dream" fees. I don't have any current pricing since I got my bi-level in March of 2008 and there have been Medicare cuts since then but here is how the monthly billing and reimbursement went thru at that time. Keep in mind a bi-level is considerably more expensive than a CPAP.

DME Billed: $239.92 - Medicare Allowed: $218.11 - Medicare Paid: $174.49 - CoPay: $43.62

I had to go back to 2006 for the humidifier since my 2006 H3i humidifier could be used w/my bi-level and I didn't have to buy a new one.

DME Billed: $548.00 - Medicare Allowed: $499.63 - Medicare Paid: $399.70 - CoPay: $99.93
a7037 - tubing used with positive airway pressure device - $48.00 - $32.82
a7034 - nasal interface (mask or cannula type) used with positive airway pressure device ... $130.00 - $94.11
a7035 - headgear used with positive airway pressure device - $45.00 - $31.80
e0562 - humidifier, heated, used with positive airway pressure device - $325.00 - $240.97
For the Resmed S8 Elite monthly billing:
DME Billed: $135.00 - Medicare Allowed: $99.95 - Medicare Paid: $79.96 - CoPay: $19.99

As you can see even at the above inflated Billings, your local DME provider is WAY OUT OF LINE on their billing for the humidifier and the Quattro!!!!!!

[idamtnboy]

Something seems wrong here. On my sales agreement, they have charged Medicare the following:

My first reaction when I read your post was, "Wow, this lady is fortunate if she doesn't know how insurance billing works because that means she's been in good health and has had few medical issues in the past!"

If that is the case, then get prepared for a whole new learning experience. If, or when, you encounter some issue you don't understand, including learning this whole sleep apnea thing and it's many intricacies, come back and ask. Many of us have way too much experience with the medical world and are always ready to help however we can.

[Hosehead4ever]

I have very frequent medical bills but I am covered 100% so I generally don't look at them. This one was nearly unavoidable because it was in the case that my machine came in.

I should be clear that I'm not unhappy with their service or my machine or anything else related to Apria. I know people that are. I'm just concerned that Medicare not get duped, so I'm I'll be watching this closely.

[Janknitz]

Well, I wrote a lengthy reply and then the internet ate it, so I decided to make a blog post since this comes up frequently.

Check this out: http://maskarrayed.wordpress.com/2011/0 ... in-common/.

(Katy, I hope it's OK that I used your original post and billing as the basis for my blogpost).

The bottom line is that a DME's bill is a work of pure fiction, so don't get too concerned, unless you are unforatunate enough to lack insurance and you agreed to pay that much.

Over $1000 for a Quattro???? Sheesh, I hope it's gold plated!

[Pugsy]

Many years ago, 1990 and a bit later, It was common for Medicare patients to be billed outrageous amounts and if the doctor or supplier was "non participating" it was common for the patient to be responsible for charges above the amounts that medicare allowed. Huge amounts.. I sold Medicare supplements and I saw them all the time. Within a few years the government put a stop to such huge overages and they started the rules where non participating providers could only charge 115% of the allowed amount, so essentially 15% more than the allowed amount. Providers could no longer rape Medicare or Medicare patients which they had done in the past and made enormous profits before Medicare started adhering to the "allowed" amounts for services.

Participating providers meant that they would accept what Medicare allowed as the reasonable fee. Providers got their 80% sent directly to them and patients were responsible for their 20 % (and the annual Part B deductible) which they either paid or had a supplement to pay. Every year they would get a list of what they could charge.

Non participating providers were limited to what Medicare said they could charge and every year they would get a list of procedures, services or supplies and what they could actually charge the patient. The patient would be expected to pay and Medicare sent the patient a check.

Most DME's will be participating providers in the Medicare system because they obviously will have a very high number of Medicare clients.

When Medicare cuts are made it is typically in what they allow for goods and services. Every year it changes and some things will go up but most things go down. They pay (and thus allow) less but the costs for items or services usually go up. Some providers elect to not service any Medicare patients for this reason or they cut corners everywhere they can to make a buck. Hence DMEs supplying the useless compliance only machines, crappy patient education and follow up. Trying to save a dime and pretty much shoot themselves in the foot because I think that with more patient education and some actual constructive follow up, CPAP patients would be a good source of ongoing revenue. Instead the patient puts the machine in the closet and the DME lost a whole bunch of potential sales.

[Slinky]

Thank you, Pugsy, for that education regarding Medicare DME history with the billing and reimbursement process!!!!

[avi123]

In my opinion it's a waste of time to try and follow the accounting procedure between a DME and Medicare.I just got a Statement of transaction details from 3/1/2011 to 3/31/2011 between my DME and Medicare. On a total charges of $515 there is $387 credits and my self pay is $6.27. So shall I hire a CPA to check the accounting and pay him/her a fee of $200/hr? I Also keep noticing that most of the claims from my DME to Medicare are denied b/c of double charges. So shall I hire a lawyer to check for Freud?