DME charge to Medicare for Swift FX

[Mr. Cellophane]

Just received a Swift fX mask from DME. The mask, headgear and pillows were in one sealed bag. DME charged Medicare:

Swift FX - $135
Headgear - $40
Pillows - $33

Total - $208

Is it any wonder that the Medicare system is in trouble?

[Lizistired]

Do you know how much medicare paid yet? They usually overbill even though they know how much they are going to get.

example: Pillows: billed $186.20, INS Approved $45.20

[Mr. Cellophane]

Do you know how much medicare paid yet?

No, I don't. I just picked up the mask yesterday. I'll post the amount later on when I receive the statement.

[Pugsy]

That is actually the way Medicare expects it to broken down. That is the way they pay even if items are all in a single unopened bag. The allowed amount won't be the billed amount though so it doesn't really matter what they initially bill as it will be reduced and a good portion written off as medicare adjustment. Somewhere around 2/3 of it maybe the final allowed amount. I can't remember exactly how much my last 20% copy for all these were but around $28 maybe. That's total. Less than $30 for sure though.

Did you get 3 nasal pillows of different sizes for the "$33" or just one? My DME gives me all 3 sizes when I get the whole mask set up.

[Mr. Cellophane]

Did you get 3 nasal pillows of different sizes for the "$33" or just one? My DME gives me all 3 sizes when I get the whole mask set up.

Yes, all three sizes were sealed in the bag.

[LSAT]

Medicare has a fixed amount that they pay for CPAP items. They will not pay anything close to what was billed. DMEs bill the MSRP.

[avi123]

Just received a Swift fX mask from DME. The mask, headgear and pillows were in one sealed bag. DME charged Medicare:

Swift FX - $135
Headgear - $40
Pillows - $33

Total - $208

Is it any wonder that the Medicare system is in trouble?

Reply,

Your post is like thousands of other previous DME bashing posts on this board. But to my knowledge no one has yet explained the DMEs arrangements with Medicare and other insurers allowing them to charge those outrageous amounts. Your posted prices seems to me to be 1/3 of the actuals. Apparently, we need to wait for someone who is trust able and familiar with it to tell us the story.

Do you know the arrangement between your DME and Medicare, i.e. what other expenses could the DME incur for supplying you the mask and stay in business?

See here my DME's standards and obligations to me the customer which probably cost lots of money.

Does a cheaper seller on the Internet have all these obligations to you?


III. Medicare Supplier Standards


Below is a summary of the standards Medicare requires of home medical equipment providers. Our company meets or exceeds all of these standards.

1.A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements and cannot contract with an individual or entity to provide licensed services.
2.A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
3.An authorized individual (one whose signature is binding) must sign the application for billing privileges.
4.A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs.
5.A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
6.A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
7.A supplier must maintain a physical facility on an appropriate site. This standard requires that the location is accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.
8.A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier's compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation.
9.A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited.
10.A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier's place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.
11.A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from contacting a Medicare beneficiary based on a physician's oral order unless an exception applies.
12.A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.
13.A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
14.A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries.
15.A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
16.A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
17.A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
18.A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.
19.A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
20.Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
21.A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.
22.All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals). Implementation Date - October 1, 2009
23.All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
24.All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
25.All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
26.Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation Date - May 4, 2009
27.A supplier must obtain oxygen from a state- licensed oxygen supplier.
28.A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f).
29.DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.
30.DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions

[yardbird]

Report that supplier to Medicare. They're not supposed to split it out like that. The billing code for a mask is for a COMPLETE mask and that includes headgear and pillows and interface tube. Can you see what billing codes they used to bill Medicare? There is a complete mask billing code and then there are codes for replacement parts like headgear and pillows.

[chunkyfrog]

Our FORMER dme broke down everything in the billing and got paid for each code.
BCBSNE was told and they did NOTHING.
So much for any chance I will consider any 'blue' Medicare supplement.
--or will recommend them to anyone else.
---Are ya listening, smurfs?

[fidget]

Nonsense, that it is a ripoff.

Medicare sets the prices, and the replacement schedule. Medicare dictates how to bill, and what requirements need to be met. Each piece has a different HCPC code, and that's how Medicare determines billing. As far as the bloated "billing" price, that's also Medicare's doing, as their allowable is a percentage of national retail, and by their allowable price, that sets the national retail price. Medicare's allowable is the same for ANY DME, and anyone who tells you different doesn't know what they are talking about. There are minor variations by area, but any in the region would be the same. Medicare replacement insurance plans have different allowables based on the national contract they negotiate with every DME so those prices could vary widely. The allowable is set by Medicare and can change quarterly.

Insurance companies use the retail price that is set from Medicare allowables and start the negotiations with the DMEs based on those prices. Prices can vary widely. Part of the reason online sellers can bill lesser amounts, is they don't have to pay a huge staff to negotiate each and every insurance contract requirements and amounts. It's a nasty job.

A7034 is the mask frame system. In my state, allowable is 106.35
A7033 is the pillow itself. In my state, allowable is 25.68
A7035 is the headgear. In my state allowable is 35.93

Seriously, when Medicare is involved, the DME has no power, the rules are made by Medicare. The true complaints should be sent to CMS, not to DMEs.

[Janknitz]

Medicare is going to pay a set amount (there's a chart available at the CMS website that breaks it down by HCPCs codes, state by state) NO MATTER WHAT the DME writes on the bill.

DME bills are works of pure fiction. They jack up the prices because Medicare does look at the difference between charged amount and paid amount in setting future rates (but Medicare bases allowable amounts on actual costs, not DME fairytales).

Medicare does allow billing of a complete packaged mask as component parts. It may not be ethical, but it is legal to do it that way.

The only time someone might pay what's actually on the DME's bill is when they don't know any better and they don't have insurance.

[LSAT]

Report that supplier to Medicare. They're not supposed to split it out like that. The billing code for a mask is for a COMPLETE mask and that includes headgear and pillows and interface tube. Can you see what billing codes they used to bill Medicare? There is a complete mask billing code and then there are codes for replacement parts like headgear and pillows.

You are wrong...Medicare allows the separate billing of the mask and headgear.

[LSAT]

Just received a Swift fX mask from DME. The mask, headgear and pillows were in one sealed bag. DME charged Medicare:

Swift FX - $135
Headgear - $40
Pillows - $33

Total - $208

Is it any wonder that the Medicare system is in trouble?

Reply,

Your post is like thousands of other previous DME bashing posts on this board. But to my knowledge no one has yet explained the DMEs arrangements with Medicare and other insurers allowing them to charge those outrageous amounts. Your posted prices seems to me to be 1/3 of the actuals. Apparently, we need to wait for someone who is trust able and familiar with it to tell us the story.

Do you know the arrangement between your DME and Medicare, i.e. what other expenses could the DME incur for supplying you the mask and stay in business?

See here my DME's standards and obligations to me the customer which probably cost lots of money.

Does a cheaper seller on the Internet have all these obligations to you?


III. Medicare Supplier Standards


Below is a summary of the standards Medicare requires of home medical equipment providers. Our company meets or exceeds all of these standards.

1.A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements and cannot contract with an individual or entity to provide licensed services.
2.A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
3.An authorized individual (one whose signature is binding) must sign the application for billing privileges.
4.A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs.
5.A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
6.A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
7.A supplier must maintain a physical facility on an appropriate site. This standard requires that the location is accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.
8.A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier's compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation.
9.A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited.
10.A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier's place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.
11.A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from contacting a Medicare beneficiary based on a physician's oral order unless an exception applies.
12.A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.
13.A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
14.A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries.
15.A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
16.A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
17.A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
18.A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.
19.A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
20.Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
21.A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.
22.All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals). Implementation Date - October 1, 2009
23.All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
24.All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
25.All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
26.Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation Date - May 4, 2009
27.A supplier must obtain oxygen from a state- licensed oxygen supplier.
28.A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f).
29.DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.
30.DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions

If this is in fact true, I don't blame the DME for trying to charge MSRP.