Medicare DME Fee Schedule for 2012

[VikingGnome]

Here's a website for those on Medicare. It's the Medicare DMEPOS Fee Schedule for 2012. You just put in the HCPCS code and then find your state and it will tell you how much Medicare will pay (includes your 20%) for OSA items. It also has a very nice lookup feature. Put in Manufacturer Name (RESMED, RESPIRONICS), etc. and it will list all the items made by that company so you can find the exact HCPCS code if you don't know it.

https://www.dmepdac.com/dmecsapp/do/hcpcssearch

I took my invoice from my DME and compared what Medicare will pay compared to what the same exact item would cost if I bought it from cpap.com.

HCPCS..Modifier..Description................Medicare Fee...TOTAL...,,cpap.com...Notes
E0601.....RR......CPAP - S9 Elite...............$92.94/mo...$1,208.22...$805.00...13 month rental
EO562.....NU......H5i Humidifier.............$278.87.........$278.87....$244.00
A7038.....NU......S9 Disposable Filter..........$5.00..........$10.00......$11.95 6 for $11.95
A4604.....NU......ClimateLine Tubing.........$61.85..........$61.85......$51.00
A7034.....NU......Mirage Activa Nasal Mask...$108.90.....$108.90.....$99.00
A7035.....NU......Mirage Activa Headgear......$34.06.......$34.06.....incl w mask

...............................GRAND TOTALS..................$1,701.90.....$1,210.95


So the next time your DME supplier whines about Medicare reimbursement, you can show 'em that they are getting MORE from Medicare than Internet Retail by about $500 for an entire CPAP set-up.

[idamtnboy]

Here's a website for those on Medicare. It's the Medicare DMEPOS Fee Schedule for 2012. You just put in the HCPCS code and then find your state and it will tell you how much Medicare will pay (includes your 20%) for OSA items. It also has a very nice lookup feature. Put in Manufacturer Name (RESMED, RESPIRONICS), etc. and it will list all the items made by that company so you can find the exact HCPCS code if you don't know it.

Boy, that is a super find. Thank you very much. Much easier to find Medicare rates there than the CMS website.

[LSAT]

Something strange here....I have the AARP Medicare Complete plan (Medicare Advantage Plan) that follows Medicare reimbursement.
A7031 Mask Cushion shows $69.59 Fee (?)....My EOB shows that my DME got paid $29.65
A7037 Tubing shows $37,97 Fee (?)....My EOB shows that my DME got paid $17.45
Several other items show the same discrepancy

[Slinky]

Keep in mind, the local DME provider has the overhead of insurance paperwork which can be a headache that the online DME providers don't have to put up with. That GREATLY reduces the number of office staff online DME providers need for billing

Keep in mind that the local DME provider gets his Medicare money for a CPAP doled out in small amounts over 13 months whilst the online DME providers get their money upfront before the device ever leaves their office.

Keep in mind that even for the "cash" items such as humidifier, mask, etc. the local DME provider has to wait 3-6 months to get their Medicare money for those items whereas, again, the online DME providers get their money up front before the item leaves their office.

[idamtnboy]

Something strange here....I have the AARP Medicare Complete plan (Medicare Advantage Plan) that follows Medicare reimbursement.
A7031 Mask Cushion shows $69.59 Fee (?)....My EOB shows that my DME got paid $29.65
A7037 Tubing shows $37,97 Fee (?)....My EOB shows that my DME got paid $17.45
Several other items show the same discrepancy

I believe the page is for Medicare original plan reimbursements. Medicare Advantage plans are independent insurance plans that contract with Medicare to take care of Medicare patients. I wouldn't expect Medicare Advantage plans to necessarily follow the original reimbursement schedule. That's why there are so many Advantage plans with differing coverages. From what I've read they also are not the money savers they were touted to be.

You only get EOBs from AARP Medicare, right? I'm on Medicare original plus BCBS. I get a summary of claims every three months from Noridian, the CMS processing contractor, and EOBs from BC.

[Janknitz]

Reimbursement varies by state. You have to look on the chart to see what the Medicare allowable is in your state.

Medicare advantage plans get the same rates for DME as everyone else, to my knowledge.

[LSAT]

Reimbursement varies by state. You have to look on the chart to see what the Medicare allowable is in your state.

Medicare advantage plans get the same rates for DME as everyone else, to my knowledge.

That's what I thought...That is why I'm questioning the HUGE difference between what my DME is being paid and the Medicare chart. My DME is being paid less that 50% of the Medicare payment chart. Has anyone else check their Medicare EOB against this chart???

[chunkyfrog]

I wonder if Medicare is kicking in AFTER the supplement amount is deducted--
in other words the supplement is lifting a part of the burden from Medicare--on YOUR dime!
Actually, if this is the case, it could lead to some CONSUMER savings if one is well-informed BEFORE signing on the dotted line.

[LSAT]

I wonder if Medicare is kicking in AFTER the supplement amount is deducted--
in other words the supplement is lifting a part of the burden from Medicare--on YOUR dime!
Actually, if this is the case, it could lead to some CONSUMER savings if one is well-informed BEFORE signing on the dotted line.

The Medicare Advantage Plan takes the place of Medicare. It is Medicare, Medicare Supplement and Part D...all in one package.
THERE IS NO PREMIUM in the AARP Plan. Medicare pays AARP (United Health Care) a fixed amount for each participant. There are co-pays involved for doctor visits, prescriptions and DME. I pay 20% of the Medicare allowed amount for DME.

[chunkyfrog]

Thank you. That makes it much clearer.
I heard there may be additional expenses if your provider is not a Medicare CONTRACTED provider.
In Lincoln there is only one listed--at least one of the other DME's claims to be 'the same thing'--(yeah, right).

[Janknitz]

Just guessing here but Medicare advantage plans are capitated. That means Medicare pays X amount for every insured "life" (person) regardless of how much medical care an individual receives (or not). If utilization is low, the HMO wins, if utilization is high, the HMO loses.

So it may just be that the HMO has to provide DME withi the capitated amount ( in other words, the insurer doesn't get any more money from Medicare if you need DME. So the HMO insurer has to negotiate its own rates with the DME, while your copayment is fixed by Medicare.

That makes sense since Kaiser advantage can limit its DME formulary and I know they negotiate rock bottom volume prices with Crapria. A Crapria RT complained about the rates kaiser pays to me, but it's craprias choice (not mine) to do business with Kaiser. They may lose a little up front. It I'm sure they make a mint on volume and long term repeat business from all the Kaiser members who have no other choice.

[diekatzepap]

From my understanding about Medicare Advantage Plans is that yes they do take the place of the standard Medicare Plan. But what most people don't know is that Medicare Advantage Plans are individual insurance plans some are HMO plans while others are PFFS (Private Fee for Service) plans and that providers must contract with each individual plan to be considered an in network provider. Each individual plan may follow the standard Medicare plan guidelines but they may have their own additional guidelines for reimbursement on services. Each contracted provider may have a different set of reimbursement rates that was negotiated in their individual contract with each different Advantage plan. Therefore each provider maybe getting paid a different rate from the Medicare standard.

Confused much?

That is why it is vitality important to know your insurance benefits and which provider is considered in network for your plan to get the higher benefit with lower cost to you. Some Medicare Advantage HMO plans do not have out of network benefits, if you use an out of network provider for services you could be stuck with the intire bill.

I hope this helps.

[idamtnboy]

Here's a few quotes about Original Medicare and Medicare Advantage Plans from the Medicare website.
Advantage Plans:

Private insurance companies approved by Medicare provide this coverage.
In most plans, you need to use plan doctors, hospitals, and other providers or you pay more or all of the costs.
You usually pay a monthly premium (in addition to your Part B premium) and a copayment or coinsurance for covered services.
Costs, extra coverage, and rules vary by plan.

You can buy Medigap policies to cover deductibles and copays if you have Original. You cannot buy a Medigap policy if you have an Advantage plan

This quote corroborates what JanKnitz says above:

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non‑emergency or non-urgent care). These rules can change each year.

Here's where I quoted from:
http://www.medicare.gov/navigation/medi ... oices.aspx
http://www.medicare.gov/navigation/medi ... art-c.aspx

The home page of Medicare has links to find all the plans for your area. There's a lot there. You just have to dig to figure it all out.
http://www.medicare.gov/default.aspx