Get A Laugh At My Expense!

hades161 · Post by **hades161** » Fri Jan 12, 2007 12:14 pm

Darn timed out again

neversleeps · Post by **neversleeps** » Sat Jan 13, 2007 12:38 pm

mattman? Where are you?

Bumping this topic back up for mattman's reply to my previous post in this thread.

Thanks!

mattman · Post by **mattman** » Sat Jan 13, 2007 1:15 pm

I'll give a shot at answering your questions.
My hope was just to let this thread die since it got so very far off my intent which was just a good natured chuckle between friends. It's very obviously gone about as far from that as possible but I'll try anyways.

1) -Some DMEs use the same code for both APAP and CPAP, accept the allowable amount from the insurance company and then write off the additional cost of the APAP. Is that correct?

To the extent of my knowledge of other providers yes this is true. This is what the company I am currently with most often does. When the insurance company allows us to do so, we will provide an APAP, bill a CPAP and then eat the difference in costs between the two machines.

2) -Some DMEs use the same code for both APAP and CPAP and then bill the patient an upcharge for the APAP. You're saying this is legal and this upcharge is determined by the insurance policy and not the DME. Is that correct?

3) -Some DMEs use the miscellaneous code E1399 for APAP. You're saying this is legal even though the existing code for APAP is E0601. Is that correct? Does using the misc. code result in a higher allowable amount from the insurance company than using E0601?

Again as I've stated previously, both these questions are operating under the incorrect assumption that an APAP has a code of E0601. This is not correct. An E0601 is a CPAP machine. That is all that code is for. An APAP machine can in some cases be billed as an E0601 however that is skirting around what the intent of that code is and further, the cases where this can be done are determined soley by the insurance company. Another example would be a provider using a standard wheelchair code to bill an electric wheelchair. Does the electric actually fill the description of a standard wheelchair - that being a piece of equipment a patient can sit in and be pushed around in? Sure it does, but it's not exactly accurate to do so.

To answer your questions though, yes there are cases where an insurance carrier may allow for a patient to upgrade to a more expensive but non-covered piece of equipment such as an APAP and pay the difference between the covered item and the noncovered.

And obviously your 3rd question about DME companies performing illegal activities is not accurate since as explained above you are working under an incorrect assumption regarding the code E0601.

4) -Are you saying the DME is not required by law to fill the prescription for an APAP, even if that is what the doctor specified on the prescription?

Again, I would hope that this is excruciatingly obvious but no, DME companies are not routinely running around changing doctors precriptions or ignoring them so as to provide lower quality equipment. No one but a doctor can change a prescription. Anyone anywhere, DME provider, drugstore or whatever can, of course, decline to fill a prescription if they wish.

Also I would hope this is also extremely obvious but I can only speak in specifics about the businesses I've worked with over the years. I can only speak in broad terms when referring to other providers around the world.

Thank you and I have been as honest and straightforward as possible and I hope I have answered your questions to your satisfaction.

NightHawkeye · Post by **NightHawkeye** » Sat Jan 13, 2007 2:19 pm

Thank you, mattman. Although I didn't ask the questions, I found your responses very enlightening and appreciate that you took the time to answer the questions. Your answers help clear up some misinformation which has been around here for a long time.

Regards,
Bill

neversleeps · Post by **neversleeps** » Sat Jan 13, 2007 3:37 pm

Thanks for answering my questions, mattman. As a result of your answers, I have a few more questions:

neversleeps wrote:2) -Some DMEs use the same code for both APAP and CPAP and then bill the patient an upcharge for the APAP. You're saying this is legal and this upcharge is determined by the insurance policy and not the DME. Is that correct?

mattman wrote:yes there are cases where an insurance carrier may allow for a patient to upgrade to a more expensive but non-covered piece of equipment such as an APAP and pay the difference between the covered item and the noncovered.

Got it. So, it is a fallacy that some DMEs charge patients an upcharge (on their own and independent of the insurance company) to compensate for their decreased profit margin in providing an APAP?

mattman wrote:And obviously your 3rd question about DME companies performing illegal activities is not accurate since as explained above you are working under an incorrect assumption regarding the code E0601.

Whoa! I didn't say DMEs were performing illegal activities. I asked if it was legal to use miscellaneous code E1399 and if it resulted in a higher allowable amount than E0601. Does it?

mattman wrote:An E0601 is a CPAP machine. That is all that code is for. An APAP machine can in some cases be billed as an E0601 however that is skirting around what the intent of that code is and further, the cases where this can be done are determined soley by the insurance company.

Got it. Can you think of any insurance companies that use E1399 instead of E0601 for APAP? Medicare, BCBS, Cigna, etc?

mattman wrote:Again, I would hope that this is excruciatingly obvious but no, DME companies are not routinely running around changing doctors precriptions or ignoring them so as to provide lower quality equipment.

Got it. Then what did you mean by this:

mattman wrote:Don't EXPECT the company to be willing to do it, regardless of what the doc writes on the prescription. The old addage is that your Doctor could write a prescription for a Ferrari but it doesn't mean anyone is going to fill it.

Thanks.

neversleeps · Post by **neversleeps** » Mon Jan 15, 2007 4:28 pm

Bumping this topic back up for mattman's reply.

Thanks!

neversleeps · Post by **neversleeps** » Thu Jan 18, 2007 6:59 pm

Well, I researched this as best I could and discovered there was a request to establish a separate code for APAP, but the request was denied.

This is from:
Centers for Medicare & Medicaid Services (CMS)
Summary Report
HCPCS Public Meeting
Tuesday, April 25, 2006

http://www.cms.hhs.gov/MedHCPCSGenInfo/ ... 25_sum.pdf

On behalf of ResMed, the speaker requests that the workgroup establish a unique code for auto adjusting sleep apnea (APAP) systems. The speaker stated that a unique HCPCS code will enable tracking of utilization and outcomes and enable doctors to order APAP tied to a specific reimbursement code. According to the speaker, key physician and patient groups support the request for a HCPCS code, and clinical data confirms previous findings in terms of patient preference and compliance.

The decision rendered was:

CMS HCPCS Workgroup Preliminary Decision:
Existing code E0601 CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICE adequately describes a category of items by that perform the same or similar function as the item in this request. Clinical information included with this application does not demonstrate a superior clinical patient outcome when this device is used, when compared with other CPAP devices categorized at code E0601.
Medicare Payment:
Fee schedule and payment rules associated with existing code apply to this product.

So, I gather from this, Medicare is saying use E0601 for both APAP and CPAP.