Letter from my DME

Bearded_One · Post by **Bearded_One** » Sat Jan 13, 2007 8:40 am

Why in the world would a DME want to know your compliance data? My CPAP has compliance data available, but I wouldn't take the machine to them to read it.

dataq1 · Post by **dataq1** » Sat Jan 13, 2007 9:07 am

Hi Guys,
Just a comment about compliance data and MY Blue Cross/ Blue Shield insurance.
My DME (when I didn't have a card) would schedule visits to my house to check the hours on my respironics machine.
I was talking to my insurance company on another matter and mentioned that I understood that they needed the compliance data, the representative said, "No we DON'T require compliance data".
The next month, when the DME called to set up an appointment for me to bring the machine in or when I could take time off work to meet with them at my house to get the compliance data, I told them what my insurance company said. LONG PAUSE, then someone else got on the phone, and said.... ah yeah, that's right.... we just assume that everyone has to have compliance info sent to the insurance company.
They have never asked me for my machine again, nor (after I was smartcard enabled) have they asked me for my card.

It's maybe not a big thing... but people might want to check with their insurance companies about this. I've had similar experiences where the DMEs have told me what the insurance company requires that I later find out are incorrect.

Then again, I may have an insurance coverage that is the exception to the rule (however, I doubt it).

Anyway the lesson I learned was: don't let your DME interprete your insurance for you. Call your insurance company yourself. And ALWAYS get a name!
Cheers,

Bearded_One · Post by **Bearded_One** » Sat Jan 13, 2007 9:19 am

Ah, the part about them coming to your house to read the compliance data explains everything. I'd bet that they billed the insurance company at least a hundred and fifty dollars to do that, probably more.

I have been on CPAP for over 12 years and nobody from any insurance company has ever mentioned compliance data. Of course the only compliance data available on my previous CPAP machine was the mechanical hour meter.

I am 100% compliant with CPAP. I have an insurance paid-for CPAP machine and a travel CPAP that I bought out of pocket. If they got the compliance data from my insurance paid-for machine, it would only show about 90% daily compliance; and they ain't gonna see the compliance data from the machine that I paid for.

Sleepless in St. Louis · Post by **Sleepless in St. Louis** » Sat Jan 13, 2007 9:27 am

I'm wondering how they can bill the insurance company for a service that is not required by them? Unless they are using another billing code that does get by, that does not make much sense to me. But then again, why would the DME keep coming out to collect data that was not needed? My DME told me they needed this data also but I never bothered to contact my insurance to verify. They only ased me once for compliance data over a period of a year. So much BS in the medical system that we know and love. Not.

Wulfman · Post by **Wulfman** » Sat Jan 13, 2007 9:31 am

Bearded_One wrote:Ah, the part about them coming to your house to read the compliance data explains everything. I'd bet that they billed the insurance company at least a hundred and fifty dollars to do that, probably more.

ABSOLUTELY!!! Except I think the charge is about $50 - $70.....per time.

If you think the insurance companies have/take time to verify your "compliance"........Mmmmmm......NO!

If you WERE to get into a pissing contest with the DME and insurance provider, YOU'D win because you could prove your compliance to the insurance co. with your printouots. PERIOD!

And, like someone asked.....how are you going to prove compliance from a REMstar Plus model that doesn't have C-Flex (which doesn't have a smart card)????? The DMEs hand these out more often that you can imagine.

TAKE CONTROL OF YOUR THERAPY!!!

Den

Bearded_One · Post by **Bearded_One** » Sat Jan 13, 2007 9:42 am

how are you going to prove compliance from a REMstar Plus model that doesn't have C-Flex (which doesn't have a smart card)?

The old Remstar Plus CPAP Machine has a compliance meter. My 12 year old Remstar had an hour meter and compliance could be roughly calculated from that.

Wulfman · Post by **Wulfman** » Sat Jan 13, 2007 9:49 am

Sleepless in St. Louis wrote:I'm wondering how they can bill the insurance company for a service that is not required by them? Unless they are using another billing code that does get by, that does not make much sense to me. But then again, why would the DME keep coming out to collect data that was not needed? My DME told me they needed this data also but I never bothered to contact my insurance to verify. They only ased me once for compliance data over a period of a year. So much BS in the medical system that we know and love. Not.

The billing code is probably "99499 - Unlisted evaluation and management service:
There also is no "set" fee....it shows as "manually priced".

I have a .pdf document that I downloaded from Respironics' website in 2005 that shows these types of "service" codes that they can bill for.

Den

NightHawkeye · Post by **NightHawkeye** » Sat Jan 13, 2007 9:51 am

Sleepless in St. Louis wrote: They don't know that you probably know more than them. Vent to us by all means but have patience with the poor picked on DMEs who are after all, the undisputed experts in this field.

Nicely summarized, Tim.

When one takes the time to question these "experts", one finds out just how little knowledge many truly possess. Sadly, much of the health care industry operates in this manner - a lot of smoke, and claims that only they possess the vital knowledge.

Not much reason for anyone who's operated a cell phone, a VCR, or a computer to be intimidated by the technology of xPAP machines. Only reason for DME's to claim otherwise is control of the money.

Regards,
Bill

mattman · Post by **mattman** » Sat Jan 13, 2007 11:15 am

Bearded_One wrote:Why in the world would a DME want to know your compliance data?

Most insurance companies require us to determine compliance at least through the first three months. Some beyond even that.

Additionally, some doctors require us to provide them with compliance data for that period as well. Some of our doctors require us to provide them with that out to a year.

dataq1 wrote:Hi Guys,
Just a comment about compliance data and MY Blue Cross/ Blue Shield insurance.
I was talking to my insurance company on another matter and mentioned that I understood that they needed the compliance data, the representative said, "No we DON'T require compliance data".
...
Then again, I may have an insurance coverage that is the exception to the rule (however, I doubt it).

Cheers,

For what it's worth I believe you really do have the exception. All 3 BCBS contracts we deal directly with all require this. 2 of them are rent for 3 months then convert to a purchase once we provide the compliance data (BCBSFED and BCSBHO) and the other purchases the unit from the beginning requires us to be able to provide compliance at any time requested (BCBSHMO). Addtionally I can't think off the top of my head any contracts we work with that don't at the minimum require us to be able to provide the data upon request> Most all of them require it after the first 3 months.

Bearded_One wrote:Ah, the part about them coming to your house to read the compliance data explains everything. I'd bet that they billed the insurance company at least a hundred and fifty dollars to do that, probably more.

Except in extremely rare cases any visit to the home is not a billable service. It's expected as part of the cost of the equipment.
About the only time you can charge for this is when you are delivering to someone who lives at the top of a remote mountain that you can only get to by helicopter AND the guy who normally does go there is out of stock AND it has to be delivered today.

Wulfman wrote:And, like someone asked.....how are you going to prove compliance from a REMstar Plus model that doesn't have C-Flex (which doesn't have a smart card)????? The DMEs hand these out more often that you can imagine.

Believe it or not for most of the insurance companies all they care about as far as compliance goes is hours used on the hour meter. Real accurate, huh?

------------------------

On a random side note to the initial poster - I of course know nothing about your particular provider but my gut feeling is to really not take it too personally.

We very often highlight passages on ALL correspondence going out to patients. We one particular letter we send out each month, we actually highlight a different part each month on a rotating basis. For others we have gone in and highlighted one part in situations where we were having an increase in complaints about something. For example there was one time when we had a real increase in the number of people who said they didn't know how to contact our respiratory department directly. So on the letters we send out every 3 months to all our RT patients, we started highlighting the part where it lists the direct number to call with any questions. Now I had never thought about it that way, but I suppose if one of the people who complained got that letter, I wonder if they felt we were singling them out and sort of saying 'Hey stupid! See! The number is right here!'. I certainly hope not 'cause it wasn't the intention!

There is the possibility that it was NOT highlighted specifically for you.

Just a thought is all.

Take care -

mattman

shippy · Post by **shippy** » Sat Jan 13, 2007 1:12 pm

(Quote)
So much for the INFORMED patient

Last week i posted a little story about feeling out my sleep doc about software. I went to my appointment and (I acted dumb) started asking Questions about software and if this could help me in my therapy etc. his answers did not surprise me at all because i kinda expected what his response would be. He replied why are you asking about software the software is only for labs, doctors, etc. and there is nothing you could use in the software. It's like these people are hiding top secret information or something GEEEEEEEEEEZ !!! anyway I proceeded to tell him (without telling him the specific site did not mention cpaptalk.com or cpap.com I CAN HAVE SECRETS TOO HA! HA!) that i found this site online and was purchasing another mask online. He asked me what prices for equipment and i gave him off the top of my head what i thought my cpap machine cost on this (remember secret site) online site. When i threw a number at him he rolled his eye's and said thats a good price. Anybody figured out yet why they want us dumb out here in the real world, the answer is GREED !!!!!!!!

Dale

shippy · Post by **shippy** » Sat Jan 13, 2007 1:23 pm

I ain't scared of these people (sleep docs, dme's whatever), I am going to get that software and as Frank Sinatra sang I DID IT MY WAY !!!!!

KansasRT · Post by **KansasRT** » Mon Jan 15, 2007 9:30 am

Coming to a DME from a sleep physician's office, I know that DME's most of the time do not have to show "Compliance data" to an insurance company. The physician does have to sign a form for most insurance companies that state that the patient is "compliant" in using their machine.(Meaning greater than 4 hours a night usage.) Most physician's just sign the form and return it with no proof.( Questionable) Some require proof- which is either hours off the machine or a download.

dataq1 · Post by **dataq1** » Mon Jan 15, 2007 10:15 am

I guess that shows just how varied the (insurances) practices are.

My wife, who works at the pulmonologist office where my xPAP therapy was prescribed and who fills out all the CMNs (Certificate of Medical Necessity) for the DMEs, tells me that her clinical office has never been questioned about compliance hours for a patient.

Likewise, in 2+ years of xPAP therapy, my doctor has never ASKED to see my compliance hours. But then, my insurance company insists that they don't require compliance hours.

What I find interesting is that apparently for some insurances it is very important information (perhaps even critical to coverage), while other insurance companies don't seem to care. Intuitively, you'd think that there would be some standard that everyone would use.

I wonder what Medicare does.

mattman · Post by **mattman** » Mon Jan 15, 2007 11:44 am

dataq1 wrote: I wonder what Medicare does.

This is what I find so highly unusual when I hear things like what your wife says her experience has been and what KRT says his/her experience has been.

Almost everyone follows Medicare Guidelines as far as documentation/coverage goes. What is typically seen whenever a deviation from Medicare Guidelines is seen is that the private insurance companies will in many cases provide coverage BEYOND what Medicare lists. I can't think of any case off the top of my head where documentation requirements were less than Medicare Guidelines.

Here is the exact verbage from the current LCD:

Medicare Guidelines wrote: CONTINUED COVERAGE BEYOND THE FIRST THREE MONTHS OF THERAPY:

Continued coverage of an E0601 device beyond the first three months of therapy requires that, no sooner than the 61st day after initiating therapy, the supplier ascertain from either the beneficiary or the treating physician that the beneficiary is continuing to use the CPAP device.

If the above criterion is not met, continued coverage of an E0601 device and related accessories will be denied as not medically necessary.

Now the criteria are obviously vague as to WHAT constitutes "continued use". It's become generally accepted over the years and from various Provider's Medicare chargebacks that Medicare satisfaction of the "continued use" clause can be obtained by forwarding hours of use to the doctor and having them sign off on the hours and that it's been providing a benefit. In a worst case scenario a supplier can document hours of use themselves, but it does fall into a gray area of an entity that will monetarily benefit from continued payment providing thier own eligibility documentation.
While it's never been pursued as fraud (To my knowledge) most providers I know are exceptionally wary of even opening themselves up to that kind of trouble unless the ordering MD simply refuses to cooperate and documentation shows that.

The chargebacks that I've read about usually came from situations where the provider questioned a patient about continued use but did not have documented usage information.

Oh the joy of working with the government!!

mattman

KansasRT · Post by **KansasRT** » Mon Jan 15, 2007 1:25 pm

I did not got into specifics, it is not with every insurance or every CPAP patient. In fact the forms requiring compliance are few and far between. Next time I will be more specific. In the office where I worked a patient followed up with a sleep physician a month after begining CPAP. Therefore when the physician got a letter from whereever the letter came from he had a pretty good idea if the patient was compliant.

Letter from my DME

one more thing i forgot