Hiya Slinky! Sorry about that - I saw your post regarding that yesterday and I totally forgot to respond. I meant to, but it slipped my mind. My apologies - I have a terrible memory at times.
Anyways - 3 things.
1) If you are curious why no claim has been submitted, call them and ask. There are 2 things that come to my mind right away. They could still be fighting for paperwork. It happens to us all the time that it can take 3 months or sometimes more just to hunt up paperwork. Things that regularly happen are:
- Prescription has no pressure setting and we have to try to get it (We are required to have a specific pressure)
- We get a titration report instead of the full sleep study. This one is the worst and the one I've spent MONTHS trying to correct.
- Prescribing doctor doesn't actually have a copy of the sleep study. This one also can take months
- AHI was less than 15 and there are none of the extra symptoms documented.
- Doctors office or hospital sent us invalid insurance information (Say, a policy number changed and wasn't updated at the last visit). This one usually doesn't take more than a day or two to change but can get hairy sometimes.
Those are the main things that can take a while to determine. Another thing is I'm not entirely sure if Medicare will show a claim if it has not yet hit approve/disapprove stage.
Remember that with Medicare thier average days to process a claim is still running around 45 and can hit 90 days in some cases. So what I'm wondernig is if the claim has been submitted but not yet either approved or declined would it even show up with the people you are asking? I really don't know the answer to that.
Regarding switching providers:
This is a tricky one. Yes you CAN switch providers whenever the heck you want. It's your choice after all.
The problem is finding anyone that's willing to take you on. This makes a lot more sense when you think of it from the provider standpoint.
Medicare is going to pay a rental for 13-15 months depending on the type of claim. That's it. 13-15 months period.
The average cost of providing equipment and filing an initial claim eat up about 1-2 months of reimbursement. In this case it's more appropriate to go high so let's take off 2 months.
Taking over an existing patient is a LOT more work intensive so take off another months reimbursement for the sheer amount of paperwork and time needed to prepare that claim (Things like having to get all information and copies of pickup and delivery paperwork from the initial provider).
You now have 10-12 months of reimbursement. Assume the worst again and say 10 months.
Now, if you are in the first 1-3 months of your rental, almost NO ONE is going to be willing to take you on. This is because the first claim has most likely not even processed yet and the new provider will not be able to file a claim until the old provider has done so. (Technically you can but it would cause all the previous providers claims to automatically deny and professional courtesy keeps most folks from doing so)
Now, if you anywhere from 5 months into your equipment or more, it's simply not going to be cost effective in most cases to take that patient on. The sheer hassle and cost of bringing that patient in will most likely not be worth it. There will always be some exceptions but that is typically how it's going to be looked at.
While there is of course the prospect of future supply sales to consider, here's what always goes through my mind. The patient had some sort of disagreement with thier current provider and wants to bail. I have talks every single day with patients who are misunderstanding something or flat out got incorrect information from a doctors office or insurance company. Who says that no matter how good a job I do this patient isn't going to jump providers again in 3 months and really leave me holding the bag?
So unless you are in say months 3 or 4 it's a tough job to find someone willing to pick you up.
Essentially, it comes down to a crap shoot. Do I want to take the risk? It'll depend on every individual situation, but the odds are usually going to be stacked against the patient in these cases.
It was wrong of your provider to say you COULDN'T change. What would have been more appropriate was to say you COULD change but you most likely would not find anyone willing to pick you up.
Now if that doesn't make things more confusing I don't know what will!
Regarding covered items. If you are a Medicare covered patient, and they have agreed to bill Medicare for items provided to you, unless there is something I'm not aware of yes they are required to file a claim on your behalf. So anything covered they have to submit a claim. Heck there are even cases where we are required to submit a claim for items we know AREN'T covered!
mattman
