cpap.com vs dme

[mattman]

Mattman, care to show us a case in which someone was charged and convicted of a crime for selling or using a chinstrap?? CPAP mask? Cushion?

By the way, I should also further clarify something here.

We do get audited every other year by JHACO and can be audited randomly at any time by Medicare, Medicaid, FDA or any Insurance company we have a contract with. I have personally gone through one Medicare audit and one from BCBS.

In all cases (JHACO and otherwise) one of the major things they do are pull random patient charts and do a complete front-to-back of everything. The very first thing they do is verify that you have a prescription on file and that it's correct. They verify that the supporting documentation is there and is correct. They verify all your PM records for any equipment that was provided in that chart. They go to that patients home and verify that any equipment you have documented as being provided is there and that it matches the PM information. They verify that the equipment is set and being used both as prescribed and as documented and as intended by the manufacturer.

They pull a random amount of charts dependant slightly upon your business size. It's typically 5-10 since it takes usually a full day just to chase down all the paperwork that spiders out from those sorts of audits.

I forget off the top of my head how many major infractions you are allowed before your accreditation is pulled but I think it's 3. So yeah, if you have a couple items you didn't have a prescription for and they get tagged on that audit... one other thing like losing a PM sheet on a concentrator and you are in for some REAL problems if it's JHACO. If it's Medicare or an Insurer you are going to risk being out of business since you would lose your ability to file claims with that entity.

mattman

[mattman]

P.S. - It still doesn't apply to online purchases though since online providers aren't regulated.

<sigh>

wanna bet?

Really? That was always one of his big selling points! When did that change? Any ideas? Heck, the FAQ sheet still says you don't need a script!

m

[Guest]

Mattman, care to show us a case in which someone was charged and convicted of a crime for selling or using a chinstrap?? CPAP mask? Cushion?

By the way, I should also further clarify something here.

We do get audited every other year by JHACO and can be audited randomly at any time by Medicare, Medicaid, FDA or any Insurance company we have a contract with. I have personally gone through one Medicare audit and one from BCBS.

In all cases (JHACO and otherwise) one of the major things they do are pull random patient charts and do a complete front-to-back of everything. The very first thing they do is verify that you have a prescription on file and that it's correct. They verify that the supporting documentation is there and is correct. They verify all your PM records for any equipment that was provided in that chart. They go to that patients home and verify that any equipment you have documented as being provided is there and that it matches the PM information. They verify that the equipment is set and being used both as prescribed and as documented and as intended by the manufacturer.

They pull a random amount of charts dependant slightly upon your business size. It's typically 5-10 since it takes usually a full day just to chase down all the paperwork that spiders out from those sorts of audits.

I forget off the top of my head how many major infractions you are allowed before your accreditation is pulled but I think it's 3. So yeah, if you have a couple items you didn't have a prescription for and they get tagged on that audit... one other thing like losing a PM sheet on a concentrator and you are in for some REAL problems if it's JHACO. If it's Medicare or an Insurer you are going to risk being out of business since you would lose your ability to file claims with that entity.

mattman

Again, mattman operates a LEGITIMATE, bonafide DME....
(Matt, why continue to waste your time arguing lol)

[Goofproof]

Didn't you hear of Jack, the Straper, over in England? Jim

The never did catch him......

[mattman]

Again, mattman operates a LEGITIMATE, bonafide DME....
(Matt, why continue to waste your time arguing lol)

Because, while the question about finding a case where someone was arrested was obviously phrased as a very combative question by someone who doesn't think it's legitimate, I still see it as a valid general question.

In many aspects of life, we DO pretty much ignore laws we don't think are important. How many times you see someone turning without using a blinker? Sneaking one of the bulk candies at the grocery store?

It's just that in a case like this, there's a bit more punishment at stake in my opinion.

That's why I respond to those! Though yeah, there are also cases where I just have to shrug my shoulders and ignore things if it doesn't seem to have any productive value beyond a shouting match.

mattman

[Rabid1]

Really? That was always one of his big selling points! When did that change? Any ideas? Heck, the FAQ sheet still says you don't need a script!
m

Are we talking about real medical equipment (CPAP's) or chin straps? Correct me if I'm wrong, but online dealers in the US are bound by federal regulations, just like everyone else. That is why they all require scripts for machines.

I'm guessing there are no federal regulations prohibiting the sale of such items as chin straps, hoses, filters & masks.

As you know, there is the intent of the law, and there is the letter of the law. Under your interpretation, if someone sells pad-a-cheeks without a script they're in violation.

Where's that midddle ground you were looking for?

[guest1112]

They want no middle ground. They see the internet taking better care of their patients than they do and so they infer that we and the internet providers are not legitimate They are very sad.

[dataq1]

So, my first question is are you sure that the allowable for the DME was $299.99 NOT the submitted amount? You would be able to determine this by looking at your EOB from your insurance and looking under the colum labelled 'payment to provider' or 'approved amount' or 'allowed amount' or something similar. Virtually everything else you see from the invoice to paperwork to the claim will show the submitted amount, NOT the allowed amount.

Hi Mattman,
And your very justified in asking that question (submitted vs allowed amounts), here is my EOB for the Hybrid mask:



Further on it states;
We sent a check to XYZ Inc for 269.56. I also paid my bill of 29.96 to XYZ. Thence my assertion that XYZ received 299.56 for the Hybrid mask.

[Slinky]

Do some B&M DMEs actually give the patient the ENTIRE mask assembly (for instance extra cushions or pillows if they come as a package) including headgear for one price?

Its seems that at least most B&M DMEs enjoy charging as separte pieces the headgear and the mask and often do NOT give all the cushions & pillows that came as a package w/the mask.

We see these masks come in entirety in one package at cpap.com. If cpap.com can order the as one unit, certainly the local DMEs can order them as one unit and it would thus seem to be there should be a one unit charge instead of two.

Is it because of this Medicare provison for a mask every 3 months but headgear only once every 6 months that they HAVE to bill that way? As two separate units?

But if that is the case then why don't the local DMEs charge as 3 separate units? Headgear, mask, cushions? Medicare has provision for the cushions once a month.

These are the types of things that are so confusing.

[dataq1]

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.

Mattman:
Things may be different in your area but around my neck of the woods in Northeast Ohio (about 90 miles from Cleveland), the competition between DMEs is so dog-eat-dog that they are thrilled if they can get xPAP patients to switch.

OK, this is not my first hand observation, but my wife's. She is a nurse at one of the leading pulmonologist groups in the area. They have many many patients on xPAP therapy. One of my wifes's least favorite activities was producing all the monthly CMNs for the DME community. She has some comments on your post to Slinky about the delay in a claim being filed.

Her Comments:
In this area the process that everyone uses is this: Physician writes a script for a specific pressure(s), type of machine, brand (if Dr. wants) and supplies (which may or maynot include humidifier). The Dr's office sends the script, demographics (which includes insurance info) and the COMPLETE ORIGINAL sleep study to a DME that is under the patients insurance plan.

The DME either telephone or faxes an acknowledgement to the Doctors office and/or cites any deficiencies. Until all the paperwork is in proper order, the DME dispatcher NEVER gets an order to deliver equipment. Consequently, all the required paper work is in the hands of the DME before the patient ever sees any equipment.

Consequently, any delays in filing a claim are entirely controlled by the DME.

I quess what is amazing is that, by and large, equipment is usually scheduled for delivery the next day (or if the paperwork arrives late in the day) the day following.

For what it's worth that's the process in our area.

Regarding the five reasons you set forth to Slinky, they well could be valid. However, if they are, then shame on the DME for not DEMANDING the legally required paperwork BEFORE issuing equipment. Just my opinion!

Have a Great Day and thanks for hanging in there.

[jskinner]

The only thing I have to say about Smart Card Readers, is: In this day of 4 GB Compact Flash cards, they are stupid.

Amen to that! Maximun 7 sessions per card, crazy! Drives me nuts...

[dataq1]

Slinky:
My Hybrid (shown in the EOB above) came as one small cardboard carton with a sealed plastic bag containing a nice blue travel bag, within which was another sealed plastic bag containing the hard plastic shell, and three cushions and three nasal pillows, and headgear. I'm guessing, but it appeared to be a complete package assembled by the manufacturer. When I look at the contents for the Hybrid mask being sold by cpap.com (for 175.00) it is exactly what I got from my B&M DME who asked for 389.00 and actually was paid 299.00

Since Teleflex is the exclusive distributor for the Hudson RCI/respcare Hybrid mask, I'd suggest that all DMEs (online and B&M) obtain the mask from this source.

Yes, Medicare permits (Mattman would say demands or requires) the pricing to be as separate units. Doesn’t seem very ethical to me.

[Slinky]

I'll stake my neck it is not my sleep lab delaying the billing to Medicare for my CPAP.

When they ordered the 02 to be added to my CPAP at 3PM, my 02 DME had a message on my answering machine before I got home at 5PM and they called and delivered by 10 AM the next day. THAT is the type of service I've ALWAYS gotten from my 02 DME.

The day my sleep pulmo and I agreed on what equipment, he wrote the order and the staff FAXed it to the xPAP DME as I stood there chatting w/the sleep lab manager. It took almost 2 weeks for them to call me to come pick the equipment up. When my sleep pulmo scripted the loaner AutoPAP, I was standing right there when the script was FAXed. It took them 3 days to call me in the late afternoon to come pick it up the 4th day

Its ironic. My 02 DME delivers and they are only 8 miles away. My xPAP DME is 25 miles away and they don't deliver diddley-squat, including any kind of real "service".

My 02 DME is only state-wide. I've never had it take more than next day service delivered to my door. I often drop things off or pick things up from my 02 DME because they are so close and are right on my way into town.

I've NEVER gotten next day service for ANYTHING from my xPAP DME and they are a 3 state-wide organization. And it is inconvenient as all billy h*ll to drop anything off or pick anything up from them because they are so far away and in a part of town I have little reason to go to.

Doesn't it figure??

[Guest]

I think we should stop attacking Mattman and appreciate his attempts to answer questions from a DME perspective.
It is clear he provides very helpful information and is willing to do so.

OTOH, I think many DME give answers based on the POLICY of their company.
I think it would be more accurate if he would differentiate between his opinion and the policy of his work and what is clear regulations.

He could have added in the audit that the auditors are or may be looking for COMPLIANCE with POLICY rather than legal considerations.
I also think a dme has not violated any law in selling equipment but they expose themselves to a hell or a liability unless they require an ORDER.
I visited a DME yesterday and was apalled at what the told me as law.
They were simply wrong, but this has evolved in the industry without anyone ever attempting to get it right!
I could be wrong
Tomjax

[TANSTAF1]

I agree. We should be thanking Congress and our legislatures for protecting us from unscripted chin straps.

We should also be thanking mattman for pointing these wise laws out and for following them. After all, non-scripted chin straps could cause a minor skin rash or they might snap and sting our cheeks. How else could we have cradle to grave security and safety?