Thinking that I may not like DME billing dept

[jmcsmomma]

I got a summary the other day listing everything being charged. The mask is the wrong one, which is a 55 dollar error, and it doesn't show where I made a payment. I called them, and was told that it never shows payments received, and then the DME fellow called and said that the masks are all the same price. Really? I may be calling my insurance company in a bit to check on that.

[dae3dae3]

My DME is terrible with billing also. They make me pay a copay even though my insurance doesn't require it and then they end up sending me a check because the payment wasn't needed. I try to talk to them about this and they seem completely stumped about why I would have a problem with it.

Also, my insurance will pay for a new nasal cushion monthly but the DME doesn't sell them individually apart from with a mask to I have to buy them out of pocket off ebay or trade for them here on the pillow exchange thread.

I can't imagine somebody who doesn't educate themselves being succesfully treated by the place.

[6PtStar]

Masks all the same price is not all that uncommon, especially if they are using Medicare billing codes. With the Medicare billing codes the price for all full face masks are reimbursed the same price. Nasal masks have there own price and nasal pillows also have their own price. Even if you are not on Medicare many insurance companies still use the Medicare billing codes for reimbursement.

Jerry

[BusyLyn]

Also, my insurance will pay for a new nasal cushion monthly but the DME doesn't sell them individually apart from with a mask to I have to buy them out of pocket off ebay or trade for them here on the pillow exchange thread.

I can't imagine somebody who doesn't educate themselves being succesfully treated by the place.

Find yourself a new DME who stocks parts for your mask.

I also had a DME who didn't stock parts. The rt there insisted that the cushion for my FFM was supposed to last 6 months (Medicare guidelines allow a new cushion every month) and I must be washing it with an improper cleanser if I felt that it was breaking down 'early' (I could see that there was wear due to the graph changes in Encore Viewer!). I was told by my insurance company that I could have different DMEs for the machine and mask, so I went DME shopping. The rt at the first place I called was himself a 10+ year hosehead, and said that of course they stocked parts, and if I needed anything that they didn't have in stock they would order it. Boy, what a difference!

There are good DMEs out there. Get the DME list from your insurance company and start calling around. The good ones will even mail out parts if you can't stop in.

Lyn

[archangle]

My DME is terrible with billing also. They make me pay a copay even though my insurance doesn't require it and then they end up sending me a check because the payment wasn't needed. I try to talk to them about this and they seem completely stumped about why I would have a problem with it.

Also, my insurance will pay for a new nasal cushion monthly but the DME doesn't sell them individually apart from with a mask to I have to buy them out of pocket off ebay or trade for them here on the pillow exchange thread.

I can't imagine somebody who doesn't educate themselves being succesfully treated by the place.

Find out the procedure to file a formal complaint with your insurance company. And look for a different DME. Find out if there are any online or mail order DME providers your insurance company will pay.

[Wonka]

I have a rented machine, I am on Medicare with an aarp supplement. When I request pillows they send one. Last week I ordered a new climate line hose. The first broke. The billing indicated a cost of $158. It can be purchased from clap.com for $58. I doubt Medicare will pay for the replacement. It was only 5 months old. If Medicare does't pay for it there's no way I'm paying their $158 charge. I don't know whether this is the standard practice, or not(billing far too high). Can a Medicare participant's change dme's for supplies if they're renting from another?

[Pugsy]

Can a Medicare participant's change dme's for supplies if they're renting from another?

Yes, you can get supplies from any DME that you wish. Most will be participating providers with Medicare. All you need is the RX or copy of it. Always ask up front if the DME accepts assignment from Medicare.

Though to be honest it is common for DME to charge inflated prices and then do an adjustment write off when Medicare finally gets around to stating the "allowable" amount. What they bill and what they finally accept is often miles apart.

You should get a copy of what Medicare finally allows for the replacement hose or if they deny it what your responsibility might be. You might be surprised and find that Medicare allows the replacement and just makes the DME accept a greatly reduced fee.

[Janknitz]

I see people get upset here all the time at how much Medicare is billed by the DME. But the truth is IT DOESN'T MATTER! Medicare has set allowable fees for each item, and that's all that Medicare is going to pay, regardless of how much the DME bills.

The DME could bill $1 million for a machine but they are only going to get the fee that Medicare sets and pays every other DME in your state (about $100 per month X 13 months). The outrageous prices are what the DME uses to negotiate fees with other insurers--large insurers with a lot of clout will pay around the same amount per item as Medicare (sometimes less!), and small insurers will pay more. But nobody except some poor sucker who walks in off the street without insurance and not knowing any better pays what the DME charges.

Period.

And all you owe is 20% of the Medicare allowable fee (plus deductible if it hasn't already been met).

Period.

If you search here you can find the Medicare replacement schedule. Educate yourself about what can be replaced when. I've posted links to the data base that will even tell you how much Medicare allows on CPAP equipment and supplies in your state, so you can calculate your 20% out of pocket cost.

Instead of sitting in the dark worrying about how much you're going to be billed for if Medicare doesn't cover something, educate yourself about what they WILL cover, when, and how much your out of pocket costs will be. This will ease your mind (Medicare coverage, for all the complaints, is pretty good coverage for CPAP) AND prevent the unscrupulous DME from taking advantage of your ignorance to charge you more or prevent you from getting what you need because it's too much trouble for them to do the Medicare billing (all that "trouble" is one of the reasons they get more from Medicare than an online supplier's retail price--they might as well earn it).

[purple]

May I add. If the DME accepts assignment. The value Medicare sets for a service or item is the maximum amount that will be paid. The Medicare assignment is the full dollar figure which they will be paid. Every so often I get a letter in which Medicare states what has been sent to Medicare for billing in my behalf, and what Medicare calls the Assignment dollar amount, and what they expect to pay, as well as what I may be legally billed. As it plays out: When I ordered a mask, cushion, tubing, filters head gear the box had that listing of all those items in the box with the retail prices. Two months later I get a bill from the DME for my percentage of the assignment. Assignment is always a lot less than the retail price.

Right now I have a dispute about a medical test where it looks like they want me to pay the twenty percent for a dollar amount that looks like their full retail price, and for a test that was performed last year when the co-pay was ten percent. Medicare pays one hundred percent for some tests, and I suspect that this test might be one of them.

One can not trust a hospital billing department run by someone more concerned with profits than truth.

[Janknitz]

My understanding is that participating DME's all "accept assignment".

Health care providers (physicians, therapists, etc.) can choose to accept assignment or not. If they accept assignment, they get paid right up front and must accept what Medicare allows. If they do not accept assignment, they must wait to be paid (you may have to submit the bill yourself) , and may charge up to 15% more than the Medicare allowable, no more than that.

[idamtnboy]

I see people get upset here all the time at how much Medicare is billed by the DME. But the truth is IT DOESN'T MATTER! Medicare has set allowable fees for each item, and that's all that Medicare is going to pay, regardless of how much the DME bills.

Not quite. As purple says, "If the DME accepts assignment." The DME must be enrolled with Medicare in order for the patient's bill to be covered by Medicare, period. But the enrolled non-participating DME does not have to accept assignment, although they can. If they don't, they can charge whatever they want. Apparently the 115% limit that applies to physician charges doesn't apply to DME. Here's a quote from the medicare.gov

If a supplier of DME doesn’t accept assignment, there is no limit to what you can be charged. You also may have to pay the entire bill (your share and Medicare’s share) at the time you get the DME.

If the supplier is a participating supplier, they must accept assignment. If the supplier is enrolled in Medicare but isn’t “participating,” they have the option to accept assignment.

If they are participating they accept assignment for all billing, they cannot pick and choose. If they are enrolled, but not participating, they are not paid directly by Medicare. Medicare pays the patient, and the patient pays the supplier. But the supplier still submits the bill to Medicare on behalf of the patient. That's the incentive Medicare uses to get providers to accept assignment. They are guaranteed to receive at least 80% of the Medicare amount.

[archangle]

My understanding is that participating DME's all "accept assignment".

Be careful that you don't get hooked up with DME or doctor who isn't enrolled in Medicare (or your insurance company). I think they're free to charge whatever they want.

[Janknitz]

My understanding is that participating DME's all "accept assignment".

Be careful that you don't get hooked up with DME or doctor who isn't enrolled in Medicare (or your insurance company). I think they're free to charge whatever they want.

As I said, “participating” DME’s.

OK, let's see if we can clear this up. Three things to understand:

1) Enrolled--meaning DME's who have met the requirements to receive Medicare payments, but who do not have to bill Medicare for you and do not have to accept Medicare rates at all.
2) Participating—Enrolled DME's who agree to accept assignment on all claims
3) IF the DME is neither enrolled nor participating, Medicare will not pay. For example, most of the online suppliers like Cpap.com are neither enrolled nor participating suppliers. You pay out of pocket.

MOST Brick and Mortar DME's are participating suppliers. That's something you should ask about before agreeing to work with a particular DME, but honestly, I haven’t seen anyone lately complaining that their DME was not a participating DME.

See: http://www.medicare.gov/Publications/Pubs/pdf/11045.pdf

“Suppliers who agree to accept assignment on all claims for durable medical equipment and other devices are called “participating suppliers.” If a durable medical equipment supplier doesn’t accept assignment, there is no limit to what they can charge you. In addition, you may have to pay the entire bill(Medicare’s share as well as your coinsurance and any deductible) at the time you get the durable medical equipment. The supplier will send the bill to Medicare for you, but you will have to wait for Medicare to reimburse you later for its share of the charge.

Important Note: Before you get durable medical equipment, ask if the supplier is enrolled in Medicare. If the supplier is not enrolled in Medicare, Medicare won’t pay your claim at all. Then, ask if the supplier is a participating supplier in the Medicare Program. A participating supplier must accept assignment. A supplier that is enrolled in Medicare, but isn’t “participating,” has the option whether to accept assignment. You will have to ask if the supplier will accept assignment for your claim.”

[archangle]

As I said, “participating” DME’s.

You know that. I know that. People who haven't been shafted by the insurance/medicare/provider scams may not realize until it's too late.

[Pugsy]

For the Medicare layperson who forgets "participating or non participating".

Simple questions to ask any DME provider, doctor or whatever.

"Will you bill Medicare? Will Medicare send the check to you or to the patient?"

If they participate Medicare will send the check to the DME provider, doctor or whatever. There are allowable charges to be reckoned with.

If they don't participate, Medicare sends the check to the patient. There are allowable charges to be reckoned with.

If they won't/don't bill Medicare, don't do business with them. Medicare's usual allowable amounts are not reckoned with and they could bill whatever they wish.