How do you deal with the DMEs?

[DeadlySleep]

Talking to the doctor about this situation might help the OP, he could ask the doctor to direct the DME not to use the SD card to change the pressure. Just let the OP set it, and get the DME out of the pressure-setting loop. Might take some talking, but once it's done, you're there, and the OP won't have to screw around any more after that.

Just a thought...

Just remember the OP has a history in the forum of confusion about how to deal with insurance companies, doctors, other medical personnel and now DMEs. (Who doesn't have that confusion?)

His post here leaves a lot to be desired regarding reporting to the forum what is going on.

John, Not saying you don't deserve help from the kind forum, but you need to be explicit about the situation.

[johnthomasmacdonald]

Talking to the doctor about this situation might help the OP, he could ask the doctor to direct the DME not to use the SD card to change the pressure. Just let the OP set it, and get the DME out of the pressure-setting loop. Might take some talking, but once it's done, you're there, and the OP won't have to screw around any more after that.

Just a thought...

Just remember the OP has a history in the forum of confusion about how to deal with insurance companies, doctors, other medical personnel and now DMEs. (Who doesn't have that confusion?)

His post here leaves a lot to be desired regarding reporting to the forum what is going on.

John, Not saying you don't deserve help from the kind forum, but you need to be explicit about the situation.

Reality has a well-known liberal bias. It must suck to be you.

[Denial Dave]

my humble suggestion is that you deal with DME's like you would deal with any used car salesman.

They'll sell you items that will make the maximum profit for them.

Verify everything they tell you.

[hyperlexis]

I've been having problems with mine in that they don't want me touching the settings even though i've got my ahi down to around .2 per night with around 7.5 hours of sleep, while with their settings, i have an ahi around 8.

They keep sending me sd-cards in the mail that supposedly will make the changes on my machine ( to agree with what I've told them I need) but the machine doesn't seem to want to read their card ( i've thought it is probably because the "starting" pressures on the machine are no longer what they thought that they are.

I'd change back to the original settings and have tried but i can't get their new card to work.

My sleep doctor doesn't seem to mind my changing the settings but she also doesn't want to get involved with the DME and of course the only one in the loop anyone really cares about annoying, the insurance company.

So, what is the best way to navigate these waters?

I want to cause the least annoyance as possible and generate no drama but i also need to be able to adjust the pressures as need be.

1.) Deal only with the respiratory therapist at the DME, not the staff. The RT is at least a professional.
2.) The Auto machine should be doing the work for you. CPAP isnt a videogame. Changing rx settings etc., shouldn't be done willy nillie. It takes time to get good data and it seems like you are still on the first three months when your insurance is tracking your use, no? If your original Rx is somehow totally wrong, then you need to discuss this with the physician, not a staff person at a DME. Discuss why the numbers aren't working with your MD and get an explanation and suggestions. An AHI under 5 is considered good, so you are really not that far off at 8. If your MD wants to change the Rx then the DME will need a call from the MD to change the settings -- the DME isn't likely going to change prescribed settings based on your opinion only. They could get in trouble for that and they don't want the liability.

f/u -- Wait it seems like you have been doing this for a long time. Why does your insurance company care about your machine and your compliance anymore?

[RogerSC]

f/u -- Wait it seems like you have been doing this for a long time. Why does your insurance company care about your machine and your compliance anymore?

Medicare, for one, requires continuing verification of compliance to keep covering supplies. Not sure how many other insurance companies do as well, but I suspect that quite a few would. The machine is one thing, that gets paid off, but supplies as you go along can also add up to some money for the insurance company.

[Janknitz]

Medicare, for one, requires continuing verification of compliance to keep covering supplies.

Since when?

Can you show me the Medicare regulation that says that???

[johnthomasmacdonald]

f/u -- Wait it seems like you have been doing this for a long time. Why does your insurance company care about your machine and your compliance anymore?

Medicare, for one, requires continuing verification of compliance to keep covering supplies. Not sure how many other insurance companies do as well, but I suspect that quite a few would. The machine is one thing, that gets paid off, but supplies as you go along can also add up to some money for the insurance company.

actually this is the First machine paid for by my insurance company, my other machines i bought myself after a home test from 1800cpap.com diagnosed the apnea. All the follow-up tests i've had basically confirmed exactly what the home test and the sleephead results already demonstrated - just needed to re-document everything for the insurance company in order to get the right machine. With the previous policy i had they wouldn't pay for a sleep test or a machine (since the machine was prescribed by an sleep test that wasn't in their network - catch 22

[kaiasgram]

So John, you are still in the compliance monitoring period, correct? And that's why you have to deal with the DME and the crazy SD card stuff?

[martinsr00]

In my experience they are either checking you for compliance or are trying to cover themselves because you are changing your pressure settings. We would have to notify the MD and insurance companies if we had someone changing the settings. We would have to get several downloads showing that we set the machine to the prescribed pressure and that the pressure was changed without our knowledge and without a prescription. It's a way to cover themselves from liability. I had a lady on a pressure of 20. Her husbands pressure was 9. His machine broke so he just used hers claiming it was his. The higher pressure damaged his lungs and he tried to sue our company because the pressure was on 20 not 9.

I live on a the West Coast and have a very good pulmonologist from a renown research institution/hospital. My pressures are 20/25 (near the limit of the machine). The pressures were prescribed by the physician that signed off on my sleep study (an independent sleep lab). My pulmonologist signed off right away on a auto Bipap and specified those settings. All he asked about was the maximum temperature and settable range for the ramp times. When asking him about whether this pressure could damage my lungs he said, on several occasions, "those pressures are really low -- you can't get into trouble with those". I took this to mean that if you had lungs that were basically in order, the pressures in a normal cpap machine (25cm H2o or lower), you were very safe. Maybe someone is conning someone.

[RogerSC]

Medicare, for one, requires continuing verification of compliance to keep covering supplies.

Since when?

Can you show me the Medicare regulation that says that???

No, that's what my sleep doctor and DME both told me. My DME first told me that before they could get me supplies for this year from Medicare I had to have my doctor send over the results of my last sleep doctor's appt. to them, which I then asked my doctor about, and he confirmed that, but yes, you got me, I haven't looked it up. It just makes sense that Medicare (or my employer's insurance) would have no obligation to pay for supplies if I'm no longer using my CPAP. For example, let's say that I set up a business selling the CPAP supplies that Medicare (or another insurance company) is buying for me because I'm not using my CPAP any more...doesn't make sense to me. Now giving them away to others that need them, that makes sense *smile*...that last part was kind of a joke, but I think that you might get my drift.

But like I said, I haven't checked to see if this is written into law, or is just part of their general operating rules (not paying for supplies that patients don't need).

[ChicagoGranny]

For example, let's say that I set up a business selling the CPAP supplies that Medicare (or another insurance company) is buying for me because I'm not using my CPAP any more...doesn't make sense to me.

There is a huge amount of that going on. Medicare is a sucker.

[idamtnboy]

For example, let's say that I set up a business selling the CPAP supplies that Medicare (or another insurance company) is buying for me because I'm not using my CPAP any more...doesn't make sense to me.

There is a huge amount of that going on. Medicare is a sucker.

Huge amount? Any kind of references to substantiate that claim? I won't argue that there is certainly some of that going on simply because many people are dishonest, but a huge amount? I suppose it could be, but then that depends on the definition of huge amount. Sadly, there is a point where enforcement costs to prevent such fraud outweigh the losses of the fraud.

You say Medicare is a sucker. But, to prevent being a sucker Medicare would need more enforcement authority over contracts and contractors, exactly the type of authority that conservatives rail against. So what shall it be, more authority with its attendant regulations, or less authority with its attendant fraud and abuse? Sorry, but people and businesses being what they are you aren't going to get less authority and less fraud simultaneously. And don't forget, Congress is the source of all agency authority which means Congress is ultimately responsible for preventing, or allowing, fraud, waste, and abuse. Sadly, when I was working for Uncle never once did I see a case where a Congressman or Senator was willing to defend a Federal employee, or Federal contractor employee, against a campaign contributing constituent, regardless of how egregious the constituent's actions were.

[Wulfman...]

For example, let's say that I set up a business selling the CPAP supplies that Medicare (or another insurance company) is buying for me because I'm not using my CPAP any more...doesn't make sense to me.

There is a huge amount of that going on. Medicare is a sucker.

Huge amount? Any kind of references to substantiate that claim? I won't argue that there is certainly some of that going on simply because many people are dishonest, but a huge amount? I suppose it could be, but then that depends on the definition of huge amount. Sadly, there is a point where enforcement costs to prevent such fraud outweigh the losses of the fraud.

You say Medicare is a sucker. But, to prevent being a sucker Medicare would need more enforcement authority over contracts and contractors, exactly the type of authority that conservatives rail against. So what shall it be, more authority with its attendant regulations, or less authority with its attendant fraud and abuse? Sorry, but people and businesses being what they are you aren't going to get less authority and less fraud simultaneously. And don't forget, Congress is the source of all agency authority which means Congress is ultimately responsible for preventing, or allowing, fraud, waste, and abuse. Sadly, when I was working for Uncle never once did I see a case where a Congressman or Senator was willing to defend a Federal employee, or Federal contractor employee, against a campaign contributing constituent, regardless of how egregious the constituent's actions were.

Even a blind squirrel can eventually find a nut. The dollar amounts of individual cases are in the millions. It would seem that those kinds of numbers would be jumping out at the groups who make the payments to those who are defrauding the system.

There's a HUGE amount of Medicare fraud taking place. One only needs to Google "Medicare fraud" to find it's in the tens of billions of dollars......I've heard numbers in the $50 - $100 billion.

From a Wiki article on Medicare fraud:

"The Office of Inspector General for the US Department of Health and Human Services, as mandated by Public Law 95-452 (as amended), is to protect the integrity of Department of Health and Human Services (HHS) programs, to include Medicare and Medicaid programs, as well as the health and welfare of the beneficiaries of those programs. The Office of Investigations for the HHS, OIG collaboratively works with the Federal Bureau of Investigation in order to combat Medicare Fraud.

Defendants convicted of Medicare fraud face stiff penalties according to the Federal Sentencing Guidelines and disbarment from HHS programs. The sentence depends on the amount of the fraud. Defendants can expect to face substantial prison time, deportation (if not a US citizen), fines, and restitution.

In 1997, the federal government dedicated $100 million to federal law enforcement to combat Medicare fraud. That money pays over 400 FBI agents who investigate Medicare fraud claims. In 2007, the US Department of Health and Human Services, Office of Inspector General, US Attorney's Office, and the US Department of Justice created the Medicare Fraud Strike Force in Miami, Florida.[14] This group of anti-fraud agents has been duplicated in other cities where Medicare fraud is widespread. In Miami alone, over two dozen agents from various federal agencies investigate solely Medicare fraud. In May 2009, Attorney General Holder and HHS Secretary Sebelius Announce New Interagency Health Care Fraud Prevention and Enforcement Action Team (HEAT) to combat Medicare fraud.[15] FBI Director Robert Mueller stated that the FBI and HHS OIG has over 2,400 open health care fraud investigations.[16]

The first "National Summit on Health Care Fraud” was held on January 28, 2010 to bring together leaders from the public and private sectors to identify and discuss innovative ways to eliminate fraud, waste and abuse in the US health care system.[17] The summit is the first national gathering on health care fraud between law enforcement and the private and public sectors and is part of the Obama Administration’s coordinated effort to fight health care fraud.

The Justice Department has used the False Claims Act to recover more than $7.7 billion from January 2009 to June 2012 in cases involving fraud against federal health care programs."

In reality, the CPAP-related part of DME fraud is probably fairly small, but every little bit adds up. Like someone said, "A billion here and a billion there and pretty soon it adds up to "real" money. I think many of us have seen various examples. However, I think there is more in the categories of "waste and abuse". Nobody really cares because as long as it's "other peoples' money", there's more where that came from and it's not theirs.

I believe that if they could eliminate the waste, fraud and abuse out of "healthcare", it MIGHT actually be financially sound.


Den

.

[idamtnboy]

As I understand it, the efforts to combat fraud, waste, and abuse, was one of the big drivers for the competitive bidding program. Honest DMEs and CPAP users get caught up in the vagaries of the limitations that ensued. The good guys are the ones who usually feel the real pain that is the fallout of such efforts.

I won't argue that FWA by providers isn't huge. I'm just doubtful that what RogerSC mentions, users selling supplies, is huge.

My observation while working for Uncle is that the rank and file, GS-12 and -13 level employees, the level of most contract officers and auditors, who can see FWA occurring, have a d*** hard time fighting against $200,000+ lawyers and lobbyists, and they don't get supported by the top level political appointees who are in a position to really do something.

[Janknitz]

No, that's what my sleep doctor and DME both told me. My DME first told me that before they could get me supplies for this year from Medicare I had to have my doctor send over the results of my last sleep doctor's appt. to them, which I then asked my doctor about, and he confirmed that, but yes, you got me, I haven't looked it up. It just makes sense that Medicare (or my employer's insurance) would have no obligation to pay for supplies if I'm no longer using my CPAP. For example, let's say that I set up a business selling the CPAP supplies that Medicare (or another insurance company) is buying for me because I'm not using my CPAP any more...doesn't make sense to me. Now giving them away to others that need them, that makes sense *smile*...that last part was kind of a joke, but I think that you might get my drift.

By definition, you wouldn't be needing supplies if you are not using your machine. And it would be a pretty slow business because Medicare limits the frequency and amount of supplies.

I don't think it's true that the DME had to continue to document your compliance for additional supplies. NEVER, EVER believe what a DME tells you. What is true is that DME's cannot hand out supplies unless there is a documented need (ie mask cushion wore out). No more automatic supplies on a schedule. But until I see it in writing from Medicare, I doubt there s any continuing compliance requirement.