DME Just Called - yikes

Dealing with this kind of crap is why I just bought my own ResMed. Once I sell my F&P I'll only be a couple hundred bucks out of pocket, which is not different than my deductible.

I still get my free masks, filters, tubes, etc every so often, but I don't even return apria's phone calls. Shrug.

Joe

Some info: using my insurance, my co-pay for my dumb CPAP was $890 (lease purchase). I coulda bought it for about $350 from our host https://www.cpap.com. With your insurance, it might make financial sense to ck out prices from the DME versus buying it yourself. Do not settle for a less than full data machine!

Is this an HMO? cause an HMO can do what they d...n well fell like doing

I have a question for Wulfman. Do you know if only DME companies can profit from CPAP machines? Or can the doctor bill for the machine like a DME company does? This is the case in Orthopedics. They can purchase, for example, a walking boot and bill Medicare and insurance companies for the product and reap a profit from it.
If they can, then patients looking for CPAP machines who get them directly from their doctors face the same conflict of interest as when they purchase them from DMEs.
That is exactly the case in orthopedics. The market is dominated by low cost, low performance walking boots. Patients often are not even aware that there are very high quality alternatives available that cost them exactly the same as the cheap ones (like CPAP machines, the code is the same for all walking boots, L4360). The high quality ones come from Europe where docs and hospitals are forbidden from profiting from products they dispense. They choose on medical merit and patient acceptance alone.

kingtronsky wrote:I have a question for Wulfman. Do you know if only DME companies can profit from CPAP machines? Or can the doctor bill for the machine like a DME company does? This is the case in Orthopedics. They can purchase, for example, a walking boot and bill Medicare and insurance companies for the product and reap a profit from it.
If they can, then patients looking for CPAP machines who get them directly from their doctors face the same conflict of interest as when they purchase them from DMEs.
That is exactly the case in orthopedics. The market is dominated by low cost, low performance walking boots. Patients often are not even aware that there are very high quality alternatives available that cost them exactly the same as the cheap ones (like CPAP machines, the code is the same for all walking boots, L4360). The high quality ones come from Europe where docs and hospitals are forbidden from profiting from products they dispense. They choose on medical merit and patient acceptance alone.

It's been reported on this forum that there are a number of (sleep) doctors who not only own the sleep labs, but the DME companies from which they can then dispense the equipment. In my opinion, this is unethical, at least, but probably not illegal. It's my understanding that Medicare/CMS has adopted rules to prevent this situation. However, it still seems to be going on with regard to billing through other insurance.
I believe there are some laws (HIPPA for one) that mandate that (any and all) prescriptions be given to the patient for the purpose of them being able to choose where the want them to be filled. Alternately, the doctor's office can fax (electronically send) a prescription to the pharmacy of the patient's choosing. It's still common to see a pharmacy within a hospital building or clinic, but it's not like it used to be (many years ago), where the doctor just routed the prescription directly to that pharmacy.

I don't know for sure whether there are any rules/laws preventing doctors from establishing vendor relationships directly with the manufacturers. It's been well known that pharmaceutical companies visit doctors and give them free samples of drugs (that may be dispensed at their discretion). Since the doctors are the ones who write the prescriptions, they're obviously the ones who have the greatest influence on which companies medications get used.
I suspect that the same thing goes on with regard to the DME items, too. The manufacturing representatives may not hand out samples of their equipment, but I believe they do call on the folks who write the prescriptions and definitely the brick & mortar establishments where they are dispensed to either show them or hand out information about their products.

There are obvious differences between the way things are done in Europe (and other places) and the U.S.A. Our politicians are bought and paid for by the special interest groups.....lawyers, insurance, pharmaceuticals, banking, etc., etc. We vote them into office and they then go about writing laws that are not in the best interests of those who put them there.

Hope that helps.


Den

Yes. That does help...especially the part about doctors owning the DME companies that dispense the products. There are no controls in place to limit doctors' and hospitals' ability to purchase DME products and then bill for them. This is completely legal and very common practice (at least in Orthopedics). To me it is utterly inconceivable that the system is set up this way. The end result is that lower quality, cheaper products thrive, and all incentive to make medically superior products gets squelched in favor of finding ways to make a cheaper product that meets the code description set by the Medicare coding boards.

The big losers are 1) the patient who pays the same for poor quality as he would for high quality. In fact this whole thread is a real life example of a patient being given an inferior device despite the availability of a more appropriate device. And 2) Medicare and the insurance companies whose patients receive inferior care for the same price as superior care often resulting in longer recovery times, more office visits and more overall cost to the healthcare system.

The solution could not be more simple. Forbid doctors and hospitals from financial involvement in the products they dispense. This practice is forbidden in Europe and it is even forbidden in our own pharmceutical business.

If anyone can help get this simple change incorporated into healthcare reform it would result in patients getting the best care available today; manufacturers having superior medical efficacy as their only incentive when designing new products; and no increase to the healthcare system whatsoever (in fact a high likelihood of significant savings thanks to shorter recovery times and fewer office visits).

Wulfman wrote:I believe there are some laws (HIPPA for one) that mandate that (any and all) prescriptions be given to the patient for the purpose of them being able to choose where the want them to be filled.

Den,

This is intriguing, since my insurance company just informed me that I had to have a referral from my primary care physician in order to change DMEs! The reasoning was that because the DME is a "service provider," I must have a referral for them. However, no referral was required for the first DME....

Kiralynx wrote:

Wulfman wrote:I believe there are some laws (HIPPA for one) that mandate that (any and all) prescriptions be given to the patient for the purpose of them being able to choose where the want them to be filled.

Den,

This is intriguing, since my insurance company just informed me that I had to have a referral from my primary care physician in order to change DMEs! The reasoning was that because the DME is a "service provider," I must have a referral for them. However, no referral was required for the first DME....

Well, I DID preface my thoughts on that post with "I believe".
With regard to your situation, I think I would challenge that.
From my recollections and searches over the last few years as this subject has come up (about the patient getting the physical prescription document from their sleep doctors), I believe it was the optometry business that was at the forefront of the reasons for getting the physical prescriptions. Traditionally, the optometrist did the eye exams and sold the glasses (sound familiar?). Somewhere back in time, that changed and now you're able to get your eyeglass prescriptions and go to wherever you want to get them. I'm sure in THAT case, you'd never get the optometrist to give you a referral to another place that sells the eyeglasses. WHY would it have to be that way with other doctors?


Den

Wulfman wrote:

Kiralynx wrote:This is intriguing, since my insurance company just informed me that I had to have a referral from my primary care physician in order to change DMEs! The reasoning was that because the DME is a "service provider," I must have a referral for them. However, no referral was required for the first DME....

Wulfman wrote:Well, I DID preface my thoughts on that post with "I believe".
With regard to your situation, I think I would challenge that.
From my recollections and searches over the last few years as this subject has come up (about the patient getting the physical prescription document from their sleep doctors), I believe it was the optometry business that was at the forefront of the reasons for getting the physical prescriptions. Traditionally, the optometrist did the eye exams and sold the glasses (sound familiar?). Somewhere back in time, that changed and now you're able to get your eyeglass prescriptions and go to wherever you want to get them. I'm sure in THAT case, you'd never get the optometrist to give you a referral to another place that sells the eyeglasses. WHY would it have to be that way with other doctors?

I have politely requested a clarification on this issue. Thanks. I am trying to sort out how I can purchase from a responsible DME, like our hosts, and be reimbursed by my insurance as several people have mentioned doing.

Reason is in the post about Apria and the Headrest.
viewtopic/t47581/Apria-and-the-Headrest-Mask.html

Kiralynx wrote:

Wulfman wrote:I believe there are some laws (HIPPA for one) that mandate that (any and all) prescriptions be given to the patient for the purpose of them being able to choose where the want them to be filled.

Den,

This is intriguing, since my insurance company just informed me that I had to have a referral from my primary care physician in order to change DMEs! The reasoning was that because the DME is a "service provider," I must have a referral for them. However, no referral was required for the first DME....

I filed a complaint with my insurance Medicare and BC/BS FEHB about Apria. My secondary insurance BC/BS called them and tried to get some satisfaction for me and trying to get them to help get me a new Bi-Pap, because my "Tank Died" Apria would not do anything to help. Both Medicare and BC/BS gave me a couple of other DME's to choose from.
I am sure glad I had a back up machine to use because i have been fighting with them since the beginning of October to get a new machine.
I finally was able to get in and get a new Titration Study. I did not need a referal to the new DME but I will have my new machine tomorrow afternoon.