Abusing the system?

akcpapguy wrote:I have asked this question because I have about 20 or so patients who bring their Respironics mask back without fail at around the 25-30 day mark. All of these patients have been doing this for over 24 months (Long before I started at this job), and some of them have been doing it for as long as 4 years.

This week my Manager asked me for a recommendation for a timeframe on an acceptable use policy. I told her I would give her an answer on Tuesday after i talked to some other DME RT's and ofcourse polled you folks here at cpaptalk.

These folks don't really switch mask either, they just simply change the size they ask for from month to month. None of them have ever had to pay for a mask, since they are returned before the billing cycle is reach.

well if your employer is dumb enough to offer and allow that policy to continue then it is their own fault.

But I doubt very seriously you are NOT getting paid for them, maybe you just don't know about it, it is more likely you are charging their insurance in the neighborhood of $315 for a $42 mask every 6 months weather they exchange it or not.

I also wouldn't be surprised to learn you are charging them for a replacement hose once a month. I have been on cpap over 6 years, never once have I had to replace a hose because it was worn out or sprung a leak.

Respironics masks are cheapest on the market to begin with, even at $42 a pop they are probably still making 400% mark up on them. Besides if you are like most DME's you get XX amount of masks FREE for every Respironics xpap machine you sell.

Snoredog,

This is not a policy set by my employer, the 30 day return policy is a Respironics policy. Others here can probably verify that.

I have full access to all of my patients billing records since all of the billing is generated by myself or the manager for all CPAP's and accessories. We do not ship/bill patients acessories that they have not specifically asked us to ship/bill them ahead of time. This request must also be in writing, and must be done everytime the patient wants this done.

As far as free masks, we have no deal with Respironics to get free masks. However we did get a free CPAP from them the last time we ordered. The supply tech and the Manager thought it was a mistake until they called the Rep and he said, "Your company has an agreement with Respironics for a free CPAP for every XX CPAP's you buy". He told the Manager the agreement had been in place for 4 years, but they had not ordered enough CPAP's to get a free one until now. This is not a cumulitive effects it is dependant on each order.

So now you might be saying see, now your selling a free CPAP for $1,500. Nope, the Manager and I decided to put it into our pool of CPAP's that we give out to people without Healthcare, and don't have the money to buy one of the internet.

Oh and no NONE of those patients in my original post have had their Insurance billed for a mask. This is how it was originally brought to the attention of my Manager. Like I said I have full access to the billing records of all my CPAP patients, and I reviewed them all to see if she was right.

WOW, people get to "try" a mask!?!?

My local Apria (Cigna makes me) DME still doesn't understand what a "mask fitting" is. When I got my machine, mask, etc. I also had a "mask fitting" which the insurance paid $50 for. The mask fitting consisted of:

The RT showed me about 5 to 10 different masks. I held then, played with the squishy parts, and "thought" about what they might feel like on my face. After I questioned that I couldn't try one on, the RT closed the door to his office, and quietly told me.. OK, you can hold it to your face... But DON'T breath into it. They apparently don't have the equipment to sterilize the masks. I was informed once I breathed into the mask it was MINE. Then they helped "fit" it to me.

A bit of time goes by and decide to get a Full Face mask. I end up having to talk to the Corporate Cigna rep at Apria. I explain what my local branch considered a "Mask Fitting" and needless to say, they probably had to replace a few ceiling tiles in the guys office. (He went through the roof!)

While I was on hold, he called his manager, and the manager at the local branch and said I DEFINITELY wouldn't have that problem again.

Well I go in to the same RT at the same branch for a Full Face mask fitting (another $50 billed to my insurance) and guess what... I get to hold the mask... feel the squishy bits and eventually hold it to my face... BUT DON'T BREATH into it.

As soon as I get my nasal pillow mask I ordered over 6 WEEKS ago through Apria, I will be contacting CIGNA and letting them know that I WILL be using a different DME or next year, I WILL be using a different insurance company.

Thanks everyone for letting me vent.

-craig

Having never really used a Brick and Mortar DME vendor, I don't know what you are talking about. Could you explain? I take it that Respironics allows mask returns. Do any other manufacturers? Is this for B&M's only, or does it extend to internet sales?

It's nice to hear of a responsible and conscientious B&M DME vendor for a change, BTW, since that's where most people go. I don't believe we have any responsible ones around here, to be honest. A tip of the hat to akcpapguy and his company.

Craig-Tx wrote:OK, you can hold it to your face... But DON'T breath into it. They apparently don't have the equipment to sterilize the masks. I was informed once I breathed into the mask it was MINE.

It's only going to take one person with TB and a runny nose to get THAT policy changed. Oh, after a few lawsuits for negligence I'm sure.

For someone turning over as many sales as Apria, I'm really surprised that they don't maintain sterilizing equipment. (My cynical guess is that they have it, and use it, but they don't want to have to use it more than they need to, so they freak you out about breathing into them.)

According to other DME RTs who've posted in the various apnea forums, both Resmed and Fisher & Paykel also have the policy of free replacement masks as long as the DME fills out the proper form and returns it to the manufacturer w/in 30 days.

I'm curious - what other services are you providing your clients? Do any of these mask-checkers have fully data capable machines? Is anybody downloading data to evaluate their therapy and effectiveness? I can't imagine an educated user who has access to a fully-data-capable machine or one who frequents a forum such as this would be trying a new mask every month. If therapy is going well, leaks are under control, and the patient is seeing improvement in how they feel, why on earth would one give up on a mask every month? Do you mail them the mask or deliver it to them? If there's a bit of obligation on the patient's part it might make them think twice about packing up and mailing the masks back to you or making the trip to hand-deliver them back for exchange. I'm just brainstorming here. My DME does not come to me. It is about 45 minutes' drive in heavy traffic, each way, at considerable gas expense, for me to go for a mask fitting or to pick up equipment. I consider this to be important to my health and make the trip; it just isn't that frequent to be a problem for me. I monitor my own data with the help of people here. If I have/had leak issues, the collective 'We' have worked through mask tweaking. Do these patients return perfectly good-fitting masks that aren't leaking for exchange? You won't know of leak issues unless there is some monitoring going on. If they don't have fully-data-capable machines, it could be a problem to find out if they are having leak issues, and preventing you from figuring out which areas of the face are giving leak problems. Another thought, do the patients have to give a reason for returning a mask? Is the reason documented. I'm thinking if a person is abusing the system and says two different sizes of the same mask are leaking, is there a specific place (like eyes), or a specific sleeping position that gives problems? This doesn't need much work, just a paper the patient would have to fill out, making it his responsibility to be truthful about the mask problems, and giving you more info to help the patients comply or document abuse, on the other hand. Just wishing this wasn't happening, as this truly is the first time I've heard of this happening. Most of us have the opposite problem, little or improper mask fitting, unwilling/uninvolved DMEs, etc.

girlsaylor

AKcpapguy,

I think it's definite abuse if these people are getting the same mask over and over again, just changing sizes. Like others said, I would track the number of times they change the masks, what they change to, and if they get the ask for the same mask and size twice the answer would be a resounding NO.

I can see switching masks and sizes until you are sure you have the best fit, but once you've tried it several days to a week, you should know if it's going to work or not.

I answered 6 months since that was the shortest time period as well, but it's more a factor of what these guys are doing. Same mask/size - NOT. Different size, OK, but only ONCE.

Best of luck setting your policy.