Is this upgrade charge reasonable?

Initially, I was issued an S8 series ResMed machine that had no data recall capabilities. After finding this forum and discovering what I had, I asked my doctor if she would contact the DME and request a data capable machine for me, which she did. I received an S9 Elite with which I have been very satisfied except that I realize that I would be better off with an S9 Auto Set in case the auto function is ever needed. The DME contacted me this morning concerning another matter and during the course of the conversation I asked what would be required for me to get an S9 Auto Set. I was told that I would need a prescription for the upgrade from the Elite to the Auto Set and that I would have to pay $300 out of pocket to cover the difference in cost of the two machines since Medicare would not pay the difference. I realize the difference in cost on the internet is only $50-$75 but I also realize how much the cost is inflated by all DME's. So, is what the DME is telling me reasonable?

Absoultely not! (Some exceptions apply, see below)

If you are still within your capped rental period (first 13 months) of machine rental, Medicare pays the same amount for a fully data capable bells and whistles cadillac machine as for the brick you already have. It is ILLEGAL for the DME to charge more--this is known as balance billing. See my post at http://maskarrayed.wordpress.com/dont-p ... -upcharge/. You don't even have to look up your state regulations, it is illegal under Medicare.

The DME does not want to provide you with the S9 auto because they make less profit. Too bad. That's their problem, not yours. They could give you a hard time, especially if you are deep into the capped rental period, and you might have difficulty getting another DME to provide that machine if they are not going to get most or all of the capped rental income. You may have to play hardball with the DME. If you need to threaten them, in writing, with reporting them for Medicare Fraud for trying to charge you extra for an E0601 machine (HCPC's billing code). But start out nicely--make sure they know you know the law, you might catch more flies with honey, yadda yadda yadda.

Exceptions: IF you have a Medicare HMO/Advantage plan or if your capped rental period is over, this doesn't apply. HMO's can do whatever they damn well please, and if your capped rental period is over, you own the brick. You're SOL for the next 5 years, and $300 isn't bad in that case.

Actually, you have "used" a brand new Resmed S8 Compact or Escape (the two compliance data only) CPAPs, then managed to exchange it w/this DME provider to an S9 Elite.

The brand new Elite is now also a "used" CPAP.

That is a quite a loss for the DME provider to swallow to give you a brand new S8 AutoSet Vantage or S8 AutoSet II, much less to an S9 AutoSet. Regardless of Medicare's ruling, I'd say you'd be darn lucky if they are willing to now provider you w/a Resmed APAP for "just" $300, especially if it is an S9 AutoSet.

The difference in price to the dealer is $100 so thats ridiculous.

I think you will have to wait to get a bill before anything can be done even then they will likely say it was an error.

Get a machine specific prescription to get the machine you want. Have the doc write the make & model on the script.

Good Luck

And the DME provider is supposed to just smile and swallow the loss on a new S8 entry level PAP and a new S9 Elite, both now USED devices, and provide an S9 AutoSet at no extra charge????

I appreciate the replies and different views on the matter. I look forward to other member's take on this situation.

I don't usually side with the DME, but in this case I think Slinky is right.

Yeah, kinda makes you a bit sick to the tummy to stick up for a local DME provider, doesn't it? But ... fair is fair. I guess. Doesn't mean we gotta like it tho.

And the DME provider is supposed to just smile and swallow the loss on a new S8 entry level PAP and a new S9 Elite, both now USED devices, and provide an S9 AutoSet at no extra charge????

Bottom line is that it's the LAW. They can't charge any more. If they had provided the S9 Autoset in the first place, they would have received the exact same amount as they did for the S8 entry level PAP. Balance billing is illegal.

On the other hand, they can refuse to change the machine at this point, because you have used the machine and they can't sell it for new anymore. They provided you with an E0601 machine as required by your prescription. That's why you need to try to make nice with them first.

The "carrot" for them is that if they treat you well, they will have your lifetime of repeat business for supplies. Over the length of your life, that can certainly offset any "loss" for the upgraded machine. But the sad reality is they may not care.

If you are only a few months into your capped rental period, you might have the best luck with another DME provider. But nobody will want you if there are only a few months of billing left.

For others who don't have equipment yet, please read this http://maskarrayed.wordpress.com/what-y ... me-part-i/ BEFORE you deal with a DME. It will save a world of headaches.

Damn that capitalism where vendors actually make a profit!!! Aren't they in business just to cater to our whims?

Isn't there something about "an ounce of prevention" at work here?

Most Insurance carriers have agreements which spell out just how these situations are to be handled when equipment changes are needed. That makes it a gamble to provide and another gamble to provide low end equipment as a preference.

You might be surprised to find I didn't make these agreements. It just didn't cross my desk

I'm sorry, I really prefer sticking up for the patient. But - in this case, the patient educated himself enough to return the entry level, compliance data only, PAP and request an Elite. He should have educated himself that extra little bit about the AutoSet before he requested and received the Elite. The Elite is a great little PAP, I still have a soft spot in my heart for mine despite now needing a bi-level.

I would suggest enjoying the good therapy that Elite can provide and save up and buy an AutoSet out of pocket on cpapauction or wherever. That worked well for me. I put a lot of hours on that Elite and not too many on the AutoSet Vantage, just enough to ensure it worked well and when traveling.

In my case, being under Medicare rental, the DME is ready to exchange the Resmed S8 Escape II that they gave me two months ago with a Resmed S8 AutoSet II, free. But only the flow generator section (the humidifier fits each). But they would not consider giving me an S9 AutoSet, free, instead.


Is anyone interested in this:

What you need to know if you rent Continuous Positive
Airway Pressure (CPAP) Devices, Respiratory Assist
Devices (RADs), Hospital Beds, or Mattress and Mattress
Overlay Pressure Reducing Support Surfaces


• If your current supplier is a Medicare contract supplier, you don’t have to do
anything. You will continue to get your equipment as usual, and Medicare
will continue to help pay.
• If you’re renting these types of equipment from a non-contract supplier
when the program starts on January 1, 2011, you may have the choice
to stay with your current supplier if your supplier chooses to become a
“grandfathered” supplier. Your supplier will let you know in writing 30
business days before the program begins whether it will or won’t become a
“grandfathered” supplier. See page 10.
• When you switch to a Medicare contract supplier from a non-contract
supplier, your current supplier and your new Medicare contract supplier
must work together and coordinate to make sure you have the equipment
you need.
• Under current Medicare rules, you own these types of equipment after
renting for 13 months. When you switch to a Medicare contract supplier
instead of using a “grandfathered” supplier or other non-contract supplier,
your 13-month rental period will start over, so you won’t own the
equipment until after the new rental period ends. This will extend your
rental period and result in additional months of coinsurance. However,
the amount you pay will be lower, because the amount you will pay will be
based on the new payment rates under the new program.
• Once you own the equipment, you must get replacement supplies and
accessories for the equipment from a contract supplier in order for
Medicare to help you pay for these items. You may obtain repairs for the
equipment you own from any Medicare-approved supplier (even a
non-contract supplier), including replacement parts needed for the repair.
See page 22.
• If you already own your equipment, you will need to use a Medicare
contract supplier for your replacement supplies and accessories (like masks
used with the CPAP device). Therefore, you will need to change suppliers
after January 1, 2011, if you’re currently receiving these items from a
supplier that doesn’t become a contract supplier under the new program.



Source:

http://www.cms.gov/Partnerships/Downloads/11461.pdf

avi123 wrote:In my case, being under Medicare rental, the DME is ready to exchange the Resmed S8 Escape II that they gave me two months ago with a Resmed S8 AutoSet II, free. But only the flow generator section (the humidifier fits each). But they would not consider giving me an S9 AutoSet, free, instead.


Is anyone interested in this:

Thanks avi for that information. I really was not aware of the changes but apparently my DME is a Medicare Supplier. I'm not in the designated areas yet, so I don't think I'll be affected immediately.