WHAT TO SAY to get better machine

Pugsy wrote:

BTW what do you charge for the S9 Autoset (before the ins write off adjustment)? Is it anywhere near the $2300 that I was quoted for a ResMed Escape from a brick and mortar DME? And again where are you? I want to make sure I avoid your place of business. It is very apparent we would not get along.

If Medicare pays the full 13 months rental, the total for an S9 Autoset would be $1010. Our host charges $853 for the same machine. The difference is, other than the $157, is the DME has to go 13 months to get the entire amount, while the online store has the money before you probably have the equipment. Also, the DME has to verify that you are using the machine, that you have followed-up with your doctor, and the doctor wrote the correct things (according to Medicare) in your chart. Then the DME has to collect 20% of the $1010 from either the customer or a secondary insurance. If the DME is audited by Medicare, and it is found that doctor's notes, or compliance data is not present on say, 5% of the files they review, they will extrapolate and deem 5% of ALL claims for a period of time, are to be refunded to Medicare, not just the one's actually found. They will assume that the 5% error (according to them) is across the board. So say I fill an Rx on an Autoset and the customer does not go back for his follow up with the physician. The customer still has the machine, but I cannot legally bill Medicare past the first 3 months of rental. So, do you really have to wonder why any business would put out any machine that they cannot recoup at least their costs in the first three months.

Wow. Thank you everyone for your posts. I really opened up a can o' worms! There was some really good advice, interspersed with personal insults. Thank you for trying to keep to the objective facts, as much as possible. Almost everyone has something valuable to offer.
I want to try to :
1. Keep an open mind.
2. Listen to everyone who offers honest advice.
Because you all know more than I'll ever know about CPAPs and DMEs.

So I called to ask for a data-capable machine, to try to figure out how to get a decent night's sleep. My DME contact is very helpful on the phone, offering suggestions as to how to solve my air (gas) problem. I have had ONE night of restorative sleep since I started 22 nights ago....but I'm NOT giving up!

I think I need a self-adjusting (pressure) machine. Data would be nice, too. But sometimes my machine is hard to get air from, hard to exhale from, and other times it's forcing air into my gut!

My DME person told me the S9 AutoSet is a $295, out-of pocket upgrade.
The S8 I have was a $90 out-of-pocket upgrade over the first machine they showed me.
I have Anthem BlueCross thru work. But according to her, it won't cover the AutoSet machine.

I am getting desperate for some restrorative sleep! I could barely stay awake at work today.....in the shower this morning I looked at my hands and thought, "What is this stuff all over my hands??" Then it hit me.....water.

jeffishere wrote: My DME person told me the S9 AutoSet is a $295, out-of pocket upgrade.
The S8 I have was a $90 out-of-pocket upgrade over the first machine they showed me.
I have Anthem BlueCross thru work. But according to her, it won't cover the AutoSet machine.

I would check directly with your insurance company. Ask them what they base their payment on. Code which is the same for all machines or the machine itself and tell them what the DME wants to do? Find out directly from the insurance company what their policy is. If it is HMO or something special, upgrade fee may be legit. Best to get the information from them though. That way no chance of something getting lost in translation..

Also, another thought with all these upgrade fees and deductible and co pays, how does your out of pocket cost compare to just buying online?

NEVER, NEVER, NEVER, NEVER, NEVER take advice on what your insurance will or will not cover from the DME. They have a lot of insurance companies to deal with, a lot of different policies within various insurance companies, and cannot be expected to remember what YOUR insurance policy will cover. And with all due respect to the DME's here, sometimes they just plain make it up and sometimes they outright LIE.

CALL Anthem BlueCross yourself. Ask if your policy covers any E0601 machine, or only certain makes and models. Ask if your insurer permits a DME to charge you more for certain E0601 machines. If not, what is their policy with DME's who try to charge more? Look up your state's rules regarding "balance billing" (google your state's name and "balance billing") and see if it's LEGAL in your state for the DME to charge you more than your insurance company's "allowable" amount (it's NEVER legal for traditional Medicare Parts A and B--if anyone disputes this statement be prepared to show me in the Medicare regs exactly where it says you can charge more than the allowable amount for traditional Medicate patients).

If you find it's legal, then you have to calculate your OOP costs and decide if you want to pay the upcharge with the DME or buy elsewhere. If it's not legal, then you have to decide if it's worth the time and energy. Sometimes a polite letter reminding the DME of the illegality of the balance billing practice is enough, sometimes you have to find another DME and then tell the current DME that you're going to return their machine unless they want to deal with you fairly and get--in return--profit on sales of supplies to you for the rest of your life.

Dumbest advice I have ever heard. Do you have any idea how many times I've have a customer in front me telling me what THEIR insurance will do and what is needed? These people are not lying, they were told total BS from THEIR insurance and if I went by what the customer said they were told, the customer's claim would be denied 100% of the time. Don't you think it's in the customer's best interest, as well as mine, to know what the insurance requirements and guidelines are BEFORE the transaction is made? The problem is, with most private insurance, the policy holder has a 800 number they call, and the providers have another number. It has been my vast experience that the lowest payed, most inexperienced person is the one answering the policy holder's call. You wouldn't believe how many times I've had a customer sit across the desk from me, telling me that their insurance told them all they needed for their insurance claim was an Rx! I pick up the phone, put it on speaker and call the claims department and ask what is required for payment of an E0601. I already know this, but I do it for the customer's benefit, because according to people like you, all DME's are liars, crooks, and thieves. Imagine the customer's surprise when they hear a COMPLETELY different story from what they were told when they called!

If you want to vilify someone, I suggest a good start would the insurance companies who put up so many obstacles, that the only reasonable explanation can be that they are doing whatever they can to deny a claim. Seriously, you go see your doctor, he says you need a CPAP, writes you an RX, you go get it filled, then the DME has to fill out a form that basically says the the doctor wants this particular patient to have a CPAP. Then you have to put that form in the doctor's hand and have him/her sign it before you can file the claim. If not the insurance will not pay. Somebody please explain to me the logic in that!

I am in complete agreement that there are some terrible DME's out there, just like there are terrible dry cleaners, and terrible car lots, and terrible coffee shops. The difference is, all those other businesses usually go out of business for being terible at what they do. DME's on the other hand, can be terrible and still have a thriving business due to alliances with insurance companies, doctors, sleep labs, and hospitals. If your insurance requires you to go to a specific company, I wouldn't expect the best. Hell, I wouldn't even expect mediocre. What I would expect is a very bad experience.

Dumbest advice I have ever heard. Do you have any idea how many times I've have a customer in front me telling me what THEIR insurance will do and what is needed? These people are not lying, they were told total BS from THEIR insurance and if I went by what the customer said they were told, the customer's claim would be denied 100% of the time. Don't you think it's in the customer's best interest, as well as mine, to know what the insurance requirements and guidelines are BEFORE the transaction is made?

So according to you, the customer should be kept in the dark and fed BS by the DME???

The DME would be "dumb" if it believes what the customer "says" the insurance would pay for, just as the customer would be "dumb" to take the DME's word for it. That was NOT my advice. My advice is that the customer needs to do his own homework, just as YOU advised in an earlier post. The DME needs to as well, but that's not the subject here.

An informed customer can make a rational decision for his own best interest, a customer who acts like a sheep and swallows everything the DME tells him gets what's best for the DME.

And YES, the information on coverage is available--I can show you exactly where to find the Medicare coverage information in every state, and people here check with their insurers all the time to get correct information on their coverage. It's not hard, and it allows the customer to evaluate if he wants to work with a particular DME or not.

Unfortnately, many people don't find out the correct information and the fact that they have some say in who they work with and how they are treated until after a bad expericnce with a DME. Homework is the key!

Janknitz wrote:NEVER, NEVER, NEVER, NEVER, NEVER take advice on what your insurance will or will not cover from the DME. They have a lot of insurance companies to deal with, a lot of different policies within various insurance companies, and cannot be expected to remember what YOUR insurance policy will cover. And with all due respect to the DME's here, sometimes they just plain make it up and sometimes they outright LIE..

Again, the dumbest advice I have ever seen. Insurance does not want to pay claims, they just want to collect premiums. DME's want claims paid. So, know those two FACTS, who has the better incentive to give you CORRECT information concerning what YOUR insurance requires for a claim to be paid? I get customers sent my way all the time by my competitors because they don't want to deal with a particular insurance. I also will not accept certain insurances because of the games they play in regards to paying claims.

The difference between what I'm saying and what you are spewing is, I live in the real world and deal with this stuff daily. You obviously had a bad experience somewhere and have an axe to grind against ALL DMEs.

EVERY DAY there are posts here from individuals dealing with DME's who out and out LIED to them. WHY should we trust DME's with our lives?????????????????????????

jeffishere wrote:There was some really good advice, interspersed with personal insults.

And the beat goes on...

(Looks like it's time to update my Foe list!)

Janknitz wrote: And YES, the information on coverage is available--I can show you exactly where to find the Medicare coverage information in every state, and people here check with their insurers all the time to get correct information on their coverage. It's not hard, and it allows the customer to evaluate if he wants to work with a particular DME or not.

Every state? You do know Medicare (CMS) is divided by regions right? The only difference the the amount of money paid. The coverage criteria is the same.

Now, since you can tell me about what Medicare will do, how about telling me what the coverage criteria for CPAP is with BCBS of South Carolina. What if the policy holder lives and works in Tennessee but his policy is BCBS from another state? Whose criteria is followed? Where do you file the claim? If I am a DME in Texas, and I am an in-network provider for BCBS of TX, am I out of network with BCBS of IL?

Do you think the minimum wage person who answers your call when you call your insurance company will be able to answer any of these questions?

You are right about concerning your advice about a person doing their homework. I HIGHLY recommend that. If someone is skeptical about what I am telling them, I not only recommend it, I ENCOURAGE it.

Janknitz wrote:EVERY DAY there are posts here from individuals dealing with DME's who out and out LIED to them. WHY should we trust DME's with our lives?????????????????????????

Care to compare that number of people to the number of people who have a grievance with an insurance company? WHY should we trust INSURANCE COMPANIES with our lives??????????

Yes, I "do know Medicare (CMS) is divided by regions "

State by state Medicare DEMPOS fee schedule, right here: http://www.cms.gov/DMEPOSFeeSched/LSDME ... PerPage=10

And for the rest of us "dummies" who care not to leave our health in the hands of the benevolent DME's, here are the HCPC's codes for commonly used CPAP items:

E0601 Continuous airway pressure (CPAP) device (e.g. smart CPAP, auto CPAP, CPAP)
E0561 Humidifier, used with CPAP device
E0562 Heated humidifier, used with CPAP device
A7033 Nasal pillows/seals, replacement for nasal application device, pair
A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap
A7035 Headgear, used with CPAP device
A7036 Chin strap, used with CPAP device
A7037 Tubing, used with CPAP device
A7038 Disposable filter used with CPAP device
A7039 Non-disposable filter used with CPAP device
A7044 Oral interface used with positive airway pressure device
A7046 Humidifier chamber - replacement
E0470 Bilevel
E0471 Bilevel with backup rate
E1399 Miscellaneous durable medical equipment items

Janknitz wrote:here are the HCPC's codes

Codes are not criteria, nor are they coverage.

Codes are easy. Meeting criteria and getting things covered are hard.

Yeah, the correct CPT and/or ICD-9 codes are needed. CPT = current procedural terminology and ICD-9 = international classification of diseases.

CPT is a registered trademark of the American Medical Association. The AMA holds copyright which prevents free use and distribution of codes.

ICD-9 can be found online for free.