Thinking that I may not like DME billing dept

Well, now I'm curious to see how many people have dealt with a Brick and Mortar DME that is not a "Participating" Medicare provider. Please chime in if you have had that experience.

I think it doesn't make sense for B & M DME's not to be participating providers because they could then require Medicare patients to pay in full up front and hope for Medicare reimbursement. DME is EXPENSIVE stuff--most people who are very ill and in a crisis who need Oxygen, wheelchairs, hospital beds, etc., don't have thousands of dollars lying around to do that, so they'll go on to the next DME who IS a Medicare participating provider and the out of pocket costs will be contained. In my days in the health profession I often referred people to DME's and I would never have referred anyone to a DME provider who wasn't a participating provider.

It could be a trap for the unwary, but we don't see anyone here complaining about falling in that trap, at least not in the year plus I've been on this board. So I suspect that most--if not all--B&M DME's who supply CPAP equipment are participating providers.

There is a lot of incorrect usage of the terminology used in this thread that may cause people to make incorrect choices so let me set the record straight.

To BILL Medicare a DME has to be enrolled with Medicare. This means the DME provider has applied and received a billing number or P-TAN. Next the provider must decide to be participating or non-participating. This as a one year commitment so this decision has to be made annually. If a provider chooses to be a participating provider then the ONLY advantage is they are listed as such on Medicare's website. So, not surprisingly, most DME companies are non-participating. Participating providers must accept assignment on ALL claims. Non-participating providers can accept assignment, or not, PER CLAIM. Assignment means that the provider accepts the Medicare allowable as the maximum amount that can be collected. If Medicare denies the claim, and all appeals are denied, then the patient owes NOTHING. In return for accepting assignment Medicare will send 80% of the allowed amount, minus any deductibles, to the provider. Most DME providers are non-participating as there is no real incentive to accept assignment on all claims as some items have an acquisition cost near the allowable (although not usually the case for sleep therapy supplies). On these types of claims many providers will go unassigned. If a provider goes unassigned then they can collect 115% of the Medicare allowable REGARDLESS of what they bill. They can collect this at the time of service. If Medicare allows the claim then a check for 80% of the allowed amount, minus any deductible amount, is sent to the patient. DMEPOS, which is the category that sleep therapy falls under, has MANDATORY CLAIM FILING. Whether a provider accepts assignment or not they MUST bill Medicare. If Medicare denies an unassigned claim as not medically necessary then the provider would have to refund the amount paid by the patient unless this denial is overturned on appeal, a "Patient Responsibility" denial is given, OR a proper Advanced Beneficiary Notice was executed PRIOR to delivery of the items denied.
So, insist that your claims go assigned or you will find a provider who will bill the claim assigned. Participating status is not an issue, assignment is.

leejgbt wrote:If a provider goes unassigned then they can collect 115% of the Medicare allowable REGARDLESS of what they bill. They can collect this at the time of service. If Medicare allows the claim then a check for 80% of the allowed amount, minus any deductible amount, is sent to the patient.

Very good summary, except for the 115% number. There is no 115% limit on DME. Here's a quote from page 8 the Medicare publication http://www.medicare.gov/Publications/Pubs/pdf/11045.pdf. The cover says ,"This official government booklet...."

If a durable medical equipment supplier doesn’t accept assignment, there is no limit to what they can charge you.

So I still have the question--has anybody experienced a DME provider who WON'T accept assignment on CPAP equipment and supplies???????????????????

Janknitz wrote:I see people get upset here all the time at how much Medicare is billed by the DME. But the truth is IT DOESN'T MATTER! Medicare has set allowable fees for each item, and that's all that Medicare is going to pay, regardless of how much the DME bills.

The DME could bill $1 million for a machine but they are only going to get the fee that Medicare sets and pays every other DME in your state (about $100 per month X 13 months). The outrageous prices are what the DME uses to negotiate fees with other insurers--large insurers with a lot of clout will pay around the same amount per item as Medicare (sometimes less!), and small insurers will pay more. But nobody except some poor sucker who walks in off the street without insurance and not knowing any better pays what the DME charges.

Period.

And all you owe is 20% of the Medicare allowable fee (plus deductible if it hasn't already been met).

Period.

If you search here you can find the Medicare replacement schedule. Educate yourself about what can be replaced when. I've posted links to the data base that will even tell you how much Medicare allows on CPAP equipment and supplies in your state, so you can calculate your 20% out of pocket cost.

Instead of sitting in the dark worrying about how much you're going to be billed for if Medicare doesn't cover something, educate yourself about what they WILL cover, when, and how much your out of pocket costs will be. This will ease your mind (Medicare coverage, for all the complaints, is pretty good coverage for CPAP) AND prevent the unscrupulous DME from taking advantage of your ignorance to charge you more or prevent you from getting what you need because it's too much trouble for them to do the Medicare billing (all that "trouble" is one of the reasons they get more from Medicare than an online supplier's retail price--they might as well earn it).

I understand. So, what's the point of the "inflated" amounts?

idamtnboy:

Like I said earlier, it does not matter what a provider CHARGES, there is a limiting charge to what can be collected. Here is the rule:

If a non-participating physician/supplier does not accept assignment, then Medicare pays the beneficiary directly and the non-participating physician/supplier may bill the beneficiary up to the limiting charge amount, which is 115% of the fee schedule amount for non-participating physicians/suppliers. Non-participating physicians/suppliers are paid 95% of the fee schedule amount.

wonka:

There are two reasons for charging inflated amounts. One has been mentioned here over and over. If you have no coverage then you can be liable for this inflated charge. The reason the charge is inflated in this instance is that you are paying for the sins of previous non payors who were non covered by insurance. This is by far the largest category for unpaid claims turned over to collection. I am not a fan of this strategy as the most vulnerable pay the most.
The second reason is DME companies must establish a usual and customary charge that has a five year look back. So, providers must estimate what charges are needed five years from now and bill that today. Silly rule that does not fit reality.

leejgbt wrote:idamtnboy:

Like I said earlier, it does not matter what a provider CHARGES, there is a limiting charge to what can be collected. Here is the rule:

If a non-participating physician/supplier does not accept assignment, then Medicare pays the beneficiary directly and the non-participating physician/supplier may bill the beneficiary up to the limiting charge amount, which is 115% of the fee schedule amount for non-participating physicians/suppliers. Non-participating physicians/suppliers are paid 95% of the fee schedule amount.

Can you provide a reference for the 115% limit? What you are saying is in direct contradiction with the booklet I link to above and which is labeled on the front as an official government booklet. The section I quoted from that book says there is no limit to what a non-participating provider can charge, and collect. The 115% number does not appear in that booklet anywhere.

Interestingly, I do not find any reference to the 115% limit on http://www.medicare.gov or http://www.cms.gov. I've done several searches of both web pages and documents. I'll do some more later unless you have an exact reference already. I think the only place I'm certain I've seen it is in my Blue Cross booklet on Medicare. I'll have to look at it again.

OK, I found a couple more references concerning how much a DME can charge Medicare patients. For unassigned claims there is no limit. The 115% number is called a "limiting charge." In a PDF document on the State of Indiana website that explains Medicare benefits it clearly states "limiting charge does not apply to DME." On http://www.cms.gov website there is a link to http://www.cms.gov/manuals/downloads/clm104c20.pdf which is the Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). In Section 30, "General Payment Rules," describing the information that goes on the invoices to patients we have the following:

You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge.

The phrase "limiting charge" and "115%" do not appear in Chapter 20. They do appear in other, but not all, chapters of the Medicare Claims Processing Manual.

In a related matter, there is a Section 120, Billing Procedures Related To Advanced Beneficiary Notice (ABN) Upgrades. This section describes what notice must be given to a patient if he/she wants a piece of DME that has features that are considered medically unnecessary and are not part of the prescribed equipment. The patient can be charged for the extra cost above the Medicare approved charge. This very well may be the section some DMEs are relying on to tell CPAP patients, who want a data capable machine when a straight CPAP was prescribed, that there will be an extra charge even though both machines are covered by the same billing code. The ABN must be signed by the beneficiary in order for the DME supplier to collect its extra charge. This applies to both assigned and unassigned claims. Here's a quote from the manual:

An upgrade may be from one item to another within a single Heath Insurance Common Procedure Coding System (HCPCS) code, or may be from one HCPCS code to another. When an upgrade is within a single code the upgraded item must include features that exceed the official code descriptor for that item.

In other words, if you are a Medicare beneficiary and you want a Resmed S9 Autoset, and your prescription only specifies CPAP, the DME is within their rights to demand extra payment.

All the above applies to original Medicare coverage. It's probably different for those who have Medicare Advantage policies. Check your individual insurance plan brochure.

Janknitz wrote:So I still have the question--has anybody experienced a DME provider who WON'T accept assignment on CPAP equipment and supplies???????????????????

My first DME would not accept Medicare assignment. I did not know enough to ask the right questions. I was told they took Medicare when I signed on. I had Medicare as primary and BCBS as secondary. Medicare set the price and paid 80% of the price they set. My BCBS paid 80% of the 20% that Medicare did not cover. We thought all we were responsible for was the 20% of the 20% that BCBS did not cover. Took 3 months to get the first bill. We were billed for the 20% of the 20 % that BCBS did not cover plus an additional 15% of the original 100% that Medicare set time 3 for the 3 months. I assume this was the 115% allowable. When we asked the said they were a Medicare Provider but not a Medicare Contractor so they did not have to take Medicare assignment. We ran as quick as we could and found one that would take us after 3 months and did take Medicare assignment.

Jerry

idamtnboy wrote:

leejgbt wrote:If a provider goes unassigned then they can collect 115% of the Medicare allowable REGARDLESS of what they bill. They can collect this at the time of service. If Medicare allows the claim then a check for 80% of the allowed amount, minus any deductible amount, is sent to the patient.

Very good summary, except for the 115% number. There is no 115% limit on DME. Here's a quote from page 8 the Medicare publication http://www.medicare.gov/Publications/Pubs/pdf/11045.pdf. The cover says ,"This official government booklet...."

If a durable medical equipment supplier doesn’t accept assignment, there is no limit to what they can charge you.

I stand corrected on the limiting fee. I have not billed unassigned since 2006 so I was unaware limiting fees were removed from DME. The point I was trying to make is to be cognizant of terminology and I missed one. DME companies are providers and I read about suppliers.

Yes, upgrades can be had for an auto CPAP from a "straight" CPAP. But the difference charged, according to Noridian Medicare is the difference in the Manufacturer Suggested Retail Price (around $100). To do this a properly executed ABN must be obtained prior to delivery of the upgrade. The cap for the CPAP does NOT start over, however. Many DME companies are using data capable auto titrating CPAPs as a standard. My recommend is to use a company that uses this methodology.

leejgbt wrote:I stand corrected on the limiting fee. I have not billed unassigned since 2006 so I was unaware limiting fees were removed from DME. The point I was trying to make is to be cognizant of terminology and I missed one. DME companies are providers and I read about suppliers.

Yes, upgrades can be had for an auto CPAP from a "straight" CPAP. But the difference charged, according to Noridian Medicare is the difference in the Manufacturer Suggested Retail Price (around $100). To do this a properly executed ABN must be obtained prior to delivery of the upgrade. The cap for the CPAP does NOT start over, however. Many DME companies are using data capable auto titrating CPAPs as a standard. My recommend is to use a company that uses this methodology.

I was not aware that the 115% number used to apply to DME since I've only been on CPAP since last summer. It looks like 115% only, or mostly, applies to physician fees anymore. I sure did have to dig to find all this out, which is good to do once in awhile!

Finding out the info about the ABN and upgrades was worth the search since the upgrade issue has been discussed so many times. Maybe we ought to point that out in a new thread just to draw attention to it.