Let's clear up some misinformation

ltts wrote:

chunkyfrog wrote:Shouldn't you be watching somebody sleep?
Your boss is watching.

LOL! I'm the boss.

No wonder the industry is screwed up. No wonder your immediate concern is not servicing the patients but making a bigger buck!

Yes we get it! You are not making enough money so we need to suck it up and suffer.

YOU are the main reason less the 50% of patients succeed with cpap!

ltts wrote: Your insurance sets the rules, not your DME provider. They just have to abide by them. Your insurance company wouldn't give you amount because you might take that as a promise to pay, and they want to reserve their right to say you don't qualify. They haven't seen your sleep study, don't know if there is a valid physician's order in place, if you will be compliant with the use, etc. All those things factor into whether they will pay.

But you did get the answer that I have been saying a patient would get if they called their insurance company. They pay one price for an E601, and they do not obilgate the provider to give you one with features like autoset. Looks like your DME provider gave you a free upgrade. Very nice of them.

Not sure why I'm bothering to respond since your mind is so absolutely closed, but what I don't get is this: you are basically saying that you're the boss, but it's not your problem. That you have no power, no mind of your own, and no responsibility to understand the patients you claim to serve or to make things better, and you don't care.

If you were a small cog in a big machine I might, just might, buy that, even though it is a cowardly and craven way to live. But you say "You're the boss."

Well, "boss," either make the industry better in your little corner of the world, or get the heck out of the business. But don't expect patients who have to deal with this crappy disorder to put up with you.

There are a bunch of issues here, and the dollar figure that you get paid is only one of them. There are the issues of DMEs saying that machines are data capable when they aren't, providing sub-standard service, and all of the other things that people have raised here that you have completely glossed over.

Make it better. Fix it. Rally your fellow DMEs into a professional association and self-police your industry. Drum the ones out who operate shadily, and reward the ones who do things professionally and are both profitable and helpful to patients.

You up to the challenge, "boss?"

NateS wrote:

ltts wrote:
From the Medicare manaul-

The following instructions apply to situations where the ABN is being used for upgrades and applies to
both assigned and unassigned claims.

An upgrade is an item with features that go beyond what is medically necessary. The Centers for
Medicare & Medicaid Services defines an upgrade as an item that is more expensive, contains more
components or features, or is greater in quantity than what is medically necessary under Medicare’s
coverage requirements. When a DMEPOS supplier knows or believes that the DMEPOS item does not
or may not meet Medicare’s reasonable and necessary rules under specific circumstances, it is the
responsibility of the supplier to notify the beneficiary in writing via an ABN if the supplier wants to collect Jurisdiction B DME MAC Supplier Manual

Chapter 10: Advance Beneficiary Notice of Noncoverage

money from a beneficiary if an item is denied. When a beneficiary prefers an item with features or
upgrades that are not medically necessary, a supplier may collect the difference between the charges
for the upgraded item and the charges for the nonupgraded item, if the beneficiary agrees to be
financially liable by signing an ABN.

What does "medically necessary" mean?
Services or supplies are considered medically necessary if they:

Are proper and needed for diagnosis, or treatment of your medical condition.
Are provided for the diagnosis, direct care, and treatment of your medical condition.
Meet the standards of good medical practice in the medical community of your local area.
Are not mainly for the convenience of you or your doctor.

Let me give you an education on how insurance payers apply this statement on a day to day basis, and let's use autoset as the example. There are no studies that show that patients without autoset are going to die or have negative MEDICAL outcomes over a static pressure setting. In fact the vast majority of studies show that autoset improves quality of life, and that's it's main advantage. That, in fact, it does not impact survival at all. Autoset IS seen as a convenience for you and/or your doctor. That's not to say you can't have that feature, just that most insurance payers don't consider them medically necessary, and won't pay for them.

It's the same reason medicare and many other payers don't pay for tub transfer benches (it's not medically necessary that you get a bath even when you can't stand up to get in the tub or shower). It's the same reason they don't pay for overbed tables (they don't care if you can easily eat a meal when confined to bed). It's the same reason they won't pay for a power wheelchair unless there is very much significant documentation that you can't push yourself in a manual wheelchair - that it's impossible for you to do so.

ltts wrote:…
If you feel that your pressures are set appropriately and you're still not feeling better you should make another appointment with your physician. And bring your current data with you to the appointment.…

Then you agree that the "current data is relevant information for the doctor to see as part of his ongoing monitoring and treatment of the patient?

And how would the patient be able to "bring your current data with you to the appointment" if they did not have a data-capable machine?

ltts wrote:Did you have many central apneas in your initial or titration studies? I don't think I would ask a person on the internet to read your data and tell you whether your numbers are good or not.

No centrals - OSA

Normally, I would agree with you about asking people on the internet for advice - however, I doubt there is one person at any DME that is more knowledgeable than Pugsy. Sometimes I think (no, I'm sure) she knows more than my doctor, the "sleep specialist". Nope, she hasn't paid me the first penny.

Back at the ranch... the sleep industry stinks! And, I still don't understand what you are trying to accomplish.

RocketGirl wrote:

ltts wrote: Your insurance sets the rules, not your DME provider. They just have to abide by them. Your insurance company wouldn't give you amount because you might take that as a promise to pay, and they want to reserve their right to say you don't qualify. They haven't seen your sleep study, don't know if there is a valid physician's order in place, if you will be compliant with the use, etc. All those things factor into whether they will pay.

But you did get the answer that I have been saying a patient would get if they called their insurance company. They pay one price for an E601, and they do not obilgate the provider to give you one with features like autoset. Looks like your DME provider gave you a free upgrade. Very nice of them.

Not sure why I'm bothering to respond since your mind is so absolutely closed, but what I don't get is this: you are basically saying that you're the boss, but it's not your problem. That you have no power, no mind of your own, and no responsibility to understand the patients you claim to serve or to make things better, and you don't care.

If you were a small cog in a big machine I might, just might, buy that, even though it is a cowardly and craven way to live. But you say "You're the boss."

Well, "boss," either make the industry better in your little corner of the world, or get the heck out of the business. But don't expect patients who have to deal with this crappy disorder to put up with you.

There are a bunch of issues here, and the dollar figure that you get paid is only one of them. There are the issues of DMEs saying that machines are data capable when they aren't, providing sub-standard service, and all of the other things that people have raised here that you have completely glossed over.

Make it better. Fix it. Rally your fellow DMEs into a professional association and self-police your industry. Drum the ones out who operate shadily, and reward the ones who do things professionally and are both profitable and helpful to patients.

You up to the challenge, "boss?"

It pays to read the thread. I'm not a DME provider. I own a company that advises DME providers on all aspects of their business, but particularly in meeting regulations, both reimbursement and quality related.

Now as to your comment about "data capable" - I think there is a basic misunderstanding on this forum about what the term means. Any machine that can collect data by any means and create a report from that data is data capable. That might be by SD card, or a wired or wireless modem, etc. 99.9% of the machines used by DME providers are in fact data capable and have been since Medicare changed their requirements in 2008. So again, no one is lying to you. Man, you guys throw that invective out there pretty freely when you don't seem to know what you're talking about. I thank goodness I don't have to deal with such people on a daily basis.

Bottom line is that patients that want features above and beyond data capable would be wise to learn what those features are called. Whether a machine has autoset or not has nothing to do with whether it is "data capable."

Finally, I can't imagine why all of you seem so convinced that it's the DME providers job to make the insurance you freely engaged with do something they are unwilling to do. You seem incensed at DME providers out of nothing more than ignorance. Where did you get the idea that DME providers set insurance company rules? It doesn't even make any logical sense.

I think the OP is simply obeying a neurotic compulsion. I thought it could have been drunk dialing last night but it continues in the light of day.....scary to watch.

NateS wrote:

ltts wrote:…
If you feel that your pressures are set appropriately and you're still not feeling better you should make another appointment with your physician. And bring your current data with you to the appointment.…

Then you agree that the "current data is relevant information for the doctor to see as part of his ongoing monitoring and treatment of the patient?

And how would the patient be able to "bring your current data with you to the appointment" if they did not have a data-capable machine?

Of course I agree that the data is important. But any machine with an SD card slot is capable of collecting data. I'm also not saying that patient's shouldn't have autoset systems or systems that monitor your AHI (for as accurate as those machines are). What I am saying is you should not expect your DME provider to buy those extra features for you simply because your insurance company doesn't deem it a necessity. Why is that so difficult to understand?

I think this thread is going nowhere and all it's doing is taking up storage space on our hosts servers.

Yep. He just admitted he advises DMEs and that puts him in the perfect place to make a difference and make things better, but apparently that is not something he's interested in. All he apparently wants is to hammer his point over and over without any give and take, and combatively at that.

He is no longer worth my time.

Elle wrote:I think the OP is simply obeying a neurotic compulsion. I thought it could have been drunk dialing last night but it continues in the light of day.....scary to watch.

Actually I'm trying to educate some of you who completely misunderstand what your insurance does and does not cover so you a) lobby your insurance to cover the features you believe you need, and b) stop wasting your time villifying your DME provider who has no influence over the insurance payers rules (believe me, they have tried).

But if folks here want to keep tilting at windmills instead of effectively advocating for themselves to the insurance payers that set the rules, I agree that is your pefect right.

Ummmm, thank you?

I am ill at the moment and have just been skimming this thread, but I fail to see why everyone is so incensed at the OP <ducking for cover here...>. Yes, she might have approached the topic with a softer start up, but she's basically just recounting what the rules and terminology are, how reimbusement works, etc. Nothing in what she's saying contradicts anyone's experience that DMEs can be a nightmare to deal with. I think some of the information she's providing is helpful. For example, I will no longer advise a newbie to make sure they get "a data capable" machine now that I know that what a DME calls "data-capable" and what I'm calling "data-capable" are two different things; rather, I'd rephrase it by telling the newbie to "make sure to get a machine that shows AHI, leaks, etc. and not just compliance". That it's allowable to give a patient a used patient in a rent-to-own scenario makes no sense to me, as eventually they will own it, but at the same time, I did always wonder what happens to all the used machines they get back when people don't meet compliance. Does this change the fact that I won't take a used machine? No. But it does mean that at least I understand that it's allowable and will have to find a DME that is willing to do more than just the bare minimum. In the long run, I think it's good to know what is permissible behavior on the part of the DME, even if one is unwilling to settle for the minimum allowable.

Insurance companies are to blame for some/much of this, and DMEs who could do more and choose to do less (e.g., not returning masks when they are aware of the 30-day return policy) are part of the problem (even if it's permissible). Still, the OP is only the messenger. She doesn't make the rules, and she never claimed to be in the business of breaking her neck to improve people's lives on a pro bono basis.

<Before everyone attacks, please keep in mind that I'm in a weakened state at the moment, having been hacking up a lung for a few days now. Also, please note that I've been sick for more than a month with only a couple of days off. OK, ducking for cover now...>

ltts wrote:

Corkster52 wrote:I am new here, and won't have my titration study done until tomorrow, so please excuse some of my ignorance. I find this thread very educational. I have been a sponge absorbing all of the information I could find since my first sleep study about a month ago, and, for the most part, all of my readings had me convinced that almost all DMEs were basic slime. Aetna is my insurance and it will be interesting to see, of the 26 DMEs within network and within 15 miles of my home, just what the span of equipment will be that they are willing to provide based on what my insurance agrees to.

Well here are some questions to ask:

1. If you and/or your doctor decide you need an autoset will they provide that at no extra cost to you?

2. Do they have a mask replacement program? Will they proactively contact you when your insurance allows for replacement supplies?

3. Do they have a mask trial program, meaning can you try a mask for up to 30 days to ensure it works well for you? If they don't and you otherwise want to use them try talking to the owner/manager and see if they have contacted their manufacturers reps about this program. Some manufacturer's reps simply haven't done the job to make these programs available to DME providers.

If you can find one that is fairly close to you (instead of 15 miles away) that would be a plus. It will make it easier for you to take the machine to schedule free checks, switch masks until you find the right one, etc. I think those are the most important points.

Good luck!

These are exactly the same set of questions that those of us on this forum repeatedly tell newbies. (And indeed one of the main proponents of Question #1 is that member of the forum whom you keep saying is spreading misinformation.) They're good questions.

But our interpretation of Question #1 and yours seems to be different. We contend that if you're patient and persistent and calm, and if you contact enough DMEs you will find one that will answer YES to the question: Will you provide me with a Resmed S9 AutoSet or a PR System One Auto for what my insurance pays?

And that's the acid test for many of us in determining a GOOD DME from a BAD DME. A good DME will provide a patient who is newly diagnosed with OSA with the best, full efficacy data machine available instead of a brick. And GOOD DME's do exist. It only took me two weeks of phone calls to find mine.

And hence, there is no reason for a newly diagnosed OSA patient to be told that that the best machine you are entitled to get with your insurance is the brick thrust upon you by a DME that you've never heard of before that contacts you after your titration test is complete.

But many of us are rushed into accepting machines from DMEs chosen for us by doctors or sleep labs who choose the DME for their convenience and not ours. And we are, alas, not encouraged by our big, bad insurance companies (or our sleep docs) to do any comparison shopping at DMEs to find the best bang for the buck.

Guest wrote: Let me give you an education on how insurance payers apply this statement on a day to day basis, and let's use autoset as the example. There are no studies that show that patients without autoset are going to die or have negative MEDICAL outcomes over a static pressure setting. In fact the vast majority of studies show that autoset improves quality of life, and that's it's main advantage. That, in fact, it does not impact survival at all. Autoset IS seen as a convenience for you and/or your doctor. That's not to say you can't have that feature, just that most insurance payers don't consider them medically necessary, and won't pay for them.…

Why don't you take a rest for a moment from telling us what we already know about the unscrupulous practices of private health insurance companies, and instead give us a reference to the medical studies you claim you know of which have concluded that it is not medically necessary for physicians to monitor xPAP patients' sd card data as part of their reasonable standards of care of apnea patients.

I would like to see and read these studies, in reputable professional medical journals, which you claim knowledge of.

And since companies like ResMed state that their ResScan software has been developed and is distributed for use by physicians and related health care professionals, how do you reconcile that with your assertion that the medical profession has concluded that they don't need this information as part of their reasonable standard of care of apnea patients?