Let's clear up some misinformation

Robespierre wrote:LTTS has made it crystal clear that insurance only pays a DME for a brick. However, she has not directly addressed the situation in which an APAP is specifically prescribed. I have trouble believing that if an APAP is prescribed, the DME is monitarily penalized by insurance for performing their duty to fill the prescription. The point of my post was to get LTTS to tell us whether a DME gets paid appropriately by insurance for a prescribed APAP. I still would like LTTS to answer.

I wouldn't hold my breath for an answer. As I said, she appears to be mentally "stuck" on one point and isn't answering direct questions about anything else.

If the decision has been made by the U.S. DME industry that patients must henceforth pay out of pocket to get AHI data, doctors and manufacturers will then make sure the PAP-machine DME industry goes down with a loud thud. And I hope to be around to stand over the remains in order to spit and applaud.

Manufacturers want their machines with AHI data to be sold. Doctors need AHI data. Patients need AHI data. If DMEs refuse to provide it without getting paid under the table by patients for it, what good are DMEs to patients, manufacturers, doctors, or anyone else on the planet?

The DMEs themselves should be arguing for the local Wal-Mart pharmacy and the Internet to be the ones to provide what they cannot. In fact, if they are taking the stance that they can't provide machines with AHI data, that is in essence the argument they are making, now, isn't it?

Maybe one of the manufacturers has some knowledge.
They wouldn't make the 'luxury' machines if they weren't being purchased--in quantity.
So what percentage are sold online/out of network?
If this is a high percentage, well, SOMEBODY is losing repeat business.
Not my fault!

I have a hard time stomaching the term "luxury" to describe these machines.

I don't feel like I'm in the lap of luxury with the machine I have. I feel like a human being that is really in trouble and requires this. It just ain't "luxurious" --

One of many "issues" I have with ltts's posts and comments.

chunkyfrog wrote:Maybe one of the manufacturers has some knowledge.

They wouldn't make the 'luxury' machines if they weren't being purchased--in quantity.
So what percentage are sold online/out of network?
If this is a high percentage, well, SOMEBODY is losing repeat business.
Not my fault!

Madalot wrote:I have a hard time stomaching the term "luxury" to describe these machines.

I don't feel like I'm in the lap of luxury with the machine I have. I feel like a human being that is really in trouble and requires this. It just ain't "luxurious" --

One of many "issues" I have with ltts's posts and comments.

Let's quote the OP correctly, you say "luxury", OP says "deluxe". We don't want to be giving out any misinformation here!

DoriC wrote:

Ltts wrote:

Kiralynx wrote:

ltts wrote:For my most recent order, I was told, flat out, that "It's not in the system. You can't order it." So I wrote to Respironics and explained that this DME was declining to sell me their products, products which were readily available. Could their local representative do something about this? Six hours after I sent the email, I had a call from the branch manager explaining that he'd found the "glitch" in the system and that my products were now on order. Uh-huh. I'll lay odds that three months from now, there's another "glitch."
And it's thanks to the knowledgeable people on this Forum that I could do this.

No DME is under any obligation to carry any make and model of supply you want. None. Your insurance company has made you captive to a limited number of DMEs by not allowing others to be in network with them and send a claim. In exchange for that exclusive contract they have demanded / set rock bottom prices for DME reimbursement. And with rock bottom prices come rock bottom service and product selection. it's economics 101, and you have your insurance company to thank for it.

When we needed to get our first replacement for our Resmed UltraMirage FF mask, we were told the DME didn't stock that mask anymore,they couldn't "special order" it and we'd have to get the "upgraded and much better Quattro" which never worked for us. I called Medicare,the nice lady said the DME should not have a problem ordering it for us, she'd take care of it and 2hrs later we received a call from the DME that some UMs were magically found on "the top shelf" and someone would bring it out to us that day,no mention of the call from "the nice lady at Medicare". We've had no problems since except that they keep forgetting to place and ship the order and it takes a repeat phone call and delayed delivery.

It's wonderful that the nice lady at Medicare convinced them to help you out. My the fact remains, they were under no obligation to carry, order, or provide a specific make and model.

ltts wrote: Be aware that Medicare competitive bidding, coming to 90 more cities in 2013, and covering a large bulk of the population will usher in the exact same thing as you are complaining about here. About a year after that other insurance payers will follow with those 25-30% cuts in reimbursement (at least the ones that haven't already). So unless you start looking to the real source of the problem - insurance payers - get used to getting what your insurance company is willing to pay for.

Don't have to look any further to understand ltts's agenda.

DMEs have been lobbying aggressively to get the Medicare competitive acquisition program repealed since at least 2009. Every year the repeal has failed,and every year a similar repeal bill is introduced, and the lobby machine swings into action again. (One source of information: OpenSecrets.org. Opensecrets.org is nonpartisan, independent and nonprofit, and is a good resource on who is lobbying for what, who is paying them, and how much firms like Lincare and others are putting into their lobbying on any given issue.)

Since the evils of the Medicare competitive acquisition program seem to be at the core of ltts's arguments (many of her posts close with a dire warning about it), it's not too much of a stretch to wonder if this person is simply trying to whip up support for the repeal bill through fear and distortion.

My goodness, what a coup it would be to get patients to argue the DME's case for them. It boggles the mind.

Obviously Medicare believes there is some obligation the DME has to it's customers if they have a provider contract with them. Let's not mention it's the decent thing to do for those afflicted with OSA and desperately needing help from them. Oh, sorry, I forgot, it's all about the "bottom line".

DoriC wrote: . . . "luxury", . . . "deluxe".

Seems that healthcare itself has become a "luxury" that only the "deluxe" can afford.

Robespierre wrote:

ems wrote:

Robespierre wrote:So, LTTS, does this mean that every time a doc prescribes an AutoPAP and the DME fills the prescription, the system is such that the DME loses money because insurance will only pay for a brick?

Maybe I'm missing something here... but... the DME has to fill the script exactly as the doctor wrote it, including setting the pressure, whether the doctor ordered a brick or a fully data compatible machine. If the insurance company pays for it (mine paid for exactly what the doctor ordered), where is the problem? Of course, some ins companies pay more, some less, with some having deductibles and co-payments.

I suspect the OP has disappeared, leaving everyone wondering what this was all about.

LTTS has made it crystal clear that insurance only pays a DME for a brick. However, she has not directly addressed the situation in which an APAP is specifically prescribed. I have trouble believing that if an APAP is prescribed, the DME is monitarily penalized by insurance for performing their duty to fill the prescription. The point of my post was to get LTTS to tell us whether a DME gets paid appropriately by insurance for a prescribed APAP. I still would like LTTS to answer.

It doesn't matter if APAP is specifically prescribed. Your insurance is only going to pay for a basic PAP device. No DME has a duty to fill a prescription they don't want to fill. They can simply tell you that don't carry that model (if only for your insurance payer), or they can offer you the machine if you are willing to pay an upgrade charge. Or they may agree to give you the upgrade for free.

You're right in that they can't fill it with a basic PAP device, but that's about it. But they can certainly turn down your business. Having a prescription from your doctor for an APAP device certainly helps your chances of getting a free upgrade because the DME has an interest in maintaining a good relationship with your physician if they are a frequent source of patient referrals. But you're still getting something over and above what your insurance payer has agreed to pay for.

Apparently people here believe what they want to believe. And it appears you enjoy denigrating the DMEs that have been providing enhanced devices that your insurance providers have declined to compensate for since they were invented. As they say, no good deed goes unpunished. This forum is certainly proof of that.

Robespierre wrote:LTTS has made it crystal clear that insurance only pays a DME for a brick.

No, Ltts has claimed that multiple times. That doesn't make it true.

Apparently, insurance will pay the same for any machine. It's just as valid to say insurance pays for a fully data capable automatic machine, but will still pay the same even if a dataless manual brick is provided.

DoriC wrote:Obviously Medicare believes there is some obligation the DME has to it's customers if they have a provider contract with them. Let's not mention it's the decent thing to do for those afflicted with OSA and desperately needing help from them. Oh, sorry, I forgot, it's all about the "bottom line".

DMEs have plenty of obligations included in their contract with Medicare. They are called Medicare Supplier Standards, and you can find them on the internet very easily. The problem is you imagine that they obligations that they do not have, like providing you with any make and model of equipment and supplies you so desire. You can shop around, at least for a little while longer, before Medicare competitive bidding is complete in 2013. At that time you will be restricted to winning bidders to supply your needs, and they will carry the cheapest they can get their hands on due to the 25-30% cuts we have seen in the first 10 areas they did competitive bidding in.

I know you want to believe DMEs are making a killing, but they aren't. Most are barely profitable. And no company can stay in business without making a profit. Their rates are set by the insurance payers who make the process of getting paid very very expensive. That's reality.

archangle wrote:

Robespierre wrote:LTTS has made it crystal clear that insurance only pays a DME for a brick.

No, Ltts has claimed that multiple times. That doesn't make it true.

Apparently, insurance will pay the same for any machine. It's just as valid to say insurance pays for a fully data capable automatic machine, but will still pay the same even if a dataless manual brick is provided.

You're not listening. The insurance payers have affirmatively and emphatically said they will not pay for any additional features that THEY consider "deluxe" and they have been saying that since autoset was invented back in 1999. Nor do they require your DME to give you a machine with features THEY (not me, not your DME) consider "deluxe." As I have said about a million times, you don't have to take my word for it. Call them and ask them.

Now I have to get back to work, so everybody have a great day.

. I know you want to believe DMEs are making a killing, but they aren't. Most are barely profitable. And no company can stay in business without making a profit. Their rates are set by the insurance payers who make the process of getting paid very very expensive. That's reality.[/quote]

If DME'S arn't making a killing at the prices they charge....they are paying themselves way too well.
I have owned and operated several businesses besides being a credit manager by profession....I certainly do understand what the "bottom line" is.......you can play with the numbers very easily by paying yourself a DECENT wage or by paying yourself an INFLATED wage.

ltts wrote: You're not listening. The insurance payers have affirmatively and emphatically said they will not pay for any additional features that THEY consider "deluxe" and they have been saying that since autoset was invented back in 1999. Nor do they require your DME to give you a machine with features THEY (not me, not your DME) consider "deluxe." As I have said about a million times, you don't have to take my word for it. Call them and ask them.

Now I have to get back to work, so everybody have a great day.

Uh, actually, YOU are not listening.

Insurance payers have never said that they refuse to pay for machines that give AHI data. And APAPs and CPAPs are the same insurance code to them. So it would be stupid for anyone to call insurance and ask anything like the question you suggest.