Let's clear up some misinformation

Maybe I was lucky, but before I got my CPAP I had no clue about this site or any of this stuff, and I think I got a pretty decent machine. Not sure if my DME gives everyone this machine, or if they gave it to me because i have wicked good insurance (my insurance bought my machine outright, 100% - no lease, no copay). I'm happy with my machine, I don't need auto. I do need, and have, a humdifier, c-flex, and a way to access the data.

My favorite part of the day is waking up and plugging in my little card to see how things went. AHI of 0.0 last night, btw. On 10 (versus the prescribed 14).

ltts wrote: It doesn't matter if APAP is specifically prescribed.

Yes it does.

ltts wrote: Your insurance is only going to pay for a basic PAP device.

The poster says again, while providing zero proof for that nonsense.

ltts wrote: 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),

In other words, they could lie. Which is the whole point. DMEs lie. For financial reasons. They can't be trusted. Thank you for again pointing that out.

ltts wrote: 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.

Or, actually, they could agree not to force a downgrade by forcing a non-AHI-data machine on someone--a machine that lacks the basic capability of most PAP machines on the market.

ltts wrote: You're right in that they can't fill it with a basic PAP device, . . .

Although they certainly would if they could get away with it, just like they get away with claiming that AHI-data is not now standard on your average PAP machine.

ltts wrote: . . . but that's about it. But they can certainly turn down your business.

As far as most of us are concerned, they already have when they treat us the way you claim they should.

ltts wrote: Having a prescription from your doctor for an APAP device certainly helps your chances of getting a free upgrade . . .

It assures that one will get an APAP. It assures that the DME will make less money, if they choose to fill the Rx. But it doesn't assure that the DME has to dishonestlly now charge the patient more under the table to get what is needed for basic healthcare, which is not, or should not be, considered by anyone to be "an upgrade."

ltts wrote: . . . because the DME has an interest in maintaining a good relationship with your physician if they are a frequent source of patient referrals.

In other words, the DME will get you what you are supposed to have only if it assures the DME of more business in the future. If not, you will be ripped off for as much as the DME can get out of you.

ltts wrote: But you're still getting something over and above what your insurance payer has agreed to pay for.

The OP says again, without providing proof.

Just because a DME can get away with passing out a substandard machine, that does not make it right.

Thanks, Dori -- for the correction from "luxury" to "deluxe" -- I stand corrected (and appreciate it -- my bad).

At first I was irritated at ltts and the statements being made. But I think I need to agree with jnk -- by doing this (and the way she's done it) it's backfired on her. Her "attitude" is why so many of us are irritated with a lot of DME's.

And I agree that it's HER that is not listening.

Sometimes, people get "stuck" and no amount of talk or logic is going to get through to them.

Note: my use of the term 'luxury' was meant in a purely sarcastic vein,
equating OP's use of 'deluxe' as a substitute for that which is the result of advanced research and development--an improvement.
The terminology is actually beside the point, as an medical advancement often takes too long to be accepted by the general medical profession,
And, if the therapy advancements involve a lower bottom line, the insurance companies may NEVER cover them--if they can get away with it.
It's 'trickle down' all over again; but gravity has encountered a few dams.

If the rest of the sleep industry was run the way the OP suggests DMEs should be run, you would arrive at a doc's office that had no chairs or waiting room, since insurance does not specify that it pays for visiting doctors that have chairs and waiting rooms. Then you would arrive for a sleep study where they charged the patient out of pocket $50 for sheets, $100 for air-conditioning, and $5 per trip to the toilet, since insurance does not specify that it pays for that. ('Hey, call them and ask them. We have a right to charge extra to upgrade you to a toilet-use PSG.')

AHI data has been standard on PAP machines for a long, long time.

I agree that insurance can mistreat patients, too. The issue is how patients get caught in the middle with these financial turf wars. Insurance plays hardball with DMEs, so DMEs attempt to get back by playing hardball with the patients. Legal? Probably. Ethical? No way. Not in my judgment.

If we are going to all play hardball, let's open up the exact numbers for all to see so that the patient knows EXACTLY how much insurance is going to pay and EXACTLY how much the machine costs the DME. Then the patient is in a position to participate in the hardball game with knowledge of the actual rules. Until that happens, patients have to be willing to play hardball back by forcing the DMEs to provide basic AHI-data-gathering machines by any means necessary. If that means getting a doc involved or something even more forceful, so be it. But until there is some honesty and above-board info available to the patient, the patient has to assume that the person lying is the person with the most to gain from lying--the DMEs.

I have resisted getting in this discussion but no one seems to have noticed this statement which he has quoted several times.

ltts wrote:a business that is mandated to provide service 24/7/365. Yes, even on Christmas, and even at 2 AM every day of the year if they provide PAP devices or other respiratory products.

I wonder why when my CPAP quit on a Friday night and I called my DME I was told that CPAPs were not a medical necessity and to come by their office after 10 a.m. on Monday. Thats why I , like many, bought a back-up out of pocket to keep from having to go through that again.

I have no real big problem with an upgrade as long as it is reasonable. The difference in price between a brick andf an Auto on line is generally about $100. My DME wanted $500 for the upgrade, that is almost the full price of the unit on-line. Got to be over 6% mark-up!!

Jerry

6PtStar wrote:I have resisted getting in this discussion but no one seems to have noticed this statement which he has quoted several times.

ltts wrote:a business that is mandated to provide service 24/7/365. Yes, even on Christmas, and even at 2 AM every day of the year if they provide PAP devices or other respiratory products.

Jerry

I noticed it and had a chuckle over it. After reading of all the trouble forum members have had with their DMEs, I have to think my DME is one of the best in the country. Yet they only provide service during regular office hours M-F. Maybe DMEs that provide such things as oxygen have more service hours. My DME is CPAP only.

Poor dmes ......
My script from my Doctor specified an apap machine, specifically a pr system one w/ aflex. I had the choice of a network dme and they filled the script as written. No upcharge passed on to me whatsoever. A network dme signs a contract with the insurance carrier and agrees to accept what the insurance company agrees to pay them. Why the hell should I care what that is? I
don't. As long as I get what I'm prescribed. Do I care about the dme's profit margin? No. If they aren't making money, go sell vacuum cleaners for all I care. This whole discussion is pointless for us consummers. Go bitch to the insurance company's.

Fullygruntled wrote:Poor dmes ......
My script from my Doctor specified an apap machine, specifically a pr system one w/ aflex. I had the choice of a network dme and they filled the script as written. No upcharge passed on to me whatsoever. A network dme signs a contract with the insurance carrier and agrees to accept what the insurance company agrees to pay them. Why the hell should I care what that is? I
don't. As long as I get what I'm prescribed. Do I care about the dme's profit margin? No. If they aren't making money, go sell vacuum cleaners for all I care. This whole discussion is pointless for us consummers. Go bitch to the insurance company's.

Agreed! But not gonna bother to bitch... pointless.

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

No, not at all. What she has made clear is that the DMEs want to only sell us a brick. The insurance company reimburses the DME for a "deluxe" machine (it's the same code as the basic machine), but the DME wants to foist a brick on the patient in order to maximize their bottom line. If the reimbursement wasn't sufficient to cover the "deluxe" machine and keep the DME in business, no DME would sell the "deluxe" machine. It's only the greedy and poorly managed DMEs that can't stay in business by selling the "deluxe" machines.

LTTS, please take note:

If you cannot understand why so many on this board are upset at their DME read this from Brenda in this thread:
viewtopic.php?f=1&t=73337&st=0&sk=t&sd=a Switching DMEs (yet again) .. this time Apria Any info?

bdp522 wrote:I've been using apria since I started, almost 6 years now. In all this time they only got 1 order correct the first time. When my new S9 auto was deliverd it was left on the doorstep when I wasn't home, no signature required! To get filters I have to call every month and request them, they send 2 at a time, and it takes at least 2 weeks for them to get here, UPS and signature required! The filters are 'special order' as are most masks. The want to send you everything you qualify for even if you don't need it. They want to send me a new hose every month,(I use the aussie heated hose), they want to send entire masks instead of just new cushions or pillows(takes at least 2phone calls from them to get them to send just the pillows or cushion). Keep in mind that whatever they send wil probably be wrong so you have to send it back(make them send a call tag) this could mean it will take a couple of weeks or more to get what you actually need. Apria is my only choice for DME so I tolerate them, but when I can afford to or can't wait for weeks, I order from cpap.com, never a problem and super quick delivery.

Brenda

This experience is NOT atypical!

idamtnboy wrote:

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

No, not at all. What she has made clear is that the DMEs want to only sell us a brick. The insurance company reimburses the DME for a "deluxe" machine (it's the same code as the basic machine), but the DME wants to foist a brick on the patient in order to maximize their bottom line. If the reimbursement wasn't sufficient to cover the "deluxe" machine and keep the DME in business, no DME would sell the "deluxe" machine. It's only the greedy and poorly managed DMEs that can't stay in business by selling the "deluxe" machines.

Actually, you're quite mistaken. In all the verbiage she has spewed, she has said not one word about what DMEs want. Only about what she perceives the DME's obligations are and what she thinks the insurance companies will pay for. I, too, find it difficult to believe a DME would sell what she calls a "deluxe" machine at a loss. That's where her credibility breaks down. However, I doubt you know any more than I do about what insurers do or do not reimburse.

I would find it appalling if, as she has asserted in answer to my question, a DME has no obligation to fill a prescription as written. I would find it equally apalling if an insurer would not reimburse a DME adequately for a prescribed device.

Robespierre wrote:Actually, you're quite mistaken. In all the verbiage she has spewed, she has said not one word about what DMEs want. Only about what she perceives the DME's obligations are and what she thinks the insurance companies will pay for. I, too, find it difficult to believe a DME would sell what she calls a "deluxe" machine at a loss. That's where her credibility breaks down. However, I doubt you know any more than I do about what insurers do or do not reimburse.

Maybe not in direct words, but certainly, IMO, in the way she has phrased all her comments. I'm not sure what you mean by "what insurers do or do not reimburse." It's quite clear in the EOBs we receive from Medicare and the ins companies what they pay for and how much. It's also clear that the HCPCS is the same for all machines classified as CPAPs. This includes the "deluxe" machines as well as the bricks.

The one thing we do not know, and probably never will, is what the manufacturers charge the DMEs for the machines. That pricing structure may be all over the map and there well may be a price difference what various DMEs pay. That may be the crux the issue. I suppose it's possible that Resmed may charge a small time DME supplier a fairly high price for an S9 Autoset so that the reimbursement leaves very little margin. Maybe Resmed sells the Escape so cheap to everyone that any DME makes a great margin, and the Autoset for very little more to a large DME supplier. In that case the large DME would make more money than would the small DME supplier. And then again, Resmed may sell the Autoset to everyone for $50 more than the Escape. One reason the insurance companies have resisted a new and higher paying code for the "deluxe" machines may be that the actual price to the DMEs is now less than it was 5 years ago. After all, all electronics have dropped dramatically in the past few years. It would be naive to think the S9s haven't also.

My interpretation of what the OP is apparently telling DMEs:

'Since insurance doesn't pay you as much as you would like, I recommend that you provide a below-average machine to all patients and then make patients pay extra for anything beyond the lowest-level machine you can give them. That will show those mean old insurance companies! And that way you can squeeze out as much profit as possible where you can. If any customers complain, tell them that the problem is their insurance and then tell any lie you have to (such as "we don't stock that machine") to keep your profits high. Tell patients that the average machine is actually a "deluxe" and that the below-average machine is the "standard" one you sell, and then claim insurance doesn't pay for what you have dubbed "deluxe." Patients won't know the difference. After all, they will be scared and sleep-deprived suckers who are afraid to make waves by getting their doctors involved in what we do, and they will be foolish enough to trust what you say if you act like you know something. They are ripe for the plucking (there's one born, or diagnosed, every minute, after all), and they are unlikely (or unable) to shop around to find a DME that may treat them fairly. If one does get a doc involved--then, and only then, give a decent machine. And if the others learn the difference at cpaptalk.com, I will go there and claim that cpaptalk.com posters are the liars, not you. Remember, you are in business to make money, not help patients.'

Hi LTTS,

First, I understand and respect your point of view, but as many have posted above, there are many instances of what "appear" to be unethical DME practices. Here's my example . . .

My understanding (and I could be totally wrong) my Medicare CPAP machine was rented on a 13 month contract. The contract was with a national company that I won't mention the name (however they probably chose the name because it was similar to apnea.)

Again, I could be wrong, but my understanding is that it is NOT a total rental. My understanding is that the CPAP machine is RENTED but the Humidifier is SOLD. So, if that's the case, the DME should CHARGE Medicare a SMALL amount for the Humidifier and LEASE a LARGE amount for the CPAP.

I am looking at the SALES SERVICE AND RENTAL AGREEMENT dated 11-23-2011:

RENT -- S9 ELITE W/0 HH --> $331.52

SALE -- CPAP HUMIDIFIER HEATED H5I --> $745.00

SRVC -- CPAP TUBING --> $125.44

SRVC -- CPAP FILTER DISP --> $ 11.67

(I assume SRVC means Service, but I'm not sure what that means.)

I suppose using you analysis, the DME made a clerical error. I'm sure they didn't switch the values so they could collect the SOLD value up front and LEASE the smaller amount.

No -- couldn't be. I'm just one of those cynical posters.