Let's clear up some misinformation

When you start a debate in a combative stance you will get combat. I missed most of the content of what the OP had to say because her unpleasant personality took over. She/he was looking for a fight. I can't imagine having that kind of energy.

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.

Elle wrote:When you start a debate in a combative stance you will get combat. I missed most of the content of what the OP had to say because her unpleasant personality took over. She/he was looking for a fight. I can't imagine having that kind of energy.

Elle
It looks like our troll was bored on night shift and decided to lighten things up....this has been done before by a troll.
You will notice the thread starts at 9:22 last night and he/she stopped posting early this morning (night shift). We need to walk away and ignore this poster.

Definitely not earning it's salary/wage then.

That was one heck of a lot of typing. At least it didn't waste a lot of time reading.

Receiver broken...transmit only function.

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.

I agree that the thread has some educational value and disagree with those using the word "troll" and calling for the thread to be deleted.

But of course Corkster52, I am sure you know to verify everything you read with several generally trusted sources.

(Including what I just wrote. )

idamtnboy wrote: Taking into consideration the financial condition of nearly every middle class working American family, let alone the working poor and unemployed, it is absolutely ignorant thinking to believe that approach has any viability whatever.

That is quite a broad statement since I know many "middle class working American families" who could pay $1000 cash for a CPAP if it were medically necessary.

But in any case I would like to see these two statements married together:

idamtnboy wrote: Taking into consideration the financial condition of nearly every middle class working American family, let alone the working poor and unemployed, it is absolutely ignorant thinking to believe that approach has any viability whatever.

DocWeezy wrote:Basically, I'm with those that think these devices need to be offered at WalMart on the open market and that we should be able to purchase machines, accessories, and masks without prescriptions. That would really bring the prices down. If I'm allowed to comparison shop for a blood sugar monitor and compare the cost of the monitor with the cost of the ongoing supplies and then buy them wherever I want, why can't I do that for my cpap equipment?

Weezy

Yes, you are right Weezy. That would create transparency and increase competition which would drive down prices and drive up quality and selection. Let's bring the machines out of the mysterious DME "closet".

To go a step further, I think this dark closet scares many people away from having that first diagnostic sleep study. "Wearing a mask" and "using a machine" is a scary mystery. Put machines and masks on display at WalMart and watch the initial fear level drop.

And talking about costs and whether middle class people could afford an xpap machine--I think it comes down to choices and personal responsibility. I wonder how many people who say they can't afford an xpap out of pocket have cable TV and data plans for their cell phones? What used to be considered luxuries are now considered necessities, but if I had a choice between keeping my cable TV and buying cpap supplies, I'd cancel the cable.

Granted, there are people who do make difficult choices and truly can't afford treatment; but there are many people who COULD afford treatment even though it would mean making choices they may not want to make. Having to make a choice doesn't always mean mean you can't afford something. I remember a news story a while back about a woman being interviewed because the local utility company had reduced her "free" heating assistance for the upcoming winter--she was upset because she would now have to pay more of her own money to heat her house. In the background of the shot was a big screen TV with at least two video game systems hooked up to it. It's all about priorities, taking responsibility, and making choices.

Weezy

I agree with NightMonkey's assertion that a 6% profit claim can be misleading, true or not ... a 6% net profit might not be that bad, and of course it is relative to total volume of sales.

If the average newbie goes to his brick & mortar DME and presents a prescription for a cpap w/heated humidifier, and he has decent insurance, this is what most likely happens:

1. He gets a "brick" (bottom of the line, cheapest machine possible) - according to the OP's argument the insured is only entitled to the cheapest product on the market... don't know where it is written that reimbursement rates only entitle one to the cheapest product the DME can provide, but...

2. The OP claims that the cost to DME of this bottom of the line cpap is $350-450, so if they give you the cheapest one, I'll use $350 as DME cost...

3. DME will bill $150 on average per month for 10 months to insurance company, of which insurance might allow a little over 50%, so they'll pay the DME $80 per month for 10 months... (or that $80 will be shared between insurance and insured in the form of copays)...

4. Assuming you are compliant with your "brick," DME will have collected $800 after 10 months for a machine they paid $350 for. That is a markup of over 125%! They will also be able to write off the difference between what they billed and what they actually received, for additional tax benefits.

Not bad for profit on 1 customer.... (even if you figure in the cost of processing the insurance billing).


As far as support, he will be lucky if the RT at the DME knows how his machine works; they might spend 15 minutes with him explaining how to use the machine; they might even give him the correct information. No one will tell him anything about leaks, AHI, or any other data that is essential to successful therapy. Because sleep apnea is a diagnosis with very little follow up after they give you a machine. Diabetics are provided equipment to monitor their blood sugar data to SEE HOW THEIR THERAPY IS WORKING... but doctors and insurance companies have decided that patients with apnea don't need to know how or if their therapy is working, even though unsuccessful therapy can result in a myriad of other health problems, including organ damage, or even death.

Thank God for forums like this where patients can help each other and fill in the immense gap that the health care industry (doctors, insurance & DMEs) leaves... for otherwise that hole would just be the repository for more of our corpses.

ltts wrote:All current PAP products on the market provide usage data, because almost every insurance company requires that to continue paying beyond 2-3 months. No one is lying to you.

A DME is lying when they insist that there is no difference between a machine that records only usage data and a machine that records full efficacy data. And many DMEs do claim that. Or claim that machines that record full efficacy data simply do not exist. Or that machines that record full efficacy data require a special prescription.

The vast majority of patients don't even know what AHI is let alone how to moniter it, and couldn't care less.

This is a major failure of the entire sleep medicine industry. The AHI is the one critical data point that lands us in trouble and that the whole crazy, uncomfortable and expensive CPAP therapy is designed to treat. If an OSA patient has no understanding of what their AHI is, why it's important to reduce it to normal levels, and how a CPAP does that, then quite frankly the whole industry is setting that patient up to fail: It's difficult enough to stick with this therapy when you know that it's actually working. I can't imagine how much harder it would be to stick with it if you didn't know that it was working. And if you really are an RT and you do not make sure that every one of your patients knows what an AHI is and the importance in monitoring it, then quite frankly you are doing your patients serious HARM instead of helping them become compliant.

It is well known that over 50% of patients prescribed CPAP therapy abandon therapy altogether during the first year. Many, if not most of those patients abandon therapy in the first 2 or 3 months. In my not so humble opinion, a huge part of that noncompliance rate can be directly attributed to the fact that newly diagnosed OSA patients are routinely expected to make an uncomfortable, expensive therapy work with absolutely NO feed back on whether the therapy actually is working as planned. The lack of patient education (by the doctors, the sleep labs, the insurance companies AND the DMEs and their RTs) and the lack of efficacy data (NOT usage data) from their machines goes a long way in insuring that an OSA patient who runs into problems sleeping with the machine during the first month and who quickly (but inaccurately) concludes that s/he seems sleeps better, more soundly, and more normally WITHOUT the machine than with it, will indeed abandon therapy all together and return the machine back to the DME (if it's still being rented) or throw the machine into the closet (if it was an outright purchase or the rental period has been completed).

But the idea that an RT (or anybody else in sleep medicine) thinks it is acceptable for an OSA patient to not know the meaning of AHI is downright appalling. The analogy that comes to mind is a nutritionist who works with diabetics saying that it is acceptable for a type II diabetic to not know what the meaning of their blood glucose reading is. For an RT (or anybody else in sleep medicine) to say that an OSA patient has no need to monitor their AHI is equivalent to that nutritionist saying that diabetics have no need to monitor their glucose on a regular basis.

And more importantly, there is no insurance company willing to actually pay for that feature. None. Period. Not a single one in the whole US of A.

As I pointed out in my first post, my insurance company DOES pay the DME enough money to cover the price of a Resmed S9 AutoSet (a FULL FEATURE APAP machine) at normal markups. In other words, my insurance company DOES pay the DME enough to make a standard profit margin even if they sell me the top of the line machine. And if my insurance company is willing to PAY the DME for the full RETAIL price of a Resmed S9 AutoSet, but the DME is only willing to provide an S9 Escape (and then keeps the extra profit), then I do indeed blame the DME if they insist on sticking me with a brick.

To use your own analogy: If my insurance company PAYS the price of a NEW Cadillac with all the latest features and I get stuck with a basic Ford Escort, then yes, I'll be angry. And if I get stuck with a USED Yugo, I'll be even angrier.

You want it because you are an informed patient, but that doesn't matter to your insurance payer, and they have no intention of paying for that feature.

As stated above, my insurance company pays the DME enough for a CPAP to cover the full RETAIL cost of the Resmed S9 AutoSet, the most expensive full-feature APAP on the market right now. So in my humble opinion, that means that my particular insurance company is quite willing to pay for a full featured machine. But, alas, they will not insist on the DME providing a full feature machine. And the DMEs know that they'll get their full $900 for the blower unit regardless of whether they provide the patient with an Resmed S9 AutoSet (routinely priced at around $850 to $900 RETAIL) or an PR System One Plus (routinely priced at around $600 RETAIL) or the even more basic PR System One DS150 (routinely priced at around $550 RETAIL.) Note that the folks who get stuck with the DS150 do not even get a form of exhalation relief.

Nor does your insurance payer pay your DME provider because "you know your own usage." They couldn't care less what "you" know.

And this is exactly why we USERS of the machine regard a machine that records only usage data as a BRICK---as in a machine that provides us with no useful data to monitor our therapy and to help our doctors make our therapy more effective in the long run.

They want cold hard data downloaded from the basic machines that they cover. And guess what? Many will even refuse to pay if your physician did not sign the download report (because, hey, s/he was just too busy to be bothered). And after all, the insurance payer does not pay them an extra fee to review it, so they won't. Why should they care if the DME gets paid? They don't.

The stuff about doctor's signatures is just plain wrong. In my case, it was the DME who did the downloads to send the usage data to the insurance company. The doc's office never did a download. And the only time they asked me to have the DME do a download and bring in the hard copy or fax them over to the docs off was at the end of my two week autotitration that was authorized because I was so clearly having serious problems with adjusting to the machine. Now mind you, I always came with printouts of my full efficacy data (provided by my DME---who WAS interested in both the efficacy data and the compliance data) and the PA always was happy to note that my AHI < 5 and that that meant my problems were not being caused by my pressure being too low. And because the leak data was extraordinarily good, we didn't go round and round on trying to fix leaks that were not there. The focus on getting me adjusted really was on "can the pressure safely be reduced a bit to make it easier to adjust to?"

The insurance payer also does not care if you have a mask leak. All they care about is that they met their minimum obligation to provide the minimum necessary product. That's it. And they are not willing to pay one dime to make sure you are treated properly. Ergo, they have continually declined to pay for the features you folks feel are necessary. I can't imagine why that is so hard to understand. It's almost as if none of you have ever had any other interactions with insurance companies.

Ok---I get it. The insurance companies are horrible. I won't argue with that. I hate my 50% copays for CPAP supplies.

But somehow you think the DME should provide products and services that are unreimbursed by insurance payers. Where did you get that idea? I constantly wonder about that, because my doctor and hospital won't do that. I wonder why patients seem convinced that DMEs should do what no other health care provider is expected to do.

Because in the long run it improves the DME's bottom line and hence is in the DME's best interest to do their utmost upfront to increase the probability that each and every new customer/patient becomes a fully compliant and long term CPAPer. And the best way to do this is to treat their CPAP customers as if they are capable of being fully involved in monitoring their own therapy and care about monitoring their own therapy.

Let's face it facts: The DMEs are in business to make money. And there is NOTHING wrong with that. And I sincerely mean that. I really hope that my DME's bottom line is in the black year after year for a very long time to come.

But how does a DME make money?

One business model (the one my DME uses) is this:

• Step 1. The typical new OSA customer/patient comes in with a prescription for an E0601 machine. As the DME, you make sure that each customer-patient IS supplied with the best possible equipment that the insurance company code will pay for---in this case the best E0601 possible. And that means that IF the insurance company's negotiated price is enough to cover a Resmed S9 AutoSet or PR System One Auto, then you don't stick the customer with a brick.
• Step 2. Make sure that each new customer-patient IS sufficiently educated about their condition AND how to monitor it by reading the on-board efficacy data so that the patient can see whether their therapy is indeed actually effective.
• Step 3. Have a reasonable mask return policy and fully inform new customers about that policy. Actively encourage customer-patients to make use of the leak data their machine records and tell each customer that if the machine is indicating there are problems with large leaks to come back in for help. Helping your customer-patients with the leaks includes both helping them with mask fitting issues and evaluating whether the person may be mouth breathing. And provide the opportunity to try both chin straps and full face masks.
• Step 4. Invite the customers to come in for data downloads whenever they want them, and suggest that they bring the full data downloads (including the efficacy data) to the doctor's office on each visit. On any given download, if there's an obvious problem with the efficacy data, make sure you tell the customer that they need to contact theier doc's office to talk about the data and ask about whether any changes to the prescription need to be made.
• Step 5. Work hard to get every single new OSA/CPAP customer-patient to become a happy, long-term CPAPer who is 100% compliant with therapy where 100% means "sleeps with the mask ALL NIGHT, EVERY NIGHT." After all, a happy, long-term CPAPer will develop a a long and happy relationship with the DME, which will bring in profit for many years to come. Steps 1-4 maximize the chances that each and every single new customer-patient will become a compliant, long-term CPAPer who will have a long and happy relationship with your DME. And hence the customer is much more likely to purchase all their CPAP supplies from your DME for many, many years. And since many insurance companies are somewhat stingy on the replacement schedule for things like filters and nasal pillows or mask cushions, insuring your customers are happy will also increase the probability that they will buy their 100% OOP supplies from you as well as the ones that go through insurance. And in five years or so, when it's time to replace the current machine? The customer will gladly come back for the new machine. And, of course, the customer will also likely refer friends and family to you whenever someone they know gets diagnosed with OSA.

Now note: Yes, the DME takes a hit of about $300 in extra profit in Step 1. And Steps 2-4 are not necessarily cheap, but even the DMEs who sell nothing but bricks spend plenty of time "helping" customers deal with adjustment problems---and usually they have the same knee-jerk response to any problem the customer reports: "You must be leaking. Let's try a chin strap or a FFM and see if that helps." But every customer-patient who a DME successfully gets to Step 5 becomes a guaranteed, long term income-stream for the DME. And the profit generated by five years of filters,hoses, masks, hose cozies and hangers and other goodies designed to improve comfort, and, then a new machine with five more years of filters, hoses, masks, hose cozies and hangers and other comfort items, will make up for that initial $300 of "lost profit" many times over.

But the more common model for DMEs seems to be this:

• Step 1. The patient comes in with a prescription for an E0601 machine. Make sure that each customer-patient supplied with the cheapest possible equipment from either Resmed or PR since the local sleep docs tend to prefer those brands. And if the insurance company's negotiated price is enough to cover a Resmed S9 AutoSet or PR System One Auto, stick the customer with the bottom of the line, usage data only machine anyway. And tell the customer that the S9 Escape or PR System One Plus that you're selling them is "the top of the line machine and records all the data the patient and doctor need to make sure that therapy is working." And pocket the difference between the insurance company's negotiated price and the price of the Escape or S1Plus as "necessary profit." After all, the customer-patient is too stupid or ignorant to know the difference and shouldn't care anyway. And, of course, don't do anything to help educate the patient about their condition unless they ask very specific questions.
• Step 2. When the customer-patient comes back in with problems, reassure them that their therapy must be working if they are compliant and/or nag them about lack of compliance. If the customer-patient's data demonstrates that they are indeed compliant and they are still obviously having real problems adjusting and are feeling much worse, then tell the person the problem must be leaks and sell them a FFM and a chinstrap (both!). Do your best to NOT just exchange the first mask for the FFM; it's best for that bottom line figure to get them to buy that second mask---particularly since the insurance company is not going to pay for a second mask so soon. And definitely do NOT inform the patient-customer that all the major mask manufacturers have a return policy that compensates you for masks that are returned during the first 30 days of therapy. After all, the patient doesn't need to know anything more about their therapy than, "Just do it!".
• Step 3. Only work hard enough with each customer to get them to simply use the machine for 4 hours on enough nights so that when the usage data is sent to the insurance company, you get paid. Once minimum usage data needed to insure the machine is (or will be) paid for has been sent into the insurance company, don't bother with any further followup unless the customer-patient actually comes back.
• Step 4. Write off the 50% (or more) of patients who don't come back after the last usage check as "that's just typical for the business---we all know 50% of CPAPers quit during the first year anyway." And hope that the remaining 50% of your customers will remember that they can purchase replacement supplies through you---if they even remember that they are supposed to replace things like the masks, the hoses, the filters and so forth. But if not, well, you've maximized the profit you can get out of that first year and that ought to be enough to satisfy the accounts ......

But at least do me one favor. Appreciate your DMEs that provide you all these deluxe features and services out of the goodness of their hearts that your insurance payers have long declined to pay for. That is the least you can do. Stop slamming them for their measly 6% profit margin.

Those of us with GOOD or EXCELLENT DMEs take the time to praise them and praise them openly. Even more important, we refer our friends and family to them when we find out they are diagnosed with OSA. But do keep in mind that these DMEs are NOT providing us with these "deluxe features and services out of the goodness of their own hearts." Rather, they've figured out that an engaged patient with a quality machine is much, much more likely to become a happy, long term customer. And the real money is to be made by selling the repeat customers supplies (and new machines) over a multi-year period and who will, if necessary, pay for the supplies they need OOP at a reasonable, full retail price*, which while it might not be as much as the negotiated price for the insurance company, is still enough to make a profit on.

*Case in point: My insurance company will pay for ONE fine filter per month. The negotiated price is $5.00 and I have a $2.50 copay. I need to replace my fine filters much more often than once a month. When I first started out, the "retail price" of a fine filter was $3.00. I was happy to pay $3.00/filter OOP and replace my filters about once a week. I only found an alternate source of fine filters when the retail price of the fine filters more than doubled to $7.00 per filter.

nanwilson wrote:

Elle wrote:When you start a debate in a combative stance you will get combat. I missed most of the content of what the OP had to say because her unpleasant personality took over. She/he was looking for a fight. I can't imagine having that kind of energy.

Elle
It looks like our troll was bored on night shift and decided to lighten things up....this has been done before by a troll.
You will notice the thread starts at 9:22 last night and he/she stopped posting early this morning (night shift). We need to walk away and ignore this poster.

I'm inclined to agree. There are many sleep professionals (not all, but quite a few) that DESPISE this forum and make it their goal to come here and cause problems by spreading inaccurate information. They've come before, caused their share of ruckus and discord, then left. And they keep on coming, with no other agenda than to cause trouble because the people that come here that empower themselves with knowledge are a threat to them and their need to remain unchallenged and superior.

It's probably not a bad idea to refute the obvious inaccuracies (mainly for new people that are just learning), but wasting too much energy on it is fruitless.

If you realize exactly what's going on and what you're dealing with, it's good for some entertainment. Nothing more.

As a disclaimer here so that nobody starts slinging crap in my face -- I have no problem with any sleep professional (tech, doctor, RT, DME, etc) that really wants to help patients get the best therapy they can. Those that come to the forum with an obvious agenda (contrary to the intent of the forum) and immediately criticizing it and the people who participate here....not a way to win friends and influence people.

LTTS,

You posted that


So I have 27 yrs of experience in this field, and am considered an expert on regulatory affairs and reimbursement regulations related to DME.

It is in this pargraph:

I'm an RCP that got her degree in 1984. I have worked in a sleep lab, then for DME businesses, and now I consult with DME companies on meeting the thousands of regulations that they are required to meet so they can stay within the law. So I have 27 yrs of experience in this field, and am considered an expert on regulatory affairs and reimbursement regulations related to DME. Here are the 3 big things consistently posted that are not supported by facts...


So,

I have a real important question to ask you. Going over my DME transactions with Medicare (actually with my BCBS medigap) I see in the DME's charges a lot of Non-Allowed Amounts. Since it's mostly duplicates by my the DME, I get the impression that the DME tries to mislead Medicare. Should I report it as a Freud since Medicare keeps asking me all time?

Take a look:

The following is a copy of one page from 8 pages that I requested my DME to provide me.



The Non-Allowed Amounts which I marked with a line leading to the amount that the DME asked to be credited but it was disallowed. It totaled $570.60 in this one bill. Overall, from the total sum of $6,800 that the DME charged Medicare for the one year period of 11/16/2010 to 12/19/2011, $2,314 was disallowed, which comes out to about 34%!

Before receiving the above mentioned annual list of transactions between my DME and Medicare I got this bill for $120 to paid from my pokcet:




But after asking for clarifications I was told that they had an error and I owe nothing. How nice!

Any thoughts?

And now I'm going to be a little bit of a *itch here --

Something the OP said early on made me go "Hmmm" because it didn't sound quite right.

But this one got me, making me question the validity of the statements....

EOB Stands for EXPLANATION of Benefits, not ESTIMATION of Benefits as OP stated. By the time a patient gets an EOB, any payments have been made (or are in process) and are NOT an estimation.

Anyone who has as much experience in the field as OP claims would know that...

Sorry -- I couldn't help myself...as I said, I'm a bit Witchy today....

EOB = "Expert" offering BS!

LinkC wrote:EOB = "Expert" offering BS!

I literally laughed out loud at that one. Hubby looked at me like I was nuts!

Your definition of EOB seems fitting here.

chunkyfrog wrote:I am surprised the OP's very first post wasn't marked SPAM and deleted.
.

I was tempted to do that but I figured it was a good education for the newbies to see what kind of slime works for the industry.