Medicare replacement schedule

squid13 wrote:How are we suppose to know weather my supplier won or lost. If they lost then I have to go with who ever won if I'm on Medicare, is that right.?

They probably will send you a letter letting you know. At least that's what my DME said the other day when I was there. They lost. There are only 2 or 3 large outfits locally who won plus several nationwide firms who I would have to deal with by phone or web.

Here's a question:

Will the DME's that are no longer Medicare suppliers, and therefore are free of the requirement that they cannot sell equipment
for less than Medicare pays, offer lower prices to cash-and-carry customers?

jdm2857 wrote: therefore are free of the requirement that they cannot sell equipment for less than Medicare pays,

I don't think that has ever been a restriction. The only restriction that I'm aware of is a DME cannot force any buyer to pay more than the contract price if that buyer is a member of a contract group the DME is also a part of. No contract, no restriction. Medicare is the only universal contract in that it covers all Americans over 65, but not all DMEs choose to participate in that contract. If a non Medicare contract supplier, i.e., not a participating provider, wants to sell a machine at 1/3 or 3x the Medicare price to anyone they want, that is their prerogative.

There's only one overriding reason DMEs participate in insurance (including Medicare) contracts -- assurance of payment.

idamtnboy wrote: I don't think that has ever been a restriction.

With regards to Medicare in the past there have been restrictions. For sure on the doctors side of things and I am pretty sure on the DME side of things. Even though where I worked we were a non participating physicians clinic...there were still restrictions if a service was performed to a Medicare patient. Still had restrictions on how much we could charge above the allowable amount and prohibited from having 2 different fee schedules with one being for Medicare patients and the other being other insurance or self pay. These restrictions are likely why a lot of doctors simply refuse to take on Medicare patients even now. It creates a billing nightmare not to mention the reduced allowable fees. We weren't even suppose to discount or write off the co pay amount for Medicare patients that were hard pressed for money. Not saying we didn't do it sometimes but it was a rarity and we didn't talk about it very loudly.

There are rules even if a supplier or doctor chooses not to be participating Medicare provider.
If we chose to provide a service to a Medicare patient ...we got stuck with rules too.
If Medicare found out that a service was provided to say a self pay person with no insurance and the fees for self pay were reduced...big fines could be levied.

Once again, no good deed goes unpunished.

Pugsy wrote: With regards to Medicare in the past there have been restrictions.
There are rules even if a supplier or doctor chooses not to be participating Medicare provider.
If we chose to provide a service to a Medicare patient ...we got stuck with rules too.
If Medicare found out that a service was provided to say a self pay person with no insurance and the fees for self pay were reduced...big fines could be levied.

You're correct, with respect to Medicare eligible patients. What I had in mind was that if a non-insured person who is not covered by Medicare, like a 40 year old, comes into the DME store, the DME is free to sell a piece of equipment at any price they wish. What they cannot do, as you say, is charge a Medicare patient an amount greater than Medicare amount x 0.95 x 1.15. I see no restriction about selling for less, although the patient will still have to pay the 20% copay. What Medicare will not tolerate is forgiving the patient's share of the cost regardless how little or how much it may be. But the payment system probably will not process a charge and payment for less than the contract amount. The only practical way to give a patient a break would be use to a code for a lesser priced item, but then again, that would be fraud.

All people over 65 are covered by Medicare, and Congress in the law said all providers are subject to Medicare rules, so in effect every person over 65 is in a contractual relationship with every provider in the country. The only question is who pays who, not how much is paid.

idamtnboy wrote:What I had in mind was that if a non-insured person who is not covered by Medicare, like a 40 year old, comes into the DME store, the DME is free to sell a piece of equipment at any price they wish. What they cannot do, as you say, is charge a Medicare patient an amount greater than Medicare amount x 0.95 x 1.15.

No, the deal is IF a provider services Medicare patients in general (non participating provider or not)...they cannot sell to a non medicare patient at a reduced amount.
There can't be 2 sets of fees with Medicare being the higher. Medicare throws a bloody fit if they find this out.
Now it likely does happen but if Medicare finds out they can get real ugly about it. Mostly it is done on the QT and no one advertises the fact.

Now if a provider doesn't ever service any Medicare patients then they can do what they wish with their fee schedule. They can of course (with patient's permission) treat a Medicare patient as a self pay but not many Medicare patients want to do that...they want Medicare to either pay them back for what they spent or pay the provider and they only owe the co pay.
This is why a lot of practices are no longer seeing any Medicare patients at all. That way they get to do what they want without all the Medicare rules. It greatly simplifies billing and weeds out the patients where they feel they aren't getting paid enough for their services.

It's really hard for a DME to take up this "no Medicare patients at all" because the people that are Medicare eligible are going to be a substantial part of their business. Maybe in the big cities they could get away with it because there is a larger market to draw from.

That's the way it has been in the past. The rules in the past were very clear about having 2 fee structures..simply not allowed if Medicare was the higher.
I don't know if this competitive billing thing is going to allow more leniency with the rules or not. I just don't see Medicare being okay with their paying $1000 for something and the same provider selling same thing to self pay patient for $500. Maybe they will be okay with it once all this new stuff gets implemented.

I notice a few Medicare providers are now restricting their service to patients in nursing homes.
Nothing like picking the weakest sheep to shear.

The difference between a Participating Provider and a Non-Participating Provider is that the Paricipating Provider must accept Medicare's allowable as the most money they
can collect from Medicare and the Patient. So, any monies paid by Medicare+co-payment/deductibles= the Medicare allowable. A Non-Paricipating Provider can bill the patient
any amount, bill Medicare but the Patient is responsible for the difference as to what Medicare paid and the gross amount of the bill and not just the allowable.

All Providers who have a provider number from Medicare must submit a bill on behalf of the patient, regardless whether they accept assignment or not; only Participating Providers
are required to accept assignment (and Medicare's allowable) as the maximum ammount they can collect.

As a rule, most companies accept Medicare's allowable and bill on assignment. Our company only bills non-assigned for general DME that has more features than the HCPCS code list for the base item.

If a company does not accept Medicare's assignment for CPAP....shop around.

Also, for non-Medicare patients, BEWARE of companies that bill your insurance plan as an OUT-OF-NETWORK provider. They may be scamming you!!!!
This is not in all cases, as some Plans have closed their IN-NETWORK Provider list and some Plan's allowables are barely above cost.

IN-NETWORK providers accept the allowable as the maximum payment amount and usually receive 80% of that amount from the Plan with the patient responsible for the remaining 20% plus any deductible applied.

Unfortunately, we know of companies that bill OUT-OF-NETWORK so they can bill 2 to 4 times what the IN-NETWORK allowable is for plan.
OUT-OF-NETWORK benefits may only be at 50% of the allowable with a much higher deductible applied (usually in the thousands of dollars before meeting the OUT-OF-NETWORK deductible).
That means you are not only paying more money than the allowable established by your plan, you are also paying a higher percentage of monies that the plan would have covered if supplied by an IN-NETWORK provider.

If the company doesn't accept your insurance plan, look for one which does. You can save yourself a lot of money.

As always, Medicare rules/allowable/providers may change if your region falls into the competitive bidding areas.
Most of us have no idea what happens then, but if history is any indicator; .

The Medicare site says I will be in the competitive bid area this summer. But they have been wrong a lot lately.
The provider list for my city has only TWO providers listed; and one does NOT sell ANY CPAP stuff.
Guess who the other one is? Apria.

chunkyfrog wrote:The Medicare site says I will be in the competitive bid area this summer. But they have been wrong a lot lately.
The provider list for my city has only TWO providers listed; and one does NOT sell ANY CPAP stuff.
Guess who the other one is? Apria.

The Competitive Bidding Program will be a train wreck on day one. CMS had 356 contract suppliers to cover the 10 CBA's in round one. In round two
they have only 799 contract suppliers to cover 91 CBA's. That's 2 times the suppliers for 9 times the locations. For Oxygen in Honolulu, Apria is the only
supplier on the Islands. The next closet supplier is located in California and another is in Florida.

Most of the Bid winners are small businesses who are not in the service area, never supplied the product and only bid in order to have someone
buy their business. However, the bid amounts are so low, no one wants their business so they are stuck........and so, now, are the patients.

On top of that, they are few companies that hold multiple contracts. If you need a hospital bed, wheelchair, support mattress for decubitis ulcers
and oxygen, you will need to contact multiple suppliers.

A national company, when interviewed on the impact of Competitive Bidding, stated that the upside would be that they no longer needed to complete
with smaller regional companies on quality of service. They simply need to deliver the product and that did not include same day or next day delivery. Equipment will
be scheduled similar to how furniture is delivered..........we deliver to your zip code on Tuesdays. Not what you want to hear on a Wednesday.

We need to fix this mess for the folks who have nothing to fall back on.
Any savings could be wiped out by poor planning---and not even our own!

chunkyfrog wrote:We need to fix this mess for the folks who have nothing to fall back on.
Any savings could be wiped out by poor planning---and not even our own!

So people need to, literally, call their Congressman and Senators and tell then to stop the current program
and support the alternative, HR1717.

Or, at least, ask their Congressman and Senators to explain why they believe the current delivery system will not be impacted with so few
providers offered contracts and so many of the contract holders not located in the areas they are contracted to service.