Medicare CPAP reimbursement cut 47% for DMEs

Of course, for every patient who dies unnecessarily,
there may be a grieving family member looking to purchase a firearm.

mcdover wrote: . . . While we're at it, why don't we just make all drugs OTC and let people determine their own dosage.

The drugs that are OTC are much more dangerous than PAP. So what is your point?

And actually, patients DO determine their dosage of every drug prescribed or provided OTC. The doc suggests a dosage, but the patient determines whether he chooses to follow the suggestion. The patient may choose not to fill the Rx at all, in fact.

Were you under the impression it all worked differently somehow?

chunkyfrog wrote:Of course, for every patient who dies unnecessarily,
there may be a grieving family member looking to purchase a firearm.

But the bullets are all sold out.

hyperlexis wrote: . . . Let the free market decide. . . .

That would require all manufacturers abandoning forced Internet pricing policies.

hyperlexis wrote: . . . It works for pharmaceuticals and hospital supplies, and it should work for DME products as well. . . .

That is apples compared to oranges, my friend.

PAP supplies and machines must be customized to the needs of each patient in order for PAP to be successful for that patient.

hyperlexis wrote: . . . Saving even one cent on a CPAP product sold to Medicare patients could translate into huge dollars when you consider the number of payments made each year.

And failures of PAP-use that occur in the interests of saving that penny will cost thousands of dollars per patient who abondons therapy. So yes, it will translate into huge dollars--only into the wrong column of the ledger.

hyperlexis wrote: . . . Actually, to most Americans, a basic CPAP brick and a simple nasal mask is probably pretty darned acceptible. . . .

That is an interesting unsubstantiated opinion that many DME empolyees run with and that may well be the biggest problem in the industry. And even if it is acceptable to 51%, the other 49% will cost the country a fortune if we don't meet their PAP-therapy needs. So medical arguments using the word "most" aren't really addressing the subject fully enough to matter, in my opinion.

hyperlexis wrote: . . . Want a fancy, data capable machine? Fine. Pay for the additional cost out of pocket or prove it is otherwise medically necessary.

All I have to do to prove I need a better machine is to fail to use the one I have.

That "fancy, data-capable machine" you keep referring to is the standard machine. The one you consider standard is called a "sub-standard machine." And the standard machine costs about $100 more than the sub-standard one.

hyperlexis wrote: . . . My question was, and remains, please cite a peer-reviewed study or authoritative text that states providing elderly Medicare patients with prescribed, basic CPAP, vs more costly data-capable machines, is inherently dangerous or would have a statistically significant result in patients causing auto accidents.

Anything, something. Even hinting at it. Please.

Every study ever made of PAP therapy by OSA patients has found that discontinuing use is dangerous.

Have you found a study that suggests otherwise?

mcdover wrote:

LSAT wrote:I check the new SPA reimbursements for my city against what my DME has been receiving for my purchases.....Under the new SPA they will be receiving a higher reimbursement for everything I normally purchase except for Tubing. I checked FF Mask, Headgear, Silicone Insert, Humidifier Cup, Filters and Tubing.

You are 100% wrong.

Well...I have my medicare EOBs that says I'm right. (Unless I'm reading the SPA chart wrong )

FF Mask A7030 My last EOB shows $80.15...my 20% 16.03.....New SPA 104.78
Headgear A7035 My last EOB shows $16.90...my 20% 3.38.... New SPA 20.00
Water Chamber A7046 My last EOB shows $8.30...my 20% 1.66 ..New SPA 14.37
Tubing A7037 My last EOB shows $17.45...my 20% 3.49 ... New SPA 11.19
Silicone A7031 My last EOB shows $29.65...my 20% 5.93... New SPA 40.00

mcdover wrote:

BlackSpinner wrote:

mcdover wrote:Medicare says they must say, making sure YOU go back to YOUR doctor for your follow up visit, and that YOU are actually using the equipment, the DME will eventually collect $550. That is assuming that every T is crossed and every i is dotted and the Medicare beneficiary actually pays the co-pay/deductible. Now go to CPAP(dot)com's website and price a cpap. If they can't sell a top-of-the-line CPAP for that price without having to have a brick and mortar store and all the expense that comes with that, and having the luxury of receiving FULL payment before the CPAP actually leaves their premises, what do you think your Medicare insurance is going to get you?.

And you know something? Cpap(dot)com is making a profit on their prices. They are not a charity. You are just talking cash flow. Business handles that all the time with the banks. Most manufacturers have to put up cash up front to buy their materials, often more then a year in advance of when they sell. Banks have been dealing with this for over 2000 years.

Apparently, you fail to understand that CPAP(dot)com is profitable at their pricing because they don't have the added expenses of an insurance-accepting, brick and mortar store.

At one time (some years back), they did have an insurance-accepting entity. Speculation was that "political pressures" were brought to bear and forced them to stop doing that. However, they DO have a storefront in Houston that you can use if you're in that area.

Den

.

chunkyfrog wrote:McDover: the facts as I have stated are indeed true--for MY area.
There is only one, (that I am aware of) NON-Medicare provider here, who has no dealings with Medicare at all.
Out of the remaining 15 or 16, who all receive Medicare business, only 2 have signed CONTRACTS
limiting them to medicare prices as full payment.
The remaining Medicare providers are not restricted on balance billing, but they still get medicare bucks.
This may be a special condition allowed only in less-populous states, or maybe those not in the bid system yet.

Nope, still wrong.

Presently, the Medicare reimbursement rate for Region D, which I assume is where you live, for a Full Face Mask, HCPC code A7030 is $176.04, effective 7/1/13, the new rate for the Omaha-Council Bluffs, NE-IA CBA is $101.00
The silicon cushion went from $65.11 to $39.77
Headgear went from $37.08 to $20.00

EVERYTHING DROPPED. Nothing went up.

I don't have any idea what you are talking about in the rest of your post. If you collect Medicare dollars, you must be a Medicare provider. There's is no middle ground.

Also, no one in the Omaha-Council Bluffs, NE-IA CBA has a contract with Medicare yet, because they were just mailed out on Thursday. Medicare won't even announce who it's contracted suppliers are until the Spring, and the official implementation date is 7/1/13. At that point, if you recently received a CPAP from a provider that did not win a contract, Medicare will allow the CPAP to continue to rent until it is capped with that provider. All new supplies will have to be purchased from a new provider that has been awarded a contract.

LSAT wrote:

mcdover wrote:

LSAT wrote:I check the new SPA reimbursements for my city against what my DME has been receiving for my purchases.....Under the new SPA they will be receiving a higher reimbursement for everything I normally purchase except for Tubing. I checked FF Mask, Headgear, Silicone Insert, Humidifier Cup, Filters and Tubing.

You are 100% wrong.

Well...I have my medicare EOBs that says I'm right. (Unless I'm reading the SPA chart wrong )

FF Mask A7030 My last EOB shows $80.15...my 20% 16.03.....New SPA 104.78
Headgear A7035 My last EOB shows $16.90...my 20% 3.38.... New SPA 20.00
Water Chamber A7046 My last EOB shows $8.30...my 20% 1.66 ..New SPA 14.37
Tubing A7037 My last EOB shows $17.45...my 20% 3.49 ... New SPA 11.19
Silicone A7031 My last EOB shows $29.65...my 20% 5.93... New SPA 40.00

No way that can be right. Here the fee schedule for non-CBA region B, which include Wisconsin:

http://www.ngsmedicare.com/wps/wcm/conn ... aultDesc=0

jnk wrote:

mcdover wrote: . . . While we're at it, why don't we just make all drugs OTC and let people determine their own dosage.

The drugs that are OTC are much more dangerous than PAP. So what is your point?

And actually, patients DO determine their dosage of every drug prescribed or provided OTC. The doc suggests a dosage, but the patient determines whether he chooses to follow the suggestion. The patient may choose not to fill the Rx at all, in fact.

Were you under the impression it all worked differently somehow?

The doc may "suggest" but with the requirement of an Rx, you still are forced to obtain his "suggestion". With the premise that was posed, you eliminate the expert and leave people with absolutely no guidance except for internet message boards.

I can see it now, no Rx requirement for CPAP, Wal-Mart has them on the shelf next to the adult diapers. George's wife nags him about snoring, so he picks up a CPAP while getting some dog food, bread and milk. He doesn't have any idea what pressure he needs, so he just guesses. George ends up with a stroke, paralysis, and confined to a bed for the rest of his short life because he never consulted a professional because he didn't have to. A little learning is a dangerous thing.....

mcdover wrote: George ends up with a stroke, paralysis, and confined to a bed for the rest of his short life because he never consulted a professional because he didn't have to. A little learning is a dangerous thing.....

A little air is NOT a dangerous thing however.

mcdover wrote:

LSAT wrote:

mcdover wrote:

LSAT wrote:I check the new SPA reimbursements for my city against what my DME has been receiving for my purchases.....Under the new SPA they will be receiving a higher reimbursement for everything I normally purchase except for Tubing. I checked FF Mask, Headgear, Silicone Insert, Humidifier Cup, Filters and Tubing.

You are 100% wrong.

Well...I have my medicare EOBs that says I'm right. (Unless I'm reading the SPA chart wrong )

FF Mask A7030 My last EOB shows $80.15...my 20% 16.03.....New SPA 104.78
Headgear A7035 My last EOB shows $16.90...my 20% 3.38.... New SPA 20.00
Water Chamber A7046 My last EOB shows $8.30...my 20% 1.66 ..New SPA 14.37
Tubing A7037 My last EOB shows $17.45...my 20% 3.49 ... New SPA 11.19
Silicone A7031 My last EOB shows $29.65...my 20% 5.93... New SPA 40.00

No way that can be right. Here the fee schedule for non-CBA region B, which include Wisconsin:

http://www.ngsmedicare.com/wps/wcm/conn ... aultDesc=0

Right or wrong.... I have EOBs from the past 2 years...I should add that I am on a Medicare Advantage Plan, but I was told that they use the Medicare reimbursement schedules. The RT at my DME has always complained about the low reimbursements.

mcdover wrote: The doc may "suggest" but with the requirement of an Rx, you still are forced to obtain his "suggestion". With the premise that was posed, you eliminate the expert and leave people with absolutely no guidance except for internet message boards.

That's the situation we have right now--no guidance. And docs suggest patients use OTC medications all the time. Making the product OTC does NOT take docs out of the loop by any stretch.

mcdover wrote:I can see it now, no Rx requirement for CPAP, Wal-Mart has them on the shelf next to the adult diapers. George's wife nags him about snoring, so he picks up a CPAP while getting some dog food, bread and milk. He doesn't have any idea what pressure he needs, so he just guesses. George ends up with a stroke, paralysis, and confined to a bed for the rest of his short life because he never consulted a professional because he didn't have to. A little learning is a dangerous thing.....

That's the situation we have right now. Payers don't wanna pay for a real PSG, diagnostic or titration, so all the patient is getting these days is whatever pressure an autotitrating machine finds set wide open. How does restricting the locations at which machines are sold help that?

As for your cute little analogy, imagine that Joe (standing right next to George in the adult-diaper aisle) does not have access to the PAP machine at Wal-Mart but DOES have OTC access to some diphenhydramine HCl and loads up on that to sleep better (washing it down with a scotch after a big meal) and dies overnight with the interaction of the drugs with his long-untreated sleep apnea. Access to the one product that IS over the counter could kill him; access to the PAP machine for his snoring could save him with something that has no significant side-effects. You do the math.

On safety, there is no argument for selling sedating medications OTC while refusing to sell the simple mechanical device OTC that could make use of the sedatives safer. Pretty stupid when you think about it, really.

In my opinion.

And I respect your right to have yours.