Medicare CPAP reimbursement cut 47% for DMEs

chunkyfrog · Post by **chunkyfrog** » Mon Feb 04, 2013 12:40 pm

At this point it looks like Medicare's left hand and right hand have no awareness of one another.
There appear to be different rules for every single jurisdiction--in spite of publications to the contrary.
Welcome to the world of mushrooms--(and we were thinking only patients were here!)
I'm not terribly surprised you have also been condemned to the wasteland of misinformation.
I would be amazed if the great and powerful even have a half a clue.

jnk · Post by **jnk** » Mon Feb 04, 2013 12:54 pm

Fantastic post. Thanks. I mean it.

And I'm not just saying that because I was born and raised near Bowman Field (Highgate Springs) in Louisville.

NiceDMEDude wrote:Hello all,

Haven't posted in some time (I lurk, but only post if I feel I can add to a discussion).

Quite a bit of confusion abounds regarding the SPA and competitive bidding in general. I submitted a bid for the Louisville CBA. I only bid in the PAP and oxygen categories, as these are the only segments of DME which I provide.

As of this writing, I am unaware of any local DME/HME who received an email stating they submitted a winning bid. Likely, many companies who do not have a physical presence in the area submitted winning bids.

I am certainly not looking to come on this board and spout off or berate anyone for their beliefs or opinions. I can simply state my views and the stance of my company.

As was pointed out by several contributors to this thread, it will not be possible to provide the DS560HS (our standard unit which every patient receives), or DS760HS (our standard machine for BiLevel) at the SPA reimbursement level.

To be honest, I do not care. I am so worn out from fighting insurance companies, constantly attempting to please everyone from clients to physicians, beating up my manufacturer reps for ever-lower pricing, etc. that I am giving up. Should I receive a bid, I will decline to participate. I will not compromise the ability to provide quality service to simply maintain a losing business model. With 7 of my 12 employees being credentialed respiratory therapists (2 of whom use PAP themselves), these reimbursement amounts are unrealistic. We offer a very high level of service, as we specialize only in sleep-related equipment. Again, this is my stance; other providers may find a way to make it feasible.

However, I am the single largest customer for each of my reps from the big three. My prices from PR, F&P, and ResMed are as good as it gets. If I can't do it, I do not believe that my local competitors will either.

Fortunately for me, I also maintain a thriving website. The website has been my focus for the last couple of years, and going forward I will shift even more resources to the online business model.

Many of you on here are customers of mine, and I sincerely appreciate your business (even if you have no clue who I am).

HME is a dying business, and will soon be unrecognizable. Likely it will be some combination of scenarios already discussed in this thread. Mail order, online, local pharmacy, direct from manufacturer, I don't know.

Apologies for the rambling, but when I saw Karen's post I felt compelled to read the thread and respond.

Best to all of you in your treatment, and thanks for being educated on the healthcare system and your therapy.

Goofproof · Post by **Goofproof** » Mon Feb 04, 2013 12:55 pm

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

I my house thats called "Checks & Balances". Jim

vic · Post by **vic** » Thu Mar 07, 2013 9:36 am

While in my local dme picking up a replacement cpap for my Father, I overheard the owner talking to a cpap sales’ rep about Medicare. She explained the results of a review they conducted prior to submitting a bid in Round 2. The intent was to bid in actual cost of providing care, service – equipment and mask supplies to cpap/bibab patients. I asked if I could listen to the review and was granted an OK.

Their review looked at MEDICARE PTS & PATIENT HAD TO BE OVER 65. The Equipment used had a smart card & modem that could monitor ahi – hours of use and leaks (plus some other stuff). Included in the review was driving time to and from pts home, paperwork such as Doctor notes, reports etc.. In addition, back out to pts home addressing problems, re-teaching and replacing masks as needed. I asked if I could post the results here and was given permission. Oh, she did mention that there were patient that would not pay for their deductible ($160.00) +/or copays.

I’m to acknowledge the results are anecdotal and further study in cost analysis is required.

The patients were reviewed two times weekly at a minimum via modem. Problems addressed within 24 hours.
Patient total 100. Providing proper and needed services, 28% of this patient population were compliant (using Medicare guidelines) within the first three (3) months. Time in total addressing these patients was 58% of the companies resources compared private ins and self-pay patients who over the same period were 80% compliant using 30% of the resources.

I’m not an accountant or business manager. To me it looks like a great deal of work addressing these patients.
The bid they submitted was based on the above with a slight profit. They bid above the accepted bid from round 1. Services were provided by an experienced Registered Respiratory Therapist. Plus, no reimbursement for labor. They didn’t come close to winning the contract.

ChicagoGranny · Post by **ChicagoGranny** » Thu Mar 07, 2013 12:21 pm

vic wrote: Providing proper and needed services, 28% of this patient population were compliant (using Medicare guidelines) within the first three (3) months. Time in total addressing these patients was 58% of the companies resources compared private ins and self-pay patients who over the same period were 80% compliant using 30% of the resources.

Let me see if I understand the results part.

- Patients using private insurance or self-pay were 80% compliant and only used 30% of the resources.

- Patients being paid for by the guv'mint were a mere 28% compliant and soaked up 58% of the resources.

Is there an obvious general truism?

Privatize medical care.

BlackSpinner · Post by **BlackSpinner** » Thu Mar 07, 2013 12:45 pm

ChicagoGranny wrote:
vic wrote: Providing proper and needed services, 28% of this patient population were compliant (using Medicare guidelines) within the first three (3) months. Time in total addressing these patients was 58% of the companies resources compared private ins and self-pay patients who over the same period were 80% compliant using 30% of the resources.

Let me see if I understand the results part.

- Patients using private insurance or self-pay were 80% compliant and only used 30% of the resources.

- Patients being paid for by the guv'mint were a mere 28% compliant and soaked up 58% of the resources.

Is there an obvious general truism?

Privatize medical care.

But you are comparing seniors who have other issues with younger people - lousy comparison. Obviously marketing to people who are required to use cpap in order to stay employed is going to be different from marketing to people who have comprehension difficulties and feel ok about sleeping most of the day.

StuUnderPressure · Post by **StuUnderPressure** » Thu Mar 07, 2013 3:49 pm

I have only been on Medicare since 4th Qtr 2012

EVERY claim submitted to Medicare thus far has been paid by Medicare at a rate LARGER than what my previous BC/BS private group plan ever paid.

vic · Post by **vic** » Thu Mar 07, 2013 8:44 pm

ChicagoGranny wrote:
vic wrote: Providing proper and needed services, 28% of this patient population were compliant (using Medicare guidelines) within the first three (3) months. Time in total addressing these patients was 58% of the companies resources compared private ins and self-pay patients who over the same period were 80% compliant using 30% of the resources.

Let me see if I understand the results part.

- Patients using private insurance or self-pay were 80% compliant and only used 30% of the resources.

- Patients being paid for by the guv'mint were a mere 28% compliant and soaked up 58% of the resources.

Is there an obvious general truism?

Privatize medical care.

Somewhat correct. The main point is the patient group - Medicare- over the age of 65 Private and PPO group were all under 65.

vic · Post by **vic** » Thu Mar 07, 2013 9:17 pm

BlackSpinner wrote:
ChicagoGranny wrote:
vic wrote: Providing proper and needed services, 28% of this patient population were compliant (using Medicare guidelines) within the first three (3) months. Time in total addressing these patients was 58% of the companies resources compared private ins and self-pay patients who over the same period were 80% compliant using 30% of the resources.

Let me see if I understand the results part.

- Patients using private insurance or self-pay were 80% compliant and only used 30% of the resources.

- Patients being paid for by the guv'mint were a mere 28% compliant and soaked up 58% of the resources.

Is there an obvious general truism?

Privatize medical care.
But you are comparing seniors who have other issues with younger people - lousy comparison. Obviously marketing to people who are required to use cpap in order to stay employed is going to be different from marketing to people who have comprehension difficulties and feel ok about sleeping most of the day.

jnk wrote:Fantastic post. Thanks. I mean it.

And I'm not just saying that because I was born and raised near Bowman Field (Highgate Springs) in Louisville.

NiceDMEDude wrote:Hello all,

Haven't posted in some time (I lurk, but only post if I feel I can add to a discussion).

Quite a bit of confusion abounds regarding the SPA and competitive bidding in general. I submitted a bid for the Louisville CBA. I only bid in the PAP and oxygen categories, as these are the only segments of DME which I provide.

As of this writing, I am unaware of any local DME/HME who received an email stating they submitted a winning bid. Likely, many companies who do not have a physical presence in the area submitted winning bids.

I am certainly not looking to come on this board and spout off or berate anyone for their beliefs or opinions. I can simply state my views and the stance of my company.

As was pointed out by several contributors to this thread, it will not be possible to provide the DS560HS (our standard unit which every patient receives), or DS760HS (our standard machine for BiLevel) at the SPA reimbursement level.

To be honest, I do not care. I am so worn out from fighting insurance companies, constantly attempting to please everyone from clients to physicians, beating up my manufacturer reps for ever-lower pricing, etc. that I am giving up. Should I receive a bid, I will decline to participate. I will not compromise the ability to provide quality service to simply maintain a losing business model. With 7 of my 12 employees being credentialed respiratory therapists (2 of whom use PAP themselves), these reimbursement amounts are unrealistic. We offer a very high level of service, as we specialize only in sleep-related equipment. Again, this is my stance; other providers may find a way to make it feasible.

However, I am the single largest customer for each of my reps from the big three. My prices from PR, F&P, and ResMed are as good as it gets. If I can't do it, I do not believe that my local competitors will either.

Fortunately for me, I also maintain a thriving website. The website has been my focus for the last couple of years, and going forward I will shift even more resources to the online business model.

Many of you on here are customers of mine, and I sincerely appreciate your business (even if you have no clue who I am).

HME is a dying business, and will soon be unrecognizable. Likely it will be some combination of scenarios already discussed in this thread. Mail order, online, local pharmacy, direct from manufacturer, I don't know.

Apologies for the rambling, but when I saw Karen's post I felt compelled to read the thread and respond.

Best to all of you in your treatment, and thanks for being educated on the healthcare system and your therapy.

StuUnderPressure wrote:I have only been on Medicare since 4th Qtr 2012

EVERY claim submitted to Medicare thus far has been paid by Medicare at a rate LARGER than what my previous BC/BS private group plan ever paid.

The company reviewed How much it cost them to provide and manage care to the over 65 population. If every thing was free the results should be the same. THIS WAS AN INHOUSE REVIEW FOR COSTING PURPOSES . If the reimbursement is $55 and the cost is $60 …Oh well. Can’t run an airline that way.
Now……this is one company doing things their way. Equipment will be supplied by the winning bidders. They will provide equipment and service their way. Will they supply good quality equip, monitor via modem (monthly fee is $7 or $8 dollars……Can't be done. The 100 patients were all new patients

vic · Post by **vic** » Fri Mar 08, 2013 9:07 am

jnk wrote:Fantastic post. Thanks. I mean it.

And I'm not just saying that because I was born and raised near Bowman Field (Highgate Springs) in Louisville.

NiceDMEDude wrote:Hello all,

Haven't posted in some time (I lurk, but only post if I feel I can add to a discussion).

Quite a bit of confusion abounds regarding the SPA and competitive bidding in general. I submitted a bid for the Louisville CBA. I only bid in the PAP and oxygen categories, as these are the only segments of DME which I provide.

As of this writing, I am unaware of any local DME/HME who received an email stating they submitted a winning bid. Likely, many companies who do not have a physical presence in the area submitted winning bids.

I am certainly not looking to come on this board and spout off or berate anyone for their beliefs or opinions. I can simply state my views and the stance of my company.

As was pointed out by several contributors to this thread, it will not be possible to provide the DS560HS (our standard unit which every patient receives), or DS760HS (our standard machine for BiLevel) at the SPA reimbursement level.

To be honest, I do not care. I am so worn out from fighting insurance companies, constantly attempting to please everyone from clients to physicians, beating up my manufacturer reps for ever-lower pricing, etc. that I am giving up. Should I receive a bid, I will decline to participate. I will not compromise the ability to provide quality service to simply maintain a losing business model. With 7 of my 12 employees being credentialed respiratory therapists (2 of whom use PAP themselves), these reimbursement amounts are unrealistic. We offer a very high level of service, as we specialize only in sleep-related equipment. Again, this is my stance; other providers may find a way to make it feasible.

However, I am the single largest customer for each of my reps from the big three. My prices from PR, F&P, and ResMed are as good as it gets. If I can't do it, I do not believe that my local competitors will either.

Fortunately for me, I also maintain a thriving website. The website has been my focus for the last couple of years, and going forward I will shift even more resources to the online business model.

Many of you on here are customers of mine, and I sincerely appreciate your business (even if you have no clue who I am).

HME is a dying business, and will soon be unrecognizable. Likely it will be some combination of scenarios already discussed in this thread. Mail order, online, local pharmacy, direct from manufacturer, I don't know.

Apologies for the rambling, but when I saw Karen's post I felt compelled to read the thread and respond.

Best to all of you in your treatment, and thanks for being educated on the healthcare system and your therapy.

You sound like the DME that I was talking to the other day. I find this entire bidding process has so many faults. Sounds like you also will not be able to provide services based on the amount of time you "give away". I just don't understand why Medicare does not cover some of the Staffs time (labor).............Good luck going forward. Thanks for the time of your staff.

Wait, here is another beauty with this bidding concept in Round 2……..If you are a company located in Philadelphia, a PA business license is required. Logical! However, that PA business also is required to have a business license in the State of Maryland & Delaware in order to submit a bid. That is an easy 100 miles between the states. Why in the world is this requirement. Who comes up with this stuff ?
I can feel the pain of my DME and the post from NiceDmeDude (above).

BlackSpinner · Post by **BlackSpinner** » Fri Mar 08, 2013 11:05 am

vic wrote:
You sound like the DME that I was talking to the other day. I find this entire bidding process has so many faults. Sounds like you also will not be able to provide services based on the amount of time you "give away". I just don't understand why Medicare does not cover some of the Staffs time (labor).............Good luck going forward. Thanks for the time of your staff.

There are good things and bad things about government bidding rules. I once had my daughter in a daycare that was associated with a hospital. When the current contract was up for renewal it was put up for bidding. The low ball automatically got it. My daycare went from a pleasant well run place with excellent food to become a kid warehouse serving kraft dinner and fries. I and many others pulled our kids out. The people at the hospital were not so lucky because it was the only place where you could get after hours or shift work care.

vic · Post by **vic** » Thu Mar 14, 2013 7:02 am

BlackSpinner wrote:
vic wrote:
You sound like the DME that I was talking to the other day. I find this entire bidding process has so many faults. Sounds like you also will not be able to provide services based on the amount of time you "give away". I just don't understand why Medicare does not cover some of the Staffs time (labor).............Good luck going forward. Thanks for the time of your staff.
There are good things and bad things about government bidding rules. I once had my daughter in a daycare that was associated with a hospital. When the current contract was up for renewal it was put up for bidding. The low ball automatically got it. My daycare went from a pleasant well run place with excellent food to become a kid warehouse serving kraft dinner and fries. I and many others pulled our kids out. The people at the hospital were not so lucky because it was the only place where you could get after hours or shift work care.

Nice example - Thanks for sharing.

vic · Post by **vic** » Thu Mar 14, 2013 7:31 am

DreamStalker wrote:
BlackSpinner wrote:
hyperlexis wrote:
Because face it. These people bitching on here are simply worried (most likely totally unwarrantedly) that Medicare is finally going to crack down on overutilization and they are no longer going to have the US taxpayers pony up for the fancier machines they have been currently getting from Medicare -- and are instead in coming years going to be eventually re-supplied only with cheaper, base model 'bricks.' -- And/or that they will then personally have to cough up the difference in price for the cadillac machines with heated tubes and fancy color displays.
And if someone wants a cadillac machine let him pay the difference or prove that a more expensive machine is absolutely needed for proper treatment to get a waiver.
Cadillac? At cost there is probably $25 -$50 difference between a data capable cpap machine and one that is a brick. That is like saying windshield wipers and rear view mirrors make a car a Cadillac.

More like going to the DME and they give you crutches but axillary pads and hand grips cost extra -- and woe the patient who asks for adjustable center posts, patients are just not competent enough to make their own adjustments. Why they might adjust it too low, fall down, and break their noggin wide open, with all their stuff falling out and messing up the floor.

One of the ways Medicare & Medicaid could save money is have the patients pay out of pocket for small axillary products like pads and hand grips, say........items costing less than $50. This would save a ton of money.

squid13 · Post by **squid13** » Thu Mar 14, 2013 7:48 am

vic wrote:One of the ways Medicare & Medicaid could save money is have the patients pay out of pocket for small axillary products like pads and hand grips, say........items costing less than $50. This would save a ton of money.

There are people that are on Medicare that couldn't even afford to do that,some just barely scrap by and with out things they really need cause they can't afford it.

DreamStalker · Post by **DreamStalker** » Thu Mar 14, 2013 8:32 am

vic wrote:
DreamStalker wrote:
BlackSpinner wrote:
hyperlexis wrote:
Because face it. These people bitching on here are simply worried (most likely totally unwarrantedly) that Medicare is finally going to crack down on overutilization and they are no longer going to have the US taxpayers pony up for the fancier machines they have been currently getting from Medicare -- and are instead in coming years going to be eventually re-supplied only with cheaper, base model 'bricks.' -- And/or that they will then personally have to cough up the difference in price for the cadillac machines with heated tubes and fancy color displays.
And if someone wants a cadillac machine let him pay the difference or prove that a more expensive machine is absolutely needed for proper treatment to get a waiver.
Cadillac? At cost there is probably $25 -$50 difference between a data capable cpap machine and one that is a brick. That is like saying windshield wipers and rear view mirrors make a car a Cadillac.

More like going to the DME and they give you crutches but axillary pads and hand grips cost extra -- and woe the patient who asks for adjustable center posts, patients are just not competent enough to make their own adjustments. Why they might adjust it too low, fall down, and break their noggin wide open, with all their stuff falling out and messing up the floor.
One of the ways Medicare & Medicaid could save money is have the patients pay out of pocket for small axillary products like pads and hand grips, say........items costing less than $50. This would save a ton of money.

They'ed be better off cutting an old broom to size and wrapping the broom bristles with old towels and duct tape.

Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs

Re: Medicare CPAP reimbursement cut 47% for DMEs