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Dealing with DME provider and Medicare?
#1
Hi Members,

Was diagnosed with severe obstructed sleep apnea while hospitalized with congestive heart failure last August. Hospital DME and O2 monitor kept me going. Physician prescribed BiPAP for home use as a condition for release. Did the sleep study within the first two months, physician evaluation report, and the BiPAP from the provider had a modem to verify my usage. Different from many in a patient would get a referral from a physician to go to a sleep lab, etc.

I have Medicare as my primary and also have a secondary insurer.

Five months after the first diagnosis and prescribed DME, Medicare denied payment to the provider for the DME as "not medically necessary". Oh-jeez

My opinion is that the \DME provider failed to gather available info from my secondary insurer and failed to submit required information requested by Medicare. I've appealed the Medicare decision and submitted as much documentation as this layman understands. My physicians are left wondering.

During the interim, my secondary coins policy is to pay 50% of the DME cost when Medicare denies the claim. Leaves me with a huge copayment to the provider that I feel is both improper and unnecessary.

A CPAP in lieu of BiPAP was delivered April 11. Titrations in January using both CPAP and BiPAP determined that I could tolerate the CPAP. My AHI to begin was 48 and night oxygen dropped to less than 70.

So, April 11, the provider delivered the DME referred by my secondary insurer, only 3 months after receiving the first of two prescriptions from my physician. The only reason the provider finally reacted was because I scheduled a pick up of the BiPAP to stop the rental charges. My secondary insurer supplied a loaner CPAP due to the continued proplem with the DME provider. The scheduled pick up was cancelled by the provider and later accomplished on April 11, when new DME was finally delivered.

The previous August 2012 delivery of the BiPAP DME as rental and purchase accessories resulted in a total charge of near $750. The latest delivery of different DME, but identical accersories, amounted to a charge of $3000. The difference is, for example, the Quatro full face mask was $178 or so last August. The same mask with the new delivery in April of 2013 is $980!

Because the billing dispute is ongoing with the provider, I feel that delivery of new DME was purposefully delayed for near 3 months. Also, due to the Medicare denial, I feel that provider purposefully inflated the new accessory costs in retribution. I'm informed that Medicare will pay for the replacement DME at 80%, as should have been accomplished in the first place. Still trying to understand what's different. Maybe the latest documentation submission will be properly. Not as happened following the original emergency hospital admittance?

A phone call from the provider's representative kind of said "I'm not used to a patient questioning my decisions." That's because the original correspondence informed me that the provider followed ALL procedures when submitting documentation to Medicare.

A recent call to Medicare resuted in asking me if I wanted to file a complaint about the provider. I informed Medicare that a complaint seemed appropriate. The Medicare rep suggested a 3 way phone conference with the provider. After 2 hours of being directed to mail boxes, the Medicare representative and I agreed that communication with the provider was impossible.

I'm now out of pocket for a week and know that Medicare sent a reply to my home address that I've yet to review. I'll get back to my residence next week. Ha, ha, I told the provider's rep that I wouldn't return to my residence until next week, yet I get a call daily to discuss the issue. Huhsign

Sure would like to know if my experience with a provider is normal and if it would be identical with other DME providers. Thinking-about

It goes without saying that the coins even with Medicare paying at 80% leaves my latest out of pocket paying almost as much for the S9, etc. purchased outright off the internet. The monthly rental for the ResMed S9 from the provider is $875 or there abouts. The past billing dispute now amounts to more than $1000 out of pocket.

Have I gone wrong in my thinking? Oh-jeez

As a new member, I'm hoping that I haven't stepped on any toes or violated any protocols. Just would like to know . . .

Joy
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#2
Holy crap. I think your DME is going to take a long vacation in Tahiti...

Suffice to say that buying the S9 machine up front would have been cheaper and you could have kept it to sell later, but I suppose that is split milk now.

Dodgy

Hope you can get the stuff strightened out.

"With ordinary talent and extraordinary perseverance, all things are attainable." - Thomas Foxwell Buxton

Cool
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#3
Hi Joy,
WELCOME! to the forum.!
I'm sorry you are having such a rough go with the DME, hope there is light at the end of the tunnel for you soon.
Hang in there for more responses to your post.
trish6hundred
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#4
(04-18-2013, 01:21 PM)Joy Hansen Wrote: Was diagnosed with severe obstructed sleep apnea while hospitalized with congestive heart failure last August. Hospital DME and O2 monitor kept me going. Physician prescribed BiPAP for home use as a condition for release. Did the sleep study within the first two months, physician evaluation report, and the BiPAP from the provider had a modem to verify my usage. Different from many in a patient would get a referral from a physician to go to a sleep lab, etc.
I have Medicare as my primary and also have a secondary insurer.
Five months after the first diagnosis and prescribed DME, Medicare denied payment to the provider for the DME as "not medically necessary".
My opinion is that the DME provider failed to gather available info from my secondary insurer and failed to submit required information requested by Medicare. I've appealed the Medicare decision and submitted as much documentation as this layman understands. My physicians are left wondering.
During the interim, my secondary coins policy is to pay 50% of the DME cost when Medicare denies the claim. Leaves me with a huge copayment to the provider that I feel is both improper and unnecessary.
A CPAP in lieu of BiPAP was delivered April 11. Titrations in January using both CPAP and BiPAP determined that I could tolerate the CPAP. My AHI to begin was 48 and night oxygen dropped to less than 70.
So, April 11, the provider delivered the DME referred by my secondary insurer, only 3 months after receiving the first of two prescriptions from my physician. The only reason the provider finally reacted was because I scheduled a pick up of the BiPAP to stop the rental charges. My secondary insurer supplied a loaner CPAP due to the continued proplem with the DME provider. The scheduled pick up was cancelled by the provider and later accomplished on April 11, when new DME was finally delivered.
The previous August 2012 delivery of the BiPAP DME as rental and purchase accessories resulted in a total charge of near $750. The latest delivery of different DME, but identical accesories, amounted to a charge of $3000. The difference is, for example, the Quattro full face mask was $178 or so last August. The same mask with the new delivery in April of 2013 is $980!
Because the billing dispute is ongoing with the provider, I feel that delivery of new DME was purposefully delayed for near 3 months. Also, due to the Medicare denial, I feel that provider purposefully inflated the new accessory costs in retribution. I'm informed that Medicare will pay for the replacement DME at 80%, as should have been accomplished in the first place. Still trying to understand what's different. Maybe the latest documentation submission will be properly. Not as happened following the original emergency hospital admittance?
A phone call from the provider's representative kind of said "I'm not used to a patient questioning my decisions." That's because the original correspondence informed me that the provider followed ALL procedures when submitting documentation to Medicare.
A recent call to Medicare resuted in asking me if I wanted to file a complaint about the provider. I informed Medicare that a complaint seemed appropriate. The Medicare rep suggested a 3 way phone conference with the provider. After 2 hours of being directed to mail boxes, the Medicare representative and I agreed that communication with the provider was impossible.
I'm now out of pocket for a week and know that Medicare sent a reply to my home address that I've yet to review. I'll get back to my residence next week. Ha, ha, I told the provider's rep that I wouldn't return to my residence until next week, yet I get a call daily to discuss the issue.
Sure would like to know if my experience with a provider is normal and if it would be identical with other DME providers.
It goes without saying that the coins even with Medicare paying at 80% leaves my latest out of pocket paying almost as much for the S9, etc. purchased outright off the internet. The monthly rental for the ResMed S9 from the provider is $875 or there abouts. The past billing dispute now amounts to more than $1000 out of pocket.
Have I gone wrong in my thinking?

Joy,

First, I am assuming you are in the US. (Other countries have "Medicare" insurance too.)

Apnea Board is replete with horror stories about DMEs similar to yours. On the other hand, I have an excellent DME, so they are not all the same. Once you get the present trouble under control, take your business elsewhere. Ask your doc for a copy of your prescription (they must give it to you) and then you can go wherever you want.

I also have Medicare, but no additional insurance. Other than nominal co-pays I haven't had to pay for anything yet. In my area Medicare contracts with Noridian (a private company) to handle billing irregularities and contact with the insured. On a couple of occasions I have called them and they were wonderful on the phone. I didn't have a case as complicated as yours, but I smell insurance fraud in your situation and I'm sure they would be interested in knowing about your DME and the billing.

And yes, something is definitely fishy. Most masks sell for $75 - $150 to the public, although the "insurance" price is somewhat higher. For sure $980 for a mask is not just outrageous, it is attempted fraud. Someone needs to stop these people. Blow the whistle loud. If necessary, call your congresscritters. I'm serious. The last thing a bureaucrat wants is a call from the office of a representative or senator.

Good luck, and post back with updates. Smile
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#5
Hi All,

I see some recent posts that might shed some light on my situation in dealing with this provider. Unfortunately, it seems that the provider is a sole source contracted to my secondary insurance. Learn a lot after the fact.

BTW, I am retired USDA . . .

Really anxious to get back to my home 20 to review the latest from Medicare. Not that I'll be pleased, just gotta know.

Seems like my desperation for a replacement CPAP clouded my judgement. Should have looked at the contract and refused the delivery to show my dissatisfaction with the inflated cost. If nothing is to change the billing, it's my nature to continue to be a pain in the ass of the DME provider!

More to come next week.

JH
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#6
Hummmm....
Yanno sometimes the insurance provider is in bed with the medical hardware supplier....
at such times the end user suffers a good deal!
(as you are seeing)

You strategy is good though. The squeeky wheel gets the grease! Wink

At the next opportunity I would go shop for a better insurance provider though....
just my 2 cents.

Good luck with those corporate scum!

Big Grin
"With ordinary talent and extraordinary perseverance, all things are attainable." - Thomas Foxwell Buxton

Cool
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#7
Hi All,

Still trying to get to the bottom of provider/Medicare/secondary ins and it's a slow and uninformed process.

Learned that both the secondary and provider say that I was told at the hospital that I didn't qualify for Medicare coverage. Meaning that my secondary left me with 50% coins.

Seems like there should be some vehicle in dealing with Medicare requirements when the preliminary studies can't be met until after the delivery of the DME. Although I appealed to both the secondary insurer and Medicare, I'm told that Medicare NEVER amends the first denial regardless of the situation. e.g. The requirements were met after delivery of the DME, such as, the sleep study, the face to face with the prescribing doctor, the prescription/diagnosis, and use of greater than 4 hours nightly for 70% of days. The sleep study indicated an AHI of 48 and an oxygen of less than 60.

Got 15 pages of gobble-de-gook brochure that seems to indicate that I met the criteria for coverage. But, not done in typical order.

Anyone know if I'm interpreting Medicare properly?

Joy
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#8
[quote='Joy Hansen' pid='35604' dateline='1367425442']
Hi All,

Still trying to get to the bottom of provider/Medicare/secondary ins and it's a slow and uninformed process.

Learned that both the secondary and provider say that I was told at the hospital that I didn't qualify for Medicare coverage. Meaning that my secondary left me with 50% coins. . . . quote]

Hi All,

A miracle happened! I checked to see if the sky was falling; however, my secondary insurance and the DME provider are in consultation concerning resubmission of the billings. I'm hoping that this involves Medicare. Yep, sometimes a squeeking wheel gets noticed.

Joy

.
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#9
There you go, Joy.
Good luck with that!

Smile
"With ordinary talent and extraordinary perseverance, all things are attainable." - Thomas Foxwell Buxton

Cool
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#10
Best of luck to you. Hopefully, things will be worked out soon.

Like you said in an earlier post, sometimes the squeaky wheel DOES get the grease.

Sleep-well
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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