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IS THIS REPORTABLE FRAUD?
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srlevine1 Offline

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Posts: 229
Joined: Sep 2015

Machine: ResMed Airsense Autoset (S10)
Mask Type: Nasal mask
Mask Make & Model: ResMed Mirage Activa LT
Humidifier: Internal to S10
CPAP Pressure: 12-15.6
CPAP Software: ResScan SleepyHead Other Software

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Sex: Male
Location: Westlake Village, California USA

Post: #1
Angry IS THIS REPORTABLE FRAUD?
I just received my Medicare Summary of Benefits and noted that my DME billed the ResMed Autoset at $874.72 and then billed an additional $835 for the Humidifier which is built-in to the AirSense Autoset unlike previous S9 and S8 units. I was wondering if I should point this out to Medicare or let it ride? I value the community's opinion on this. Thanks.

"The object in life is not to be on the side of the majority, but to escape finding oneself in the ranks of the insane." -- Marcus Aurelius
08-22-2016 10:40 PM
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icyura10 Offline

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Machine: RESMED AirCurve 10 VAUTO
Mask Type: Nasal pillows
Mask Make & Model: Phillips Respironiscs DreamWear under the nose nasal ma
Humidifier: INCLUDED
CPAP Pressure: IPAP (20); EPAP (12); PS (8)
CPAP Software: ResScan SleepyHead

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Post: #2
RE: IS THIS REPORTABLE FRAUD?
(08-22-2016 10:40 PM)srlevine1 Wrote:  I was wondering if I should point this out to Medicare or let it ride? I value the community's opinion on this. Thanks.

I might consider calling the DME as a potential new patient telling them you have an Rx for a ?PAP, suggesting you will be paying cash for the device and ask for a price on the device.

Then depending upon the response, make the decision about the appropriate response to Medicare might be.

But then again, I tend to think most places should be given enough rope to successfully hang themselves...

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08-22-2016 11:22 PM
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justMongo Offline

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Machine: ResMed VPAP Auto (S9)
Mask Type: Full face mask
Mask Make & Model: ResMed Mirage Quattro
Humidifier: ResMed H5i
CPAP Pressure: 18 IPAPmax - 11 EPAPmin, PS=5
CPAP Software: Other Software

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Sex: Male
Location: Калифорния

Post: #3
RE: IS THIS REPORTABLE FRAUD?
We've seen this before with the 10 series ResMed Machines.
The DME's customarily bill for the blower unit and the humidifier as separate entities.

However, I've not heard of it being so evenly split.
I would at least compare the billing codes against the Medicare chart for CPAP equipment.
I believe the blower unit code is E0601; and the heated humidifier is E0562.

That's what they billed -- how much will Medicare allow?
I think they'll take a hit on the humidifier. Plus, Isn't it carved out as a 13 month rental?

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.
08-22-2016 11:29 PM
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FrankNichols Offline

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Machine: AirSense 10 Autoset
Mask Type: Full face mask
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Humidifier: Builtin
CPAP Pressure: 17-19
CPAP Software: ResScan SleepyHead Other Software

Other Comments: I've figured out how to get my AHI down to 5, I quit sleeping!

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Location: Live Oak, Florida

Post: #4
RE: IS THIS REPORTABLE FRAUD?
Billing is almost never what is paid for something in the medical industry. If you have the time and are interested I would follow justMongo's advice. But, I would. contact CMS (Center for Medicare Services) and not Medicare itself, since Medicare already knows what it paid. It is CMS's (http://www.cms.gov) job to hold down costs, part of which is fraud prevention.

I am not a Medical professional and I don't play one on the internet.
Started CPAP Therapy April 5, 2016
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08-23-2016 07:26 AM
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PoolQ Online

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Machine: AirCurve 10 VAUTO
Mask Type: Full face mask
Mask Make & Model: Amara View
Humidifier: Integrated
CPAP Pressure: 6.2, 15, PS4.0
CPAP Software: SleepyHead

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Sex: Male
Location: Sillicon Valley

Post: #5
RE: IS THIS REPORTABLE FRAUD?
It's more of a billing code issue then fraud. each part has a separate billing code and Resmed has a single unit. Medicare and insurance has fixed pricing for both, if they did not separate it out they would get a fraction of the cost. Medicare and insurance knows what is going on, it's the only way it can be done-and no they don't get paid for what is billed no matter how much it is.
08-23-2016 11:52 AM
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DariaVader Offline
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Machine: Resmed S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: Airfit P10 for Her
Humidifier: H5i humidifier with ClimateLine heated hose
CPAP Pressure: 8-15
CPAP Software: SleepyHead

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Location: Oregon

Post: #6
RE: IS THIS REPORTABLE FRAUD?
basically, billing codes has not caught up to integrated units yet. The price of an A10 is comparable to S9+H5i. the only way they can currently bill the A10 and get compensation that covers the cost is to bill both codes. Probably this will change, but its the govt.... Everyone knows what is going on and has agreed to it. Ins/Govt/DME/Resmed else Resmed could not have put out an integrated unit - no one would resell it.

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
Tongue Suck Technique for prevention of mouth breathing:
  • Place your tongue behind your front teeth on the roof of your mouth
  • let your tongue fill the space between the upper molars
  • gently suck to form a light vacuum
Practising during the day can help you to keep it at night

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
08-23-2016 02:59 PM
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Mike1953 Offline

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Machine: Resmed S9 Escape Auto
Mask Type: Nasal pillows
Mask Make & Model: Resmed P10
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CPAP Pressure: 12
CPAP Software: ResScan SleepyHead

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Sex: Male
Location: Kansas USA

Post: #7
RE: IS THIS REPORTABLE FRAUD?
If you would look more closely you would see what the DME billed, what Medicare acceptable amount is, then what amount of that they paid. So no it is not Fraud.

For free Medicare assistance for your state check out this page. http://www.seniorsresourceguide.com/directories/National/SHIP/
or here http://www.medicareinteractive.org/
08-23-2016 04:17 PM
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srlevine1 Offline

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Posts: 229
Joined: Sep 2015

Machine: ResMed Airsense Autoset (S10)
Mask Type: Nasal mask
Mask Make & Model: ResMed Mirage Activa LT
Humidifier: Internal to S10
CPAP Pressure: 12-15.6
CPAP Software: ResScan SleepyHead Other Software

Other Comments:

Sex: Male
Location: Westlake Village, California USA

Post: #8
RE: IS THIS REPORTABLE FRAUD?
(08-23-2016 04:17 PM)Mike1953 Wrote:  If you would look more closely you would see what the DME billed, what Medicare acceptable amount is, then what amount of that they paid. So no it is not Fraud.

I was told to wait for the second EOB before calling to question the payments on the integrated humidifier.

FYI, here is the first billing which could be the first installment of the 13-month rental period.

BREATHING DEVICE (CPAP) (charged $874.72; approved $45.80; paid $36.64, secondary paid $9.16)

HUMIDIFIER FOR AIRWAY DEVICE (charged $835.00; approved $139.44; paid $111.55; secondary paid $27.89)

I will update this with the second EOB payment when it arrives.

"The object in life is not to be on the side of the majority, but to escape finding oneself in the ranks of the insane." -- Marcus Aurelius
08-23-2016 06:40 PM
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WSHenry Offline

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Machine: PR System One REMStar DS560S
Mask Type: Nasal pillows
Mask Make & Model: ResMed AirFit P10
Humidifier: PR System One + Heated Tube
CPAP Pressure: 6-15 cm H2O
CPAP Software: SleepyHead

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Sex: Male
Location: Washington State, USA

Post: #9
RE: IS THIS REPORTABLE FRAUD?
I agree with other posters who mentioned that the "billed" amount is not the amount actually paid by Medicare. The "billed" amounts seem to be fantasy-based. What is important are the contracted prices. My experience is that the contract pricing is much lower than the "billed" pricing.
(This post was last modified: 08-23-2016 06:46 PM by WSHenry.)
08-23-2016 06:45 PM
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justMongo Offline

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Machine: ResMed VPAP Auto (S9)
Mask Type: Full face mask
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CPAP Pressure: 18 IPAPmax - 11 EPAPmin, PS=5
CPAP Software: Other Software

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Location: Калифорния

Post: #10
RE: IS THIS REPORTABLE FRAUD?
Interesting that the humidifier would be approved for more than the blower unit.
It does sound like that will be what's paid per month for a 13 mo rental -- which is about $2500 over 13 months.

Didn't you mention that your DME lost it's medicare contract? Perhaps the machine is grandfathered in if you took possession prior to 01 July 2016.
I'm signed up with http://www.medicare.gov -- I usually can see my EOBs before they arrive in the mail.

Now to finish writing my letter to Sylvia Mathews Burwell to thank her for being a part of the death panels.

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.
08-23-2016 06:57 PM
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