Medicare rules

[Catnapper]

My doctor ordered a new bipap machine for me at my last visit. I have been using a bipap for over 11 years, most of that time being paid for by Medicare. For the new machine they want to see a sleep study that shows I failed cpap. When I got my bipap, all that the doctor needed to order it was the statement from my RT documenting my 7 month long struggle with cpap.

You would think that 11+ years of successful therapy would be sufficient. I hope my doctor can convince them to approve it.

Has anyone had this experience? I guess I will do the study if I have to do so, but it seems a waste of money after all this time. I did have a titration study for bipap after I got it. Apparently that does not count.

Catnapper - Joanie

[Pugsy]

Have you confirmed with Medicare that they require the new sleep study and it's not just the DME saying that Medicare requires it?
Medicare should have all your old records showing why you need bipap.

Sometimes DMEs make up their own rules and blame the insurance company when it is really their own in house rules.

[chunkyfrog]

Contact Medicare directly.
If the info is not coming directly from them, I would not trust it.

[Catnapper]

Thanks for the feedback. I forgot how the DME operates. The one I have tries to get out of supplying anything. They insist they haven't gotten new orders from the doctor, so I always get a copy to show them. Then they miraculously find the order in the computer.

I haven't heard from the doctor yet, just the DME. I still have hope he will resolve the issue. if not, I will definitely call Medicare to be sure.

Catnapper - Joanie

[Pugsy]

Is this the original same DME that you used for the first BiPap?

[Catnapper]

Not the same DME. I didn't have Medicare at that time. I did start Medicare about a year later and they paid for supplies with no problem. I had to replace the original bipap after 5 years and Medicare gave me no problems at that time. Then Medicare had the local DMEs bid for their contract. A different one got the bid, and boy did everything get bad. The winner bid really low and no other DME will accept that low price, so we only have one choice in the whole area. Their employees treat customers rudely and never stay very long with that company. It must be a terrible place to work because it is a terrible place to get supplies.

I loved the original DME. I still talk to them when I need something, and can buy stuff without any grief. I bought my son a new mask for Christmas and had to exchange it but no problems at all.

Catnapper - Joanie

[bombayone]

Thanks for the feedback. I forgot how the DME operates. The one I have tries to get out of supplying anything. They insist they haven't gotten new orders from the doctor, so I always get a copy to show them. Then they miraculously find the order in the computer.

I haven't heard from the doctor yet, just the DME. I still have hope he will resolve the issue. if not, I will definitely call Medicare to be sure.

Catnapper - Joanie

The DME not supplying does not make sense. The DME does not make any money unless they supply product. DME's usually oversell supplies.

[Pugsy]

Ahhh...makes more sense now. This DME doesn't have the records the first DME had about the cpap failure stuff.
They are proceeding like this was your first BiPap that Medicare has ever paid for...and part of the paperwork they have to send in to Medicare is documentations of the diagnostic sleep study and and the subsequent documentation of the cpap not working out well and the switch to the BiPap.
DMEs have to supply more than we think when getting Medicare approval and they have state that such detailed documentation is available at their facility in case of a Medicare audit. This new DME doesn't have the documentation that proves need for BiPap.
They need to get it and those records are available through the doctor.

They don't have available what the other DME had available. Your doctor should be able to provide the necessary documentation needed....and Medicare should have some of it already in their records.

Do talk to Medicare for sure to find out exactly what is needed...if anything.

[chunkyfrog]

--and file a complaint if appropriate . .

[ChicagoGranny]

The DME not supplying does not make sense. The DME does not make any money unless they supply product.

The management responsible for profits does not always know what the front line people are doing. The front line people are often poorly motivated.

[Catnapper]

Another call just now telling me they still have not heard from the doctor about the documentation. The person calling me does not speak English very well, and spends most of her time apologizing to me. She has some of my records, but not all. I asked how they could give me a bipap machine in 2012 with no problem but could not do so now. She said she does not have those records. I insisted on speaking to a supervisor. Of course, the supervisor was in a meeting. I continue to insist. A supervisor finally came on the line. She does not speak English very well either. I insisted that she explain to me how Medicare could give me a machine in 2012 with no problem but could not do so now. Finally she located some record that she believes will fix the problem. Someone will call me, she says. She cannot explain why she did not have that record 2 minutes ago.

I asked her to make a complaint for me. My current bipap stops in the middle of the night and won's restart until I push the start button. I explained that can seriously affect someone's health and therapy and perhaps life. You can imagine the rest of what I had to say. She promised to tell them.

She promised I will hear from someone soon.

Anyone want to bet?

Catnapper - Joanie

[chunkyfrog]

I'm not allowed to hold my breath . . .

[Catnapper]

Dear chunkyfrog, I would not want you to hold your breath that long anyway.

[Catnapper]

Another call. A perky young woman tells me that I cannot have a new machine because Medicare only allows a new machine every 5 years, and also that my 2006 sleep study did not document my need for bipap. She said I got my current machine in August 2013. I informed her that I got the machine in 2012. She had to check my records again. She agreed that I did get it in 2012. (Anyway it has been 5 years since August 2013. I can do that math.) She then said she had her math wrong. DUH!

So she cheerfully informed me now that I can have a machine and that Medicare has changed their rules since I had my first sleep study. She has informed my doctor to change his records and she believes he will make that change today. She made an appointment for me to come in so they can show me how to use the machine on Wednesday. It won't take long she says because this is my second machine. I informed her this will be my 6th machine.

I pointed out her complete reversal and asked for her explanation. She said she had just been going from memory. What?!

What a professional company. It remains to be seen if my doctor will change his records based on her telling him to do so.

Next week I expect another phone call.

Catnapper - Joanie

[palerider]

I just gotta wonder, catnapper, why you're buying from such bumbling incompetents