Medicare, DME, and replacement Bi_level machine

[purple22]

I sorta asked about this before. I am further along in the process now, and wondered if anyone would like to suggest any way to speed up the process, or insure I get new machine.

I have finished five years on my current Resmed auto VPAP S9. I think it was not working quite right at least two years ago. It now has over 19,000 hours, and yes it makes a bit of noise. I am aware that Medicare says the current machine has to fail before it can be replaced. I see notes that sometimes machines are replaced because of the hours being over (14,000), and I am well over that, or the machine makes noise, keeping the patient awake.

Doc said it was easy for him, he just needed to write a prescription for the new machine. It is not which machine I should get that I am concerned with. The doc already wrote for the replacement. It is the Medicare Rules of Replacement, and also my DME has a special board to approve the need for a Bi-Level machine. No doubt, the DME will not approve my getting a new machine unless Medicare agrees to pay for it. (I am guessing Medicare will make an approval for the new machine before the DME will agree to provide it. I dunno?)

IF my current DME does not provide machine, I will start looking for a new DME. My current DME has been very generous, and good natured in the past. Lincare is widely dissed here on the forum, but my local office has been great to me.

As I have put up with a machine that obviously was not quite up to snuff (In My Opinion) for two years, I have anxiety. Anyone have any insight?

[LSAT]

Here are the rules..(Current..I think)
https://www.cms.gov/Outreach-and-Educat ... 905064.pdf

[palerider]

my DME has a special board to approve the need for a Bi-Level machine.

DMEs have no say in the matter, Doctors approve it, insurance(Medicare) agrees to pay for it, DMEs don't get to "approve" squat.

Unless I'm VERY wrong about everything I've ever heard.

[Pugsy]

DMEs don't get to dictate medical care or equipment. Their job is to dispense what the doctor orders and not question what the doctor orders.

[palerider]

DMEs don't get to dictate medical care or equipment. Their job is to dispense what the doctor orders and not question what the doctor orders.

However, they HAVE been known to lie... frequently.

[LSAT]

DME works like a pharmacy...They must fill the Doctor's prescription as written.

[klm49]

I sorta asked about this before. I am further along in the process now, and wondered if anyone would like to suggest any way to speed up the process, or insure I get new machine.

I have finished five years on my current Resmed auto VPAP S9. I think it was not working quite right at least two years ago. It now has over 19,000 hours, and yes it makes a bit of noise. I am aware that Medicare says the current machine has to fail before it can be replaced. I see notes that sometimes machines are replaced because of the hours being over (14,000), and I am well over that, or the machine makes noise, keeping the patient awake.

Doc said it was easy for him, he just needed to write a prescription for the new machine. It is not which machine I should get that I am concerned with. The doc already wrote for the replacement. It is the Medicare Rules of Replacement, and also my DME has a special board to approve the need for a Bi-Level machine. No doubt, the DME will not approve my getting a new machine unless Medicare agrees to pay for it. (I am guessing Medicare will make an approval for the new machine before the DME will agree to provide it. I dunno?)

IF my current DME does not provide machine, I will start looking for a new DME. My current DME has been very generous, and good natured in the past. Lincare is widely dissed here on the forum, but my local office has been great to me.

As I have put up with a machine that obviously was not quite up to snuff (In My Opinion) for two years, I have anxiety. Anyone have any insight?

As long as the Doctor is following Medicare rules and the DME submits the order to Medicare and it is approved the DME has no input in the matter.

[purple22]

I am sure Pugsy and Pale Rider are correct in what the rules that I read about say. My doc was explicit," I don't worry about Medicare rules. I will just write the prescription," (leaving the DME to fight the battle as to whether I qualify under Medicare rules.) My doc would have easily have written the script if I was buying the machine. Proof of failure of previous machine, or need because of the hours of use is not something he worries about. or is going to write a justification for.Sleep Doc had did say on the subject is that his front office had the current list of available DME's in my area, just ask for it.

My DME has to consider whether they will provide the machine, or perhaps let me migrate to another DME. I made none of the deductibles or Co-Pays on anything I get from Lincare in the past five years. Yes, that includes a Bi_Level machine. It is possible they actually lost money on my account. Likewise I would expect to not make any of the deductibles or Co-Pays on my next machine, if I get it from Lincare or somewhere else.

The DME said they had a specific division to approve whether they would agree to provide a Bi_Level machine to me. I suspect that group is more for those who are applying for a Bi-Level machine for the first time. That is, the DME will not apply to Medicare for payment for a Bi-Level machine for those who clearly would not qualify. Or should I say, there job is to make sure the paperwork has all the correct parts checked so that Medicare will pay them.

There may be group who represents the financial interest of the DME assuming the risk of those who do not pay, and those they realize that they are going to write off the Co-Payments. The expected rule of a group like that is for them to act like an insurance company; "Deny All Claims." The DME has not behaved that way in the past. My local office is concerned with helping me with my Sleep Apnea problems. Money things they do not know, and seem to care less about than I do.

I guess what I was looking for was someone to say, this is rule that applied in my case of getting a Bi-Level machine with Medicare, and this is how the thing played out.

[Pugsy]

I remember your issues and why you went to bilevel.
Those reasons are sufficient for Medicare to approve a bilevel per Medicare's requirements.
All the doctor has to say is "unable to tolerate cpap because of aerophagia issues"...that's all that Medicare would need.
This DME saying they get to decide...bull shit. They don't get to decide medical care...that's not their job.
If they give you grief or a hard time..tell them where to go and get another DME that works with Medicare.

[purple22]

Medicare might say; "We don't have proof your current machine is broken. 19,000 hours and being over five years is not enough to have your machine replaced. If I think that the machine is not working well. Then take it to DME, who will send it to manufacturer for several weeks, and charge me a lot of money to decide if it works properly."

As I am sure most of you know, the current standard of proof at the DME office is to put a Manometer on the machine output, it the airflow is the same as what is dialed in. The machine works. I believe that the changes in the rate of airflow might not be correct. Be my luck if I paid all the money to have it sent to manufacturer, they do the same simple test the DME does. I don't think I want to do without a machine for weeks, then spend all that money for a manufacturer test. I don't have that money anyway.

This is about a Replacement, not the first machine, a whole different kettle of fish under the current regime of government savings for health care. The DME I had when I first applied for a bi-level machine (who sent me to Lincare) said Medicare refused to cover the first bi-level machine. I realized later it was (likely) because they were using the standard code of a CPAP, not the Bi-Level. Paperwork is everything to Medicare.

Unlike a lot of you, I have less fear of how well my DME is inclined to treat me, and my needs, than Medicare. I suspect, If it was up to my local DME, I would already have the machine on my bedside stand. Now the part of their company who does the money part, (I think they are in Florida), They might have a different opinion.

Enough hypothesis. I will let you know how it plays out.

[Okie bipap]

The OP did not state is this is a straight Medicare purchase, or if it is through a Medicare Advantage plan. If it is a Medicare advantage plan, then all bets are off. The "special board" that reviews bilevel purchases may actually be the insurance company making the decision.

[SewTired]

Well, it's something new. Lincare was my brother's provider when he got his second bipap machine. There was no approval group at the time, but in addition, we weren't stuck with the bid process either at that time. I would just say wait it out. Lincare goes by the policy of 15,000 hours as 'worn out' but if it is making noise, it is also in the process of failing.

FWIW, Medicare will not repair a machine more than 5 years old. So the fact that it is making noise should be sufficient to allow a replacement. What the approval group probably has to determine is if all the i's are dotted and t's crossed so they get paid before shipping the bipap.