(Hi there) And did my med supplier commit fraud with my Ins?

Guest · Post by **Guest** » Mon Sep 24, 2007 1:14 pm

DME_Guy wrote:What a DME get reimbursed is based on HCPC code E0601. All CPAPs fall within this code. According to the government, there isn't a medical need for CPAPs that provide compliance data, efficacy data, or auto-titrating. I haven't seen a study that says these more expensive CPAPs work better than a basic CPAP. They usually say "works as well" as a regular CPAP.

This is important because most if not all insurance companies follow Medicare guidelines. When they negotiate reimbursement for a CPAP, they negotiate based on code E0601. If a DME bids a price that is based on the most expensive CPAPs, they will lose the bid. One major insurance company reimburses about $430 for a CPAP. Even with a basic CPAP, it's tough to make a profit.

It's interesting that many of you blame only the DMEs. Why do the manufactures charge so much extra for the higher end machines? I really doubt they cost twice as much to manufacture. Why don't the insurance companies pay a higher reimbursement for the high-end machines? Don't they think you're worth it?

Please don't take this as I'm sticking up for DMEs. I know there are a lot of bad ones out there. DMEs are a part of a bad health care system. IMO, patients should be financially motivated to shop around for the best price/service. For items such as CPAPs, the insurance companies should just pay their money to the patients in the form of a "spending" account and let the consumer demand a great product and service for THEIR money. Competition and consumer choice is a beautiful thing.

Not trying to pick a fight, but just want to make a few points.

"According to the government....." Yeah....that means alot. What if somebody could PROVE that having PAP machines with data capabilities and the software would help people become more compliant? When you take into consideration who pays for the "studies", it's not hard to control the outcomes. Patients' needs change, they get mis-titrated and a whole host of other situations arise that would be beneficial for them to have better machines for self-monitoring.

"It's interesting that many of you blame only the DMEs." Not true. The insurance industry, the government (CMS/Medicare) and the manufacturers are also on "the list".

"I know there are a lot of bad ones out there. DMEs are a part of a bad health care system." Yep. We see that every day on the forums. And, you can also throw in the doctors.

My thoughts:
All you have to do is..... "Follow the money."
Everybody's out to make a profit on our misfortune.....and the whole healthcare business stinks to high heaven.

"For items such as CPAPs, the insurance companies should just pay their money to the patients in the form of a "spending" account and let the consumer demand a great product and service for THEIR money. Competition and consumer choice is a beautiful thing." ABSOLUTELY!!!

Den

mindy · Post by **mindy** » Mon Sep 24, 2007 1:24 pm

Wulfman,

I'm curious about how many people who have had bad experiences have had a serious conversation with their sleep doc/DME etc. about it. Do people generally have that awful a time? I'm hearing a good deal on this forum about problems and yes, I have had my share of them over the years.

I do think that compliance is greatly improved with knowledge and it's so important for all of us to communicate that, especially to the sleep docs (those who are willing to listen). If we don't at least attempt to tell them, they'll never get it.

Perhaps I'm a pollyanna but I personally know quite a number of docs who are not money-grubbing creatures. Same goes for other professions. That doesn't mean they should get a free pass, but I do think an attempt at civil discourse is warranted.

Mindy

Wulfman... · Post by **Wulfman...** » Mon Sep 24, 2007 1:54 pm

mindy wrote:Wulfman,

I'm curious about how many people who have had bad experiences have had a serious conversation with their sleep doc/DME etc. about it. Do people generally have that awful a time? I'm hearing a good deal on this forum about problems and yes, I have had my share of them over the years.

I do think that compliance is greatly improved with knowledge and it's so important for all of us to communicate that, especially to the sleep docs (those who are willing to listen). If we don't at least attempt to tell them, they'll never get it.

Perhaps I'm a pollyanna but I personally know quite a number of docs who are not money-grubbing creatures. Same goes for other professions. That doesn't mean they should get a free pass, but I do think an attempt at civil discourse is warranted.

Mindy

I really don't know, Mindy.
All I know is what I have seen on the forums for the last 2 1/2 years and from my own experience. Add to that, the "studies" that say that almost 50% of diagnosed apnea sufferers are "non-compliant" with their therapy (probably everything from "occasional user" to "it's parked in the closet" to "got rid of it").

In my own situation, my sleep doctor prescribed me a pressure of 18 cm and by using my REMstar Pro 2 and the software, was able to "prove" that I could do quite well on pressures of 10 - 12 cm. He didn't want to believe that I could be doing that well on almost half the pressure he prescribed and didn't believe the machines were at all accurate and we almost came to blows. I have only had about a total of three meetings with him.....have not seen him since June of '05 and NEVER want to see him again. Some of his other patients had warned me about his personality/demeanor/bedside manner and they were right.....only problem is that he's the ONLY one around this area.

Unfortunately, there are also a lot of people who don't want to get "into" their therapy or know anything other than they strap on a mask at night and go to sleep.....they don't have any idea how their therapy is working. Then, some of them can't figure out why their therapy quit working after a few months......and fortunately, some find their way to the forums to get help.
I wonder what the others do.....?

Den

mindy · Post by **mindy** » Mon Sep 24, 2007 1:56 pm

Wulfman,

Thanks for the very thoughtful answer!

Mindy

msheda · Post by **msheda** » Mon Sep 24, 2007 1:57 pm

[quote="Wulfman]I wonder what the others do.....?
[/quote]

They think that XPAP is mumbo jumbo, and that the doctors are blowing something up another orifice.