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IS THIS REPORTABLE FRAUD? - srlevine1 - 08-22-2016
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.
RE: IS THIS REPORTABLE FRAUD? - icyura10 - 08-22-2016
(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...
RE: IS THIS REPORTABLE FRAUD? - justMongo - 08-22-2016
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?
RE: IS THIS REPORTABLE FRAUD? - FrankNichols - 08-23-2016
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.
RE: IS THIS REPORTABLE FRAUD? - PoolQ - 08-23-2016
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.
RE: IS THIS REPORTABLE FRAUD? - DariaVader - 08-23-2016
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.
RE: IS THIS REPORTABLE FRAUD? - Mike1953 - 08-23-2016
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.
RE: IS THIS REPORTABLE FRAUD? - srlevine1 - 08-23-2016
(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.
RE: IS THIS REPORTABLE FRAUD? - WSHenry - 08-23-2016
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.
RE: IS THIS REPORTABLE FRAUD? - justMongo - 08-23-2016
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.