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Carrot and Stick of CPAP Compliance for DMEs
So the Carrot for the DMEs, or Durable Medical Equipment providers, is that they get paid if they get patients "compliant." The stick for the DMEs is that they don't get paid if they don't get patients compliant.
So how is this playing out in real life? We all know it takes some patients months to really comply with CPAP therapy. Does that mean DMEs are taking back the machines from the patients if they aren't using it enough for the DMEs to get paid? What do the DMEs do with the machines then -- they're used at that point? Does all the risk of loss fall on the DMEs shoulders, or is the risk of loss somehow split with the patient, or is it shifted entirely to the patient? So many questions... I'm very inquisitive today.
So how is this playing out in real life? We all know it takes some patients months to really comply with CPAP therapy. Does that mean DMEs are taking back the machines from the patients if they aren't using it enough for the DMEs to get paid? What do the DMEs do with the machines then -- they're used at that point? Does all the risk of loss fall on the DMEs shoulders, or is the risk of loss somehow split with the patient, or is it shifted entirely to the patient? So many questions... I'm very inquisitive today.
Views: 51
Replies to This Discussion
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Permalink Reply by Daniel on
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I don't think anyone has the answers yet. Just today, I received data from a patient who is trying hard to be successful, but she is three months in and hasn't met Medicare's compliance standards. Am I going to take her device away from her? No, because she sincerely wants to be compliant.
In answer to some of your questions, I think all the risk falls on the DME. In order for me to get paid, the patient not only has to meet the compliance standards within three months, but must also have a face to face follow-up with the prescribing doctor so that the doctor can confirm compliance, not me. What happens when a patient is compliant and successful, but they don't get around to seeing their doctor till the 92nd day?
No matter how good a DME is, there will always be some non-compliant patients. I understand the intent of the new regulations, but the unintended results can be devastating to both patient and DME.
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Permalink Reply by Mike on
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Daniel, I would think this carrot and stick model will ultimately favor you, even though it does seem tough. after all, service and high compliance rates are what you've been delivering all along. now the other DMEs will have to either step up, or fall by the wayside.
Daniel said:I don't think anyone has the answers yet. Just today, I received data from a patient who is trying hard to be successful, but she is three months in and hasn't met Medicare's compliance standards. Am I going to take her device away from her? No, because she sincerely wants to be compliant.
In answer to some of your questions, I think all the risk falls on the DME. In order for me to get paid, the patient not only has to meet the compliance standards within three months, but must also have a face to face follow-up with the prescribing doctor so that the doctor can confirm compliance, not me. What happens when a patient is compliant and successful, but they don't get around to seeing their doctor till the 92nd day?
No matter how good a DME is, there will always be some non-compliant patients. I understand the intent of the new regulations, but the unintended results can be devastating to both patient and DME.
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Permalink Reply by RockRpsgt on
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That is kind of a crock Daniel! Especially when you put this post next to the Resmed income report. Is there any protection for the DME? It also makes me wonder why there are so many bad reports on DMEs. Are you considered subcontractor?
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Permalink Reply by Judy on
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Rock Hinkle, until this year all a DME supplier had to provide as proof regarding patient compliance was a form letter filled in and signed by the patient that they were using their xPAP at least 4 hours a night and at least 5 nights a week. That's why so many xPAPs were being paid for as they sat in the closet on the floor. That is all I ever had to provide. My DME supplier never did a download of my data.
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now do they have to prove compliance?
Judy said:Rock Hinkle, until this year all a DME supplier had to provide as proof regarding patient compliance was a form letter filled in and signed by the patient that they were using their xPAP at least 4 hours a night and at least 5 nights a week. That's why so many xPAPs were being paid for as they sat in the closet on the floor. That is all I ever had to provide. My DME supplier never did a download of my data.
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Beginning this year the DME supplier MJST be able to PROVE w/DATA on hand that the CPAP is being used the minimum amount of time, I believe still at least 4 hours per night and at least 5 nights a week, meaning they are going to have to provide CPAPs that are capable of reporting compliance data. There are CPAPs out there not even capable of reporting compliance data which will no longer be acceptable for Medicare reimbursement. Daniel Levy can most likely clarify this matter better than I since he has to work w/Medicare guidelines all the time.
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Permalink Reply by Sandra Limbach on
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I am not sure here, as I bought my childrens bi-pap machine quite awhile ago. But I compaired the cost of the machine VS the DME rental. There was no compairson at the time. It was so much cheaper to just buy it. I submitted the receipt to the insurance and they paid. There were no questions re.compliancy.
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Sandra,
This is only a Medicare issue, so it does not apply to your child's BiPAP, although when Medicare makes changes to their rules that allow claims to be denied, I wouldn't be surprised if private insurance companies also adopted similar rules.
Rock,
Subcontractor? Not sure what you mean. SomniHealth is licensed directly with Medicare, so I am bound by their regulations when dealing with Medicare patients. Protection for the DME? None, zero, nada. In addition to the new compliance regulation, there is also a new regulation that all Medicare providers must provide a surety bond of at least $50,000. This is part of Medicare's efforts to prevent fraud, but it is a huge extra burden for a small provider like SomniHealth. Also, I don't see the connection to ResMed's profits at all. Yes, more and more CPAPs are being sold, but it is becoming harder and harder for a small DME to make a profit. I don't place an order with ResMed for 50 CPAPs at a time. I have to pay more per CPAP than a large scale national provider does.
Mike,
I fail to see how these regulations will favor SomniHealth in the long term. Perhaps you mean that less caring providers will simply stop accepting Medicare patients, theoretically driving more business to SomniHealth, or that other competitors will go out of business because they are not getting paid for devices they had to purchase from the manufacturers. Both scenarios seem kind of grim to me, since I think patient care will suffer when there is less choice and fewer providers accepting Medicare.
Judy,
Your explanation matches my understanding of the new regulations.
Daniel
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my thinking was that getting patients truly compliant with cpap therapy is hard, and takes skill, and that most of your competition will not be willing or able to do what Somnihealth does, which i figured would enable Somnihealth to gain market share.
Daniel said:Sandra,
This is only a Medicare issue, so it does not apply to your child's BiPAP, although when Medicare makes changes to their rules that allow claims to be denied, I wouldn't be surprised if private insurance companies also adopted similar rules.
Rock,
Subcontractor? Not sure what you mean. SomniHealth is licensed directly with Medicare, so I am bound by their regulations when dealing with Medicare patients. Protection for the DME? None, zero, nada. In addition to the new compliance regulation, there is also a new regulation that all Medicare providers must provide a surety bond of at least $50,000. This is part of Medicare's efforts to prevent fraud, but it is a huge extra burden for a small provider like SomniHealth. Also, I don't see the connection to ResMed's profits at all. Yes, more and more CPAPs are being sold, but it is becoming harder and harder for a small DME to make a profit. I don't place an order with ResMed for 50 CPAPs at a time. I have to pay more per CPAP than a large scale national provider does.
Mike,
I fail to see how these regulations will favor SomniHealth in the long term. Perhaps you mean that less caring providers will simply stop accepting Medicare patients, theoretically driving more business to SomniHealth, or that other competitors will go out of business because they are not getting paid for devices they had to purchase from the manufacturers. Both scenarios seem kind of grim to me, since I think patient care will suffer when there is less choice and fewer providers accepting Medicare.
Judy,
Your explanation matches my understanding of the new regulations.
Daniel
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