BiPAP Medicare Question

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KimT

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PALS
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The Beach
According to what I've been told by the DME company, I'm renting the BiPap and will own it after 13 months. They also said that I couldn't change to a Trilogy after 90 days and would not be eligible for one for 5 years. When all this started I was convinced I would buy the BiPAP I have now for a starter and backup. That didn't work out.

Is this correct?
 
There are new NIV regs for Medicare and private payors are following suit. As of 1/1, the DME has to certify that you need BiPAP 24/7 and they get paid less. The ALSA and COPD groups are fighting this, but it's the rule for now.

So most DMEs are going to be allergic to Trilogy discussions these days. Of course, always double-check what they say against your payor.

But your machine lacks only an internal battery to be Trilogy-like and you don't need it during the day yet and regs are going to change again, so I wouldn't worry just yet.

Yes, 13-mo capped rentals are a ripoff and just a reminder to look at cash vs. the total "reimbursed" outlay w/ Medicare.
 
I'm worried because of the power outages we have in Florida during Summer. Is there a battery backup for it?
 
So most DMEs are going to be allergic to Trilogy discussions these days.

So true! It seems that a large part of the problem is that the Trilogy can provide both BiPAP and full ventilation. That makes it considerably more expensive than a typical BiPAP and more than a Standard vent as well. Insurance doesn't want to pay for this combo when a patient can only use one or the other modes at a time. Insurances will therefore limit reimbursement to a BiPAP until the switch to a vent is necessary. As I understand it, the people caught in the middle are those who want to avoid a trach by using the vent via a sip mouthpiece. My personal opinion is that I wouldn't want to have to continually do the sip and have the sip tube in my face. A trach connection to the vent lets me ignore the whole breathing problem and be continually well oxygenated. And able to be suctioned or use a Cough assist as needed, convenient, preferred, or effective. And, please, none of that nonsense about the difficult and time consuming routines needed for trach care. Wash your neck with soap and water. That is all that is necessary for for the dreaded "Trach Care”.

Sorry, wandered off track there.

So, I am beginning to think that the inventors of Trilogy should have focused on building a better BiPAP with more possible setting adjustments, not to mention a battery system that makes it truly portable. And one that is easily mounted on a wheelchair. Those last two things were more problematic for me than settings! Anyway, they have created a machine that sounds great in marketing because it serves the user through both BiPAP and Ventilation. But it isn't feasible for the extra price.
 
Yes, you can buy an external battery for the ST-A (would fit into your lap, a bag, whatever) and pretty much any modern PAP. Don't buy from the OEM if you don't have to -- much more pricey. Let me know if you need a link.

To comment on what Diane said, that's one advantage of the ST-A -- it's classified as a BiPAP because it can't be used with a trache -- well, technically...but in truth the Trilogy's "portability" and the Astral's are why they have been written for PALS in a "one and done" move so the DME doesn't have to order a 2nd machine when going out becomes a factor.

As for sip and puff, it can be done with a regular BiPAP and 22mm mouthpiece on the end of a PAP hose. Just eliminate the backup rate and tweak the trigger settings.
 
Thanks, Laurie. When you get a chance, please PM me a link.
 
Hi Laurie, Steve was called while I was at work today by the DME company telling us that we now owe them 2800.00 for the Triology rental that we have had since December. We never asked for the trilogy. His doctor must have ordered it. Anyways, Medicare and his supplement plan Aetna will not pay for the entire amount of the 1,400 rental. We think the Trilogy rental of 1,400 per month is a total rip off. We were never told that it was not approved. Steve wants to buy the BiPAP ST and not deal with insurance or DME rental. He wants them to come out and pick up the Trilogy. We decided a long time ago that he would not vent.

Can you send me the link so we can look into buying one? I am not sure why Medicare and Aetna just don't pay for the BiPAP instead of renting a Trilogy.
 
To buy new and used BiPAPs: secondwind.com. Even if it's not listed on their site, they can probably put together an S9 ST-A VPAP for you (my recommendation for PALS).

Kim, there are some new batteries out and doubtless the cheapest solution is deep cell batteries, but for those of us who fear electrical maneuvers, the C-100 battery has been around for a while and gets decent reviews. To use it with an S9, you need a 24v adapter. I see an Amazon price for $318 for the pair (from the C100 page). As with any battery, using heated humidification cuts battery life, so some people advise running the humidifier at 3 with the heat off, which I could certainly see as a possible Florida strategy. I believe that same battery/adapter is on the secondwind site as well for a few dollars more, but they do not identify the brand; you could ask since you've dealt with them previously.

Best,
Laurie
 
Hi Laurie, Steve was called while I was at work today by the DME company telling us that we now owe them 2800.00 for the Triology rental that we have had since December. We never asked for the trilogy. His doctor must have ordered it. Anyways, Medicare and his supplement plan Aetna will not pay for the entire amount of the 1,400 rental. We think the Trilogy rental of 1,400 per month is a total rip off. We were never told that it was not approved. Steve wants to buy the BiPAP ST and not deal with insurance or DME rental. He wants them to come out and pick up the Trilogy. We decided a long time ago that he would not vent.

Can you send me the link so we can look into buying one? I am not sure why Medicare and Aetna just don't pay for the BiPAP instead of renting a Trilogy.

Medicare is renting my BiPAP (the one Laurie recommended) for 13 months, then I own it. I don't even know what they are charging but I was told that my Supplemental policy would cover what Medicare didn't cover. The whole thing is a rip off.
 
Something is screwed up. The billing codes for BiPAP and Ventilators changed on Jan. 1 and it is very likely the Medicare is denying the claim because the DME is using outdated an outdated or incorrect code. Most likely they are trying to bill the Trilogy as a BiPAP. "Ventilators must not be billed using codes for CPAP (E0601) or bi-level PAP (E0470, E0471, E0472). Using the CPAP or bi-level PAP HCPCS codes to bill a ventilator is incorrect coding, even if the ventilator is only being used in CPAP or bi-level mode. Claims for ventilators used in CPAP or bi-level PAP scenarios will be denied as incorrect coding.code".

Or they may be correctly calling the Trilogy a ventilator but using an outdated code such as E0450, E0460, E0461, E0463, or E0464.

If your billdoesn't show the code used, go to mymedicare.gov and sign up so you can see your bills. Click on the long number at the left of a claim and you will see the the breakdown of the claim and, at the bottom, the code used.
You will also see the amount the DME is charging Medicare for one month's rent and the amount Medicare allows. The DME will only get that amount regardless of what ridiculous amount they bill Medicare for. The next number is how much of the allowed amount Medicare pays them. That is 80% of the allowed amount. The remaining 20% is what you owe. The DME is not allowed to bill you for anything more than that 20%. That will be billed to your other insurance and they will pay their covered % of that, and the rest is what you actually owe. You won't get anything from your insurance for the first the first part of the year. They won't pay until you have met your deductible and your Out of Pocket amount (which is probably several thousand dollars). I am not sure whether that $1400 is for a BiPAP or a vent, the amount billed to Medicare or Medicare's allowed amount, but there is no way you owe the DME $1400 a month even if your insurance isn't paying anything at all yet this year!!!
 
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Remember, Diane, as of 1/1 in addition to the coding, new med necessity criteria as to 24/7 need, can be applied. That will omit a lot of our NIV PALS and is why the ALSA is part of the protest.

I have seen other exorbitant Trilogy rentals here and elsewhere, so not sure how high a DME might feel it could go in a denial scenario. They are trying to make up for the reduced reimbursement they get for that category across the board.
 
Thanks for the link and info Laurie. Diane, The trilogy was ordered by his doctor and at the time I had Steve under my insurance and they approved it. I left my job to take another job with less travel and Steve went on Medicare and Aetna. Steve is under 65 so he could not get a plan F and had to get Aetna supplement plan.

The DME called and said that the Trilogy would only be paid 55%. I am calling Medicare and Aetna tomorrow. Steve doesn't do to well taking care of these issues and the DME knew they were supposed to call me. Steve wants to tell them to pick up the Trilogy and buy a BIPAP because he feels that it's a rip-off to us and the taxpayers to pay 1,400 a month to rent a machine that he doesn't even need.
 
Scared, my husband was 61 when he went on Medicare and was able to get a Plan F from AARP/UnitedHealthcare.
 
How do we know what machine is right for my husband? His doctor has ordered the Trilogy machine but I don't know enough about the BiPaP and or ventilator to have any idea what works the best. I did find a DME that will send my claim through my insurance as a purchase instead of a rental. The first one that the order went to would only do a rental and it was close to $1000 a month to rent it.
 
Medicare supplement plan availability is different from state to state. Even though I am 60 I was able to purchase Plan F or Plan G (both rich plans). They cost me anywhere from $500 to $800 a month depending on the company. I went with Blue Cross of Florida. In some States, everyone, no matter the age pays the same premium for any given supplement (New York, for example.) I had no choice but to get the plan that covers everything I will need in the future. If I were 65, the same plan would cost $135 a month.
 
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