Medicare 2011 DME Changes

In case you are not aware, beginning January 1st, Medicare begins its Competitive Bidding Program. This program will take effect in 9 areas of the country and puts forth new rules about getting durable medical equipment, prosthetics, orthotics and certain supplies (which includes test strips). If you don’t live in one of the 9 areas but travel to one of those areas, you will need to follow the rules in order to get your supplies covered while you are away from home.

The areas included are North Carolina, South Carolina, Ohio, Kentucky, Indiana, Texas, Missouri, Kansas, Florida, Pennsylvania and California. Now I know that I listed 11 states and said 9 areas – that is government math for you! They have Cincinnati, Oh grouped with areas in Kentucky and Indiana so those three are considered one area, but the Cleveland area is listed as a separate group. It is not necessarily the whole state that will be affected. They have Pittsburgh listed but not Philadelphia. I live a couple hours from Pittsburgh and will not be in the changes for this year. The best thing to do is click on the link below if you are in one of the states I listed and enter your zip code to see if you are part of the 2011 change.

http://www.medicare.gov/Supplier/static/SupportTab.asp?activeTab=3&language=English&subTab=1&viewtype=

Medicare has updated some of the requirements for suppliers to participate in the program. From what I understand, most suppliers that you are currently using will be in the new program although some will not be.

If you are renting durable medical equipment (like oxygen), you should check to make sure that provider is still a Medicare provider. You may be able to continue renting your equipment from that provider if the provider chooses to be grandfathered in. However, the supplier may choose not to be grandfathered in and you will need to change suppliers.

To see if your supplier is on the new supplier listing, you can check the link below or just go to http://www.medicare.gov and you will see it at the bottom of the page under “Resource Locator.” Please note that just because your supplier comes up does not mean that they are one of the Medicare suppliers – the Medicare suppliers have a little green “p” next to the supplier name. You can still get stuff from a supplier that is not a preferred supplier, but if they charge $100 and Medicare allows $40, you would be responsible for the $60. With a preferred provider, the supplier has to accept what Medicare pays. You will still be responsible for any co-pays and deductible amounts.

Here is the supplier directory link:

http://www.medicare.gov/Supplier/Include/DataSection/Questions/SearchCriteria.asp?version=default&browser=IE%7C7%7CWinXP&language=English&defaultstatus=0&pagelist=Home&CookiesEnabledStatus=True

There is a big concern about this program is – it is called the competitive bidding program. That means that suppliers put in bids to be able to sell products and the lowest bidders will be able to sell those products. The supplier will get paid a fixed fee for the product, regardless of what brand it is. There has been a lot of discussion over concerns that suppliers will only carry inferior products because they won’t make money on selling better quality products.

On American Diabetes Wholesale, a box of 50 Aviva test strips is $25.99 per box. A box of Advocate test strips is $15.99 per box. Now if I am a supplier selling test strips and I am going to get paid $25 or even $30 no matter what brand of test strips I send to you, which ones do you think that supplier will send? Many of us have pumps that use certain brand strips and most of those strips are the more expensive ones. The fear is that the suppliers will only offer the cheaper brands and you will not have the option of finding those brands at another supplier.

I know when I tired the Wavesense Presto, I was very disappointed in it. The Presto was running 20-30 points higher for me. I even tested it at the lab and was 84 per the lab and 110 per the Presto – a little too far off for me. I prefer to hang out in the 70s and 80s and I need a meter that is accurate. Other people love the Presto meter, but it was not accurate for me. This meter conversation came up on TuDiabetes one day and one of the women said that one meter ran high for her, but it read fine for her husband. I do believe that there is something in our makeup that can throw different meters off for us that might work for someone else.

When my foot wound was first starting to heal, I had to start the process to get orthotics. I was still doing HBO at the time, so the wound center made arrangements with a Pittsburgh supplier to come to the wound center and take care of everything for me. That first pair lasted about a year and when I went to get another pair, I used a local supplier. Less than 3 months after I got them, they started to fall apart. When I showed my doctor, he of course said that they should not be doing that. I went back to the supplier and all they did was glue them and that did not even hold a week. While I was there, some guy came in that had bought some diabetic shoes from them and his shoes were also falling apart. I guess they just carried crappy stuff. I started using a place in Pittsburgh for my orthotics. Orthotics are considered DME and part of the competitive bidding program.

I understand that Medicare has to cut costs. I also understand that there is a lot of fraud that needs to be taken care of. I am just not sure that how they are going about it is the right way!
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8 thoughts on “Medicare 2011 DME Changes

  1. We are seeing rural smaller DME’s just throwing their hands up and saying, “this industry has gotten past the point of ridiculous-I’m outa here” and they are leaving, closing, retiring, selling (if they can sell that is)…. It is sad. DME’s are the solution-not the problem. Why the government is paying 200$ in man power to fight a 100$ claim is absurd too. Many denials get overturned at the redetermination level anyways. So they paid 200$ to deny it, then paid 100$ too. Talk about spending a dollar to save a penny. No wonder they are out of money…They can say they are saving millions and billions but in the long run it is just hurting small businesses. I never hear of the good DME’s do or how they got a patient home sooner, or kept them out of a nursing home. It’s sickens me to know that we have paid into a system all of our lives and now they say “we have no money”-it’s just unacceptable period. 80’s and 90’s financial statements should be brought back under the microscope. Paying 5 times the retail amount and paying claims twice or four times with flood gates wide open back then. Who’s accountable for that fiasco back then?

    • Danyelle, unfortunately, I think we are going to see a lot of the bigger DMEs also just close up shop. They may be able to hold on a little longer than some of the smaller ones, but they are getting hit also. You are right, no one hears about the good things and how someone is able to go home instead of going to a nursing home, not to mention to the costs associated with sending someone off to a nursing home. They should go back and review some of the stuff that was paid out – the IRS and Social Security both take back money that was overpaid. No reason Medicare shouldn’t either.

  2. Hi Kelly. The plight you have described has been aggressively opposed by most reputable providers in the HME/DME industry as we realistically anticipated the government securing Competitive Bidding (CB)contracts to lower their out of pocket costs in this healthcare sector only. Unfortunately, the categories currently included in CB target the most vulnerable of individuals and products they need on a regular basis to sustain health and well-being. With CB bids, HME/DME suppliers will be forced to provide the cheapest products to make ends meet. The consequence, though, is that insurance recipients will have to make due with these products, even if it means switching from brands they have become accustomed to using previously. In addition, we anticipate that there will be spikes with in-hospital or acute-care incidents, thus increasing overall expenditures for Medicare and other insurance policies that will naturally follow Medicare’s lead. So, you will probably see a ‘bleed over’ into other insurances doing the same as Medicare has done. We have seen some of this happen already in MN! Basically, taking from one pocket and putting into another. Managed Care at its worst. Government spending a dollar to save a penny. Plus, it will take more government workers to manage this program… enlarging our government payroll while claiming that we save money with healthcare expenditures. As a Registered Nurse and HME business owner, CB is one of the most ridiculous measures to purport containment of rising healthcare costs. I look at close family and friends and shudder at the prospect of CB coming to the MSP area of MN with the next round. I pray that none of my relatives nor I are on oxygen or require enteral nutrition feeding….yes, my husband and I are approaching Medicare coverage…whoever thought of CB as a valid mechanism to control expenditures for our Senior citizens and Disabled Adults in core product categories should be taken out into a deep forest somewhere and given only a knife for survival and told to find their way back to civilization + ‘good luck’.

    • Joan, thank you for your comments. The more I am learning about this, the scarier it gets. I know that you are right that it is going to increase hospital costs by a lot more than what it will save. For me personally, if I am not able to accurately tell what my blood sugar is when it is low, that means more ER trips from passing out. And on the flip side, more health problems from my blood sugar being out of control.

      I had my foot surgery on a Friday afternoon. Going into the surgery, my doctor did not know for sure what was going to happen until he actually opened my foot up so it was not possible to make plans for the future. I was not able to talk to him about what happened until Saturday morning and I was released from the hospital on Monday. Had I not been able to get a wheelchair immediately, I would not have been able to go home. My sister went to pick the wheelchair up and met us at my mother’s house to be able to get me out of the car. These people that are on equipment that literally sustains their lives are really going to be in trouble – it is terrifying to think about what is going to happen to them.

      The doctor that I see for my foot in Pittsburgh specializes in wounds and he sees a lot of elderly and disabled patients like me. When I was there in Nov, I told him that I feel like because I have health problems, some people think it is OK to just let me die. I see him in a couple weeks so it will be interesting to get his take on what is going on now. I disagree with your statement that “Senior citizens and Disabled Adults in core product categories should be taken out into a deep forest somewhere and given only a knife for survival and told to find their way back to civilization.” Sad to say, but I don’t think we are even being given the knife for survival! A less cruel way would be to just line us up and shoot us because they obviously don’t care about what happens to us. My life is just as valuable as someone else’s and this should not be happening.

    • You are certainly correct in your findings. We have owned and operated a DME in Georgia now for 12 years. This is the worst case senerio for all involved, but most certainly the Medicare Recipients. We have no control over pricing and once CB comes into play we probably will be put out of business. There isn’t a company out there can can supply the needs of this upcoming generation on a CB fee schedule. I don’t care who you are! It only means reduced quality care as well as inexpensive equipment being used. You always get what you pay for!

      I pray this government wakes up quickly. Joan is correct, they aren’t saving a dime…they are just going to be paying it out in Part A payments not Part B. (which is what DME bills under). Reduced care just means more ER visits and hospitalization as we cannot take care of the patients the way we have grown accustom to with their reduced payments. Which is a lot more expensive than paying DME’s. Medicare needs to hear an outcry from this generation. Speak UP NOW!!
      God Bless

      • Thanks Eileen. I have been trying to encourage people to speak up. I know this is going to be a nightmare when it goes nationwide. It will put a lot of DME places out of business then everyone will be in trouble.

  3. Hi Kelly!

    I’m from an organization called People for Quality Care that is working to have these Medicare changes reversed. Take a look at our website and join us on Facebook.

    http://www.peopleforqualitycare.com
    http://www.facebook.com/peopleforqualitycare

    It looks like you already know the issue inside and out. You would be a great advocate for us! We are telling the stories of those who will be affected by these changes. Please get in contact with me or fill out the “Share your story” information on the website homepage.

    Thanks!

    -Beth Cox

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