Medicare 2011 DME Changes

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I posted the following article on my WordPress blog yesterday but also wanted to post it here in case anyone was not aware of the upcoming changes to Medicare. Medicare is making changes to the DME portion of Medicare – that includes stuff like test strips, wheelchairs and oxygen. Starting January 1st, Medicare is starting a Competitive Bidding Program. Suppliers that bid the lowest price will be the only ones allowed to supply equipment thru Medicare. This new rule will do away with most of the local medical supply companies. Most of us don’t care if we have to get strips via mail order, but we do care about the quality of the test strips that we get. However, if you need oxygen or a wheelchair, having to wait to have stuff shipped across the country will make things difficult. If your oxygen equipment breaks on a Friday, you will end up being in the hospital for a few days until your new equipment arrives. I had the surgery for my foot on a Friday afternoon and was released from the hospital on Monday. My heel bone was removed and I was not allowed to put any weight on my foot. If I had not been able to get a wheelchair immediately, I would have had to go to a rehab center and spend my time in bed.

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There is a Facebook group, People for Quality Care, that is working to try and get this ruling changed. You can check them out at:

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http://www.facebook.com/pages/People-for-Quality-Care/156877017673916

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Here is the story that I put on my WordPress blog:

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http://kellywpa.wordpress.com/2010/12/29/medicare-2011-dme-changes/

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Medicare 2011 DME Changes

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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.

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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.

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

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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.

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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.

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To see if your supplier is on the new supplier listing, you can check the link below or just go to 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.

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Here is the supplier directory link:

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

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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.

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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.

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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.

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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.

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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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This is potentially very bad. Our legislators & their families should all be on Medicare to understand the many ramifications.

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You are right Gerri, they should have to use the same system we do to understand what people have to deal with but that will probably never happen. I watched some of the videos on the Facebook link and one guy that looked to be in his 20s had muscular dystrophy – he was on some breathing equipment and his family said the service they use now would come in the middle of the night if they had problems. That won’t happen anymore. It is really scary what is going to happen to some of these people.

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Thanks for the info, Kelly. I get my supplies thru a Medicare Advantage plan, I wonder if it will effect that too? I will check with the company.

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Catlover, for right now, you will continue to get your supplies however your Advantage plan tells you to. I also have an Advantage plan. I don't know what will happen after 2011 though!

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I guess I do not understand. I am new to medicare, but almost all of my pump supplies now are done by medtronic and are done mail order, I do live in Indiana and what I had not figured out was why all these companies, Medtronic, Edgepark and three or four others sent me a notice saying they still participated in the medicare program. So I gues I am a little confused. Will I need to sus[pend my relationship with Medtronic in order to qualify for medicare pricing and reimbursement?

Now on the issue of bidding, I am all for it, and mail order is a small price to pay for better efficiency in the system. Private insurance carriers have been pushing mail order DME for years, and frankly the benefit has been substantial. The difference is of course private insurers allow exceptions for difficult situations. I think the issue is that medicare will nto allow these compassionate exceptions.

In a plan I was associated with, we had an older lady who refused any drugs or products not dispensed by a particular pharmacy. The plan required the use of mail order, but she paid the full cost rather than doing mail order and it created a very difficult hardship. Given the situation, I worked it out that the pharmacy would order the drugs and supplies and dispense them for the same price (zero profit) to the lady. I honestly believe it saved her life, and really who was hurt? No one. So it was a way an employer could step in and help an enrollee who needed some help.

The issue with medicare is that there is no way in a thousand years that medicare will arrange compassionate relationships to take care of people who because of special situations need a different arrangement. Actually, what we need is a special office of medicare that handles very specific issues like this one, that could be arranged with no additional cost to medicare yet, operate in a humane manner.

That fine lady passed when she was 92, and despite the hassle she caused, she willed $5,000 to the insurance plan, (yeah an insurance plan) because we helped her out and she appreciated it. Imagine someone appreciating medicare in that manner? A little humanity goes a very long way.

rick phillips

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Rick, your pump supplies are not included in this round of the competitive bidding program but your test strips are. Edgepark can sell test strips to anyone not living in any of the 9 districts covered by the new rules but they cannot sell you test strips. Being a Medicare provider does not give them the right to sell every item that Medicare covers. In order for you to get the items on the list covered, you have to use one of the vendors that are allowed to sell you those products. There is a medical supply store right down the road from me. They sell stuff like CPAP machines, test strips, walkers and power chairs. Those 4 things are all under the new rules but if they are not chosen as the low bidder, I might only be able to use them for a walker and none of the other three things.

Here is the CMS list of providers and you can see that Edgepark is not one of the allowable vendors for test strips:

http://www.cms.gov/DMEPOSCompetitiveBid/01A2_Contract_Supplier_Lists.asp?utm_source=Members-Only+Updates&utm_campaign=c5f0abea33-WiW_Report_11_3_10&utm_medium=email

If you only asked if they were still a Medicare provider, you did not ask the right question. I would suggest that you call Edgepark back and ask to speak to someone in the billing department and ask specifically about the items included in the competitive bidding program. If their billing people are not aware of the new program, they will have a rude awakening when they start submitting bills to Medicare. I would also call Medicare and ask them – you will be getting a different story than what Edgepark tells you.

The Pittsburgh area only has three vendors that people there can use to get test strips from. One of those vendors, Seeley Medical, does not even have test strips on their store site. Even better, their store is not on their website but is an Amazon store. I don’t exactly get a warm & cozy feeling buying medical supplies from a company that sells stuff on Amazon.

From everything I have been reading, this was not exactly a fair bidding process. A lot of vendors were not allowed to even submit bids. Something like 17% of the companies have severe financial problems and will have problems getting supplies from their vendors. That means if you don’t have a choice of who to call, you will have to wait to get those supplies. Even if they have the equipment and yours breaks, you have to wait for it to be shipped and can’t just use a local place. Medicare might save some money on durable medical equipment but they are going to spend all their savings plus some with more hospital and rehab stays because people are not able to stay at home without the equipment they need to live.

Things like test strips might not be a problem getting mail order if you have a choice in what you can get. Suppliers that did win bids are already saying they are going to carry cheaper items because they cannot afford to sell the quality products at the prices they are getting paid. I don’t know if you ever had a cheap wheelchair break on you while you were sitting in it, but I have and it is not fun. My mother thought she was doing me a favor and bought me a backup walker so I would have an extra walker – it is so unstable I can’t even walk outside my door with it. There were no quality controls put in place with this program. They can ship you a wheelchair that can’t handle holding more than 75 pounds and you are a 150 pound man. You got your wheelchair and it doesn’t matter about the quality.

There was a study done on the impact of this change on patients. It is worth reading:

http://www.aahomecare.org/associations/3208/files/FinalReport-TheRisksOfDMECompetitiveBidding091010.pdf

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Thanks for this news, Kelly. My neighbor’s parents live near Pittsburgh and her father is on oxygen, so I’ve forwarded a copy of this to her. With any luck, they won’t be under this change!

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I hope that your neighbor’s parents are in a zipcode not included in this Angela! I think it is going to be a nightmare for alot of people. I have an appointment with the one doctor I see in Pittsburgh for my foot in a couple weeks so I am anxious to hear what he has to say about this.