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    Medicare Reimbursement Hassle

    In 2004, my private pay medical insurance purchased an Activeaid Shower/Commode Chair with 5 inch caster wheels. Fast forward 8 years. I am retired and have been on Medicare for 2+ years. The chair is in perfect condition, but the seat needed to be replaced. I tried to find a local or internet durable medical equipment supplier who would provide the seat and submit the claim to Medicare. While I found recognized Medicare suppliers, those who had Medicare provider numbers, none of them would submit the paperwork for the claim. I purchased the seat from SpinLife and submitted the claim on the Medicare's form. Patient's Request for Medical Payment CMS1490S.

    Medicare denied the original claim and my first appeal because:
    1. Provider: Unknown Supplier (I submitted a supplier number given to me by SpinLife)
    2. The equipment is covered only if rented. This item is regarded as a Capped Rental Item. Based on the Internet Only Manual, Publication 100-4, Chapter 20, Section 30.5 this item can only be rented. Therefore no payment will be made.

    I am preparing the second appeal and thought I'd run this up the flagpole here to find out if anyone has gotten reimbursement for purchase of a replacement shower/commode chair SEAT. I am beginning to doubt that Medicare agents really read these appeals since I have provided everything they need on the forms and have written letters providing details of my disability, my inability to use a regular toilet, explaining why I need the replacement seat, and why I am making the claim myself.

    Any ideas?

    Thanks,
    GJ

    #2
    Can you get a doctor prescription for this from a doctor? I am not sure Medicare accepts anything specifally requested by patient. Another thing with Medicare is, they want the patient to use the cheapest way for them to reimburse - i. e. buy vs. rent. It is ridiculous. But I think if you can get thins information from a doctor and have the doctor signature on all the paperwork, it would get provided to you. Of course it has to fall into all of the guidlines why you need it.

    Comment


      #3
      Medicare does not pay for shower-commode chairs (or any other bathroom equipment). This includes grab bars, shower chairs, bathroom lifts, or toilet modifications (bidets, etc.). It will pay only for a bedside commode (the really cheap ones), and even then, only for a rental.

      Rarely will Medicare pay for repair of equipment they did not purchase. This would be considered a repair.

      Sucks, I know, but those are the regulations that Congress encouraged Medicare to set.

      (KLD)
      The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

      Comment


        #4
        I will second KLD's comments. For the out of pocket replacement seat, you have a better shower chair/commode than anything you would get via rental.

        Plan in advance and maintain that shower chair and get replacement parts while you still can.

        Never understood how taking a shower/tub was not medically necessary.
        Every day I wake up is a good one

        Comment


          #5
          Congress has made Medicare rules unreasonable and arbitrary... heaven help us all under the Patient Protection and Affordable Care Act!!!

          All the best,
          GJ

          Comment


            #6
            Originally posted by gjnl View Post
            Congress has made Medicare rules unreasonable and arbitrary... heaven help us all under the Patient Protection and Affordable Care Act!!!

            All the best,
            GJ
            No, I think we will do better under the ACA.

            Most of these Congressional mandates came from the Regan, Bush#1 era and continued under Bush #2.
            Look for the Complex Medical Equipment bill specific to DME. Talk to your Senators and Congressmen--it will make a difference in your life, especially when you need a new customized Power chair.
            Every day I wake up is a good one

            Comment


              #7
              Originally posted by cheesecake View Post
              No, I think we will do better under the ACA.

              Most of these Congressional mandates came from the Regan, Bush#1 era and continued under Bush #2.
              Look for the Complex Medical Equipment bill specific to DME. Talk to your Senators and Congressmen--it will make a difference in your life, especially when you need a new customized Power chair.
              I am a retiree currently on Medicare. Will Medicare change commensurately with the Patient Protection and Affordable Care Act? All that I have read is that if you are currently on Medicare you don't have to "worry" (really) about changes in coverage and care.

              I planned ahead, and my private employer provided medical insurance covered a customized power chair and cushion a year before I became eligible for Medicare. Medicare has paid for repairs and replacement parts on the power chair (Medicare did not provide the chair), i.e., replacement casters, battery charger, replacement arm rests. These items were obtained from and claim submitted by a local durable medical equipment supplier with a Medicare provider transaction access number. Unfortunately, this same supplier would not order the replacement commode/shower chair seat and submit the claim, probably because they knew they wouldn't get reimbursed or because they don't support Activeaid products.

              The conundrum is that Medicare would RENT a very standard commode chair (not that as a C6/7 complete quad, I could use it) for me from a local durable medical equipment supplier that accepts Medicare. That commode has a metal frame and adjustable legs, fits over a toilet or uses a bucket (bucket needs to be purchased extra for $15.00) and does not have drop arms for transfers. Medicare would pay $360 a year rental ($30.00 a month) for this chair that I couldn't use...but they won't pay $175.00 for a replacement seat to make my current commode/shower chair useable for 3-4 years to come. Fascinating the economic sense that makes!!!

              All the best,
              GJ
              Last edited by gjnl; 8 Oct 2012, 7:19 PM.

              Comment


                #8
                Yeah, frustrating. KLD is right - you will never get Medicare to cover this. They will never pay for this sort of "convenience item". They just don't cover any bathroom equipment. So this is why they will repair your wheelchair, but not this chair. Of course, your logic is reasonable. But I would recommend you save your energy... and sanity... and not bother to appeal.

                Totally understand your frustration.

                Also, Medicare will never accept a claim if it was submitted by you.... EXCEPT.... someone on this site recently had a claim accepted when his provider (mistakenly) told him to submit it himself to Medicare. Medicare now will allow you to submit one claim for approval, but after that they warn you it must go through a provider. So now you've had your one warning. You must search for a provider willing to submit for you or you must assume you will pay for it yourself.

                And no - Medicare will not change in any sort of relevant way for this due to Obamacare. I'm still grateful to have Medicare though for my Dad.... and that we live near several major medical centers that are still willing to take Medicare.

                Comment


                  #9
                  We had good insurance through my employer when Dave had his SCI and got his powerchair.
                  Now he is on medicare and when his chair needed repairs they would not cover because it did not "exist."
                  So it sounded like they would pay for a new one, but not a few hundred dollars for a repair.

                  Comment


                    #10
                    The conundrum is that Medicare would RENT a very standard commode chair (not that as a C6/7 complete quad, I could use it) for me from a local durable medical equipment supplier that accepts Medicare. That commode has a metal frame and adjustable legs, fits over a toilet or uses a bucket (bucket needs to be purchased extra for $15.00) and does not have drop arms for transfers. Medicare would pay $360 a year rental ($30.00 a month) for this chair that I couldn't use...but they won't pay $175.00 for a replacement seat to make my current commode/shower chair useable for 3-4 years to come. Fascinating the economic sense that makes!!!
                    I agree that it is asinine and am behind you 100% regarding the logic. This information should be sent to your Federal Senator and Congressional representative. There is an attempt going on to change the complex medical equipment guidelines. The illogic that you demonstrated is part of the reason it needs to be changed.

                    Medicare is operating off of 40 yr old laws--back when folks with disabilities rarely worked or left home. Technology has changed and the guidelines need to change with it.

                    My advice stands--maintain and buy spare parts for your shower chair now--while they are still available. realize that the antiquated guidelines won't purchase a new one.

                    FWIW, the DME company would not submit the claim because they knew it would not be covered--they just didnt have the guts to tell you straight up.
                    Bad business in my opinion.


                    ETA: ACA would NOT have AARP's endorsement if it was going to hurt seniors and Medicare recipients. Hospitals are being held accountable for their billing practices---billings that you as an Advantage plan member probably pay 20% of. The changes are good for everyone.
                    Every day I wake up is a good one

                    Comment


                      #11
                      If I were a dishonest person, and if I had a touch of larceny in my soul, I would have Medicare rent this commode chair under the "Capped Rental Item" provision. That is, Medicare would rent this totally useless commode chair for me for 13 months, after which (since I would still need it) ownership would transfer to me. Since I wouldn't have used this commode chair, it would be in good enough condition to sell on EBAY, and I could probably recoup the $175.00 I paid for the replacement commode/shower chair seat for my Activeaid. Trouble is, I am inherently honest and wouldn't/couldn't stick to the man like this. But, if I can think it, I'll bet good money that somebody pulls this kind of chicanery everyday.

                      While I have been doing some research on this issue, I called around (I live in East Bay area of San Francisco) to find a durable medical equipment supplier who accepts medicare assignment. Out of 6 calls, I didn't find a single one. "Oh, I'm sorry, we don't accept medicare assignment anymore."

                      So, if no one accepts Medicare assignment and won't submit claims, how are you to get any kind of reimbursement for durable medical equipment and who knows what else.

                      I ran into a similar problem after two cataract surgeries. The Medicare provision is that Medicare will pay for one pair of single vision prescription lenses in a standard frame. I could not find an optometrist, after an exhaustive search, in a 10 mile radius who would accept medicare assignment or would submit a claim to Medicare. None of these providers that I contacted could tell me how much Medicare would reimburse for eye glasses. Medicare couldn't tell me how much they would reimburse.

                      I purchased frames and lenses, and although I knew I wouldn't get reimbursed by Medicare (the supplier did not have a Provider Transaction Access Number), I submitted the claim anyway. After a denial, I wrote my congressman, senators, and Kathleen Sebelius, US Secretary of Health and Human Services. The outcome of one of those letters was a call from the Medicare contractor who made the determination of denial. We talked at great length about the problem and he told me he needed to talk to a superior to find out how much Medicare would reimburse for these eyeglasses. When he called back he said he had been unable to find out the reimbursement amount. No one knows (or no one is telling). I did a lot of searching on the internet and found one reference on a forum to a reimbursement amount for the one time only purchase by Medicare of eyeglasses after cataract surgery...are you ready...$68.50. You can't purchase a replacement temple for a pair of eyeglasses for that!!!

                      You gotta laugh, otherwise you would drown in tears!!

                      All the best,
                      GJ

                      Comment


                        #12
                        If BJ's or Cosco has an eyeglass special, you can get them for $80 with lense and decent frames. I have private vision insurance and it pays next to nothing towards glasses and worse for contacts.
                        Every day I wake up is a good one

                        Comment


                          #13
                          Originally posted by cheesecake View Post
                          If BJ's or Cosco has an eyeglass special, you can get them for $80 with lense and decent frames. I have private vision insurance and it pays next to nothing towards glasses and worse for contacts.
                          I did check Costco, but ended up finding a new start up company on the web called Warby-Parker (http://www.warbyparker.com/). They have some rather attractive modern frames and a free try on program. They send you 5 frames at a time to try for 7 days. You give them a credit card number, but they don't charge anything to it and they pay shipping of these frames both ways. You can receive another set of 5, if the first 5 don't work out for you, no obligation to purchase. When you decide on a frame, you provide your prescription and for $95.00, you have your new eyeglasses in 7 days. Free shipping at purchase too!

                          Of course, the irritation is that there is a Medicare provision for eyeglasses after cataract surgery, but it is bloody impossible to take advantage of it.

                          All the best,
                          GJ

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