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Finally gonna try to use Medicare to get a chair

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  • #31
    I might be about to have to eat my shorts. Just got an email from the DME, with the 2nd CAD drawing and a line item breakdown. If I sign an ABN, for non-covered options, -$2,100 Medicare payment, he will sell me my ZR spec for $2,800. He claims there was no problem getting the pre-approval via Medicare. Huh. Why am I still skeptical?!
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

    "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

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    • #32
      Thanks for the update with numbers.
      Be interested to know what the Non-covered items are ($2,800).

      Do you have secondary insurance?

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      • #33
        Oh, that $2,800 is just the usual DME overpriced knick-knacks. $1,000 for a new cushion and carbon backrest. Upgraded bits on the chair make up the balance, I.e., fixed back canes, custom V front width, curved rigidizer, CF side guards, upgraded forks and casters, compact wheel locks, and new spinergy cf wheels. Stuff like that. Nothing really out of the ordinary. It just adds up quick at DME retail! I'm still negotiating, so we'll see how it turns out. I've seen nothing official from Medicare yet, so I'm still wondering.
        "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

        "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

        "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

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        • #34
          Most supplemental Medicare policies will only cover the 20% of Medicare approved price and features, and will not covered at all the features/costs not approved by Medicare.

          (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.

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          • #35
            You seriously have more of an attention span than I do. Over 4 months, I'd just buy the stupid thing, lol. But good that it seems so far that the gubmint might actually chip in towards something that didn't get sourced from Alibaba.com. I'm watching this story...

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            • #36
              Well, well, well! What an unexpected turn of events! Not.

              Got the official EoB from Medicare today. Chair was approved, SmartDrive was approved, all options except...drum roll please...titanium frame upgrade and color anodizing.

              Boom. EoB cites the exact Medicare Policiy Guideline document I told the DME about 5 months ago, and he billed it exactly how I told him wouldn't work according to that policy (titanium as a separate upgrade item).

              Colossal waste of time. Their time. No way I'm paying out of pocket nearly $3k for an aluminum ZR. Value just isn't there IMO.

              I haven't seen the entire official out of pocket bill yet, just his first estimate. IF the titanium frame upgrade can be already included in the $2,800, then I'll consider moving forward negotiating that down. Otherwise, not happening. I'd rather put that money into a HoC custom titanium chair. Last I checked his frames start at $1,500 + options and finishing bits (casters, forks, locks, back, etc).

              At the end of the day, I wanted my own direct experience with this process, and I'm getting it. Confirming most of what I knew (and suspected) along the way.

              We'll see. It's all about exactly what's included in the $2,800 OoP price this point.
              Last edited by Oddity; 03-13-2019, 03:01 PM.
              "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

              "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

              "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

              Comment


              • #37
                Here is an image of part of the EoB, with references to the LCD and Policy Article numbers addressing the titanium denial/non-coverage:



                Sad, but true. They'll buy me an $8,000 SmartDrive (that I'll rarely use) but not spring an additional few hundred for the "upgraded" frame material that I'd benefit from every day.

                To be clear: Medicare believes frame material is already included as part of their base ~$2,100 K0005 assignment/reimbursement amount, as such, TiLite deciding to make titanium an order form "option" means DME providers can not select that option and bill for it separately.

                To be even more clear: DME providers can't even bill US separate for the option, since CMS has determined doing so is "un-bundling", which essentially means double billing for one item: Medicare pays for frame material in base reimbursement, then dME charges us for frame material a second time. That's a HUGE no-no, totally illegal, to "un-bundle" Medicare Billings.

                Here's what's gonna happen from here: I'm going to ask the DME to eat the titanium upgrade cost, and make it back by marking up the other non-covered option to cover the cost of the titanium. If he discloses this new marked-up cost to me on an ABN form, and I agree by signing it, he's free to charge me whatever I agreed to pay on the ABN, and not run afoul of the Medicare unbundling policy (since he is technically NOT billing me for the titanium upgrade specifically.)

                It may well run afoul of some other rule about eating costs and marking up others to cover the loss, but that's above my pay grade. Can't hurt to ask.

                Stay tuned.
                "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

                "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

                "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

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                • #38
                  What an interesting job it must be looking for ways that something cannot be done. I wonder at what point the cost for such an employee is surpassed by 'savings' found by such letters denying things (I wont get into if AL is cheaper than TI in the long run considering stress cracking...).

                  Better you than me, I hate dealing with nonsense like this, lol

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                  • #39
                    Kinda took nearly a year to get back to what you already told them when first started on chair?
                    Means another Face-to-Face with doctor or seating clinic, don't it? Think there is a 90 day time limit, isn't there?
                    DME you would think know rules and what is/isn't covered? Is it like billing, not the Tech or salesperson's department, so they don't check or even listen when told?
                    Have admit dealing with DME does help one work on their patience, don't you think?

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                    • #40
                      Got my TiLite TR3 approved and paid for with Ride Custom cushion and SmartDrive. Just waiting on delivery now. Only took 2-1/2 years. But to be fair, it was more HMO issues than DME issues that took so long. It seems like the HMO medical group was price shopping and selected the lower bids. You know what happens when you go on the lowest bid. The first DME closed shop in California (probably because they were low balling to get the business only to find they couldn't turn a profit). The second DME was new to this and when they found out that they actually have more work for less money compared to a power chair, they canceled the order. The third DME (the highest bidder) has been great.

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                      • #41
                        There was a window between when they deactivated the K0009 HCPCS code (forcing manufacturers to code all their "ultra-light" wheelchairs K0005) and when the "unbundling" policy letter referenced in my EoB was issued (Dec 2017), during which the titanium upgrade option (with separate billing code and additional reimbursement) worked fine. I know a number of folks who used this method between ~2014 and late 2017 to acquire TiLite TR and ZR titanium frames. Sadly, no longer, it seems.

                        On a complete side note, I've gotten a handful of PMs about HoC chairs, and my "$1,500" statement. To be clear: I don't know first hand how much a completed chair costs. They've posted prices in comments on their Instagram feed of starting at $1,500 for simplest raw frame, and between $3,000-$5,000 for complete chairs. I could imagine spending $5k on one and being very happy, relative to my experience these past 10 years pushing the Lasher.
                        Last edited by Oddity; 03-16-2019, 05:59 PM.
                        "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

                        "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

                        "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

                        Comment


                        • #42
                          Well I have the HoC order form but, I can't figure out how to post a picture. $1,500.00 is just a bare frame.

                          on a side note if it were easier to post pictures I think more people would use this site.

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                          • #43
                            If everything was approved can't you just pay for the titanium upgrade and color anodizing?

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                            • #44
                              Partly true. By signing an ABN form (advanced notification of uncovered costs form from Medicare) Medicare patients CAN pay out of pocket for uncovered options. CMS just requires we know ahead of time what those costs will be, before we decide. I explained the "unbundling" issue, in an earlier post, as to why this doesn't apply to frame material upgrades (like titanium). I could indeed use this ABN form process to pay for the color anodizing myself, but not the titanium upgrade.
                              "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

                              "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

                              "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

                              Comment


                              • #45
                                Originally posted by Oddity View Post
                                Partly true. By signing an ABN form (advanced notification of uncovered costs form from Medicare) Medicare patients CAN pay out of pocket for uncovered options. CMS just requires we know ahead of time what those costs will be, before we decide. I explained the "unbundling" issue, in an earlier post, as to why this doesn't apply to frame material upgrades (like titanium). I could indeed use this ABN form process to pay for the color anodizing myself, but not the titanium upgrade.
                                This is so absurd. I mean I totally get that insurance companies (Medicare especially) doesn’t want to pay for medically unnecessary stuff. But a frame that is 2# lighter offers at least the potential of benefit, at least let us pay for the upgrade. I double the bright pink anodizing you’re planning on getting is going to put any less strain on your shoulders.

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