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Thread: Medicare reimbursement for chair/cushion

  1. #1

    Medicare reimbursement for chair/cushion

    Real long story short

    I bought a chair last July and the DME provider said that I had to pay up front and then get paid back by Medicare. I did that and it took him until November to get me the RX from the doctor and receipts from him. I fronted almost $6k dollars for a Ride Designs cushion ZR2 chair and Dino wheels. I had to call him every week and bug him until he finally provided them. He said that DME suppliers were no longer allowed to submit for patients and I would have to do it myself. I have been busy with a move to Las Vegas and building a new home so I am just getting around to it now. I have been on the Medicare website and the only thing I have been able to find is saying that the DME provider must submit for you and if they aren't reconginzed by Medicare then they won't pay anything. Also in looking over my paperwork I discovered that the Rx forms he sent the doctor to fill out were for Med-cal and not Medicare.

    I think this guy might have purposely mislead me and may have never planned on giving me the papers if I wasn't such a pest. Does anybody have any info or experience on what the procedure is for Medicare reimbursement or am I screwed?

    thanks

  2. #2
    Yes, it sounds like they are trying to screw you. I'm sorry they have your money. But you do have the chair? By paying up front you probably got your chair quicker at least....

    They absolutely have to submit the claim for you, IF they are a Medicare provider. You actually can never submit a claim yourself and get reimbursed. The Medicare websites are unclear, and even if you call and ask for help, Medicare customer service often tells you the wrong thing.

    Are you sure the DME provider is a Medicare provider? If so, they are required to submit the claim for you. If you send the claim yourself, Medicare will mail you back a denial in 2 months saying the provider should have submitted the claim for you.

    If you don't use a Medicare provider and try to file the claim yourself, Medicare just sends you a denial letter for not using a Medicare provider.

    So my next concern is that they aren't a Medicare provider at all, and misled you at the time of purchase by letting you think that you could submit the claim yourself.

    The only time you submit a claim is if you are submitting TO GET A DENIAL LETTER, if you have a secondary insurance that covers some things that Medicare does not. You then send the denial letter to your secondary insurance.

    I might call Medicare (although I hate calling them....), ask to speak with a supervisor in DME, and get their advice. They can confirm your provider is a Medicare provider, and ask them EXACTLY what you should say to the provider to get them to file the claim. Do not mess around with anyone but the supervisors/bosses at Medicare... and at your DME from this point on.

    My biggest concern is that since they have your money, they don't have much incentive to help you.

    EVERY TIME we have paid up front for a piece of equipment and asked the provider to submit the claim for us, we have had problems. The provider either "forgets" to file it, so I wind up calling Medicare/the provider every month to make sure it got submitted. Or just as often, the provider files it incorrectly and it gets rejected.... but the rejection letter goes back to the DME and not to you, so you only find out the claim is in limbo and needs to be resubmitted by calling every month yourself. They have their money, so what do they care? Medicare "requires" that providers submit all claims within ?18 months I think. WHAT?!?! That is a ridiculously long time....

  3. #3
    I have the chair and have sent an email to him to see if they are provider. I'll see what he says back. I have secondary insurance so maybe I might be able to submit through them if this goes bad. Otherwise I am going to have to sue him I think, I have tons of emails and everything proving what he did.

  4. #4
    Honestly, I wouldn't mess around with emails. I would check on Medicare's website yourself (or call medicare like I suggested) to confirm whether they are a Medicare provider. If they are, call and ask to speak with the highest guy up you can or even better, go in person. If they still refuse to submit it, remind them that you will have to report them to Medicare, the Better Business Bureau, and online review sites if they are committing fraud. Of course, sometimes being aggressive will piss people off. But I have found being nice gets you nowhere either.

    So that's why calling Medicare to get the exact wording of what you need to say to the provider may help.

    Also keep records of every phone call, the date/time, the name of every person you talk to.

    If you do have secondary insurance that pays for some things Medicare does not, then you will need to submit the claim to Medicare yourself anyway if the provider refuses, and get the rejection letter to send to your secondary insurance. It's great you have this. Because even if you can get the provider to submit the claim for you now, I am sure they would screw it up. And of course, most of your upgrades will get rejected by Medicare anyway, and will need to cross over to your secondary insurance for coverage.

  5. #5
    Senior Member jschism's Avatar
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    You got screwed, Medicare doesn't re-imburse and they only pay a certain amount when approved, most likely a lot less than you paid out of pocket. Do you have anything in writing to prove that you were told by DME provider you WOULD get reimbursed? They are knowingly lying to you and can get get in serious trouble from ht emedicare/medicaid system. If not you are screwed, if you do, threaten to turn them in and sue. Had same thing happen to me. Contact states attorney consumer affairrs division if you have proof, they will look into the case so you don't need to hire a lawyer, although this will take longer. There is no way to find out from medicare if they filed, I even had a lawyer trying to get that info for my case and he got nowhere.
    What I have found out since then, if they did in fact actually submit to medicare, you WOULD HAVE gotten a letter reguarding wether it was approved or not. This usually never takes longer than a month if the dealer is legit.
    Last edited by jschism; 05-07-2012 at 09:47 AM. Reason: add

  6. #6
    Senior Member jschism's Avatar
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    You can also file a complaint with NRRTS:
    http://www.nrrts.org/registrants/complaint-form
    Not that this does much, but it WILL get their attention

  7. #7
    Quote Originally Posted by jschism View Post
    You got screwed, Medicare doesn't re-imburse and they only pay a certain amount when approved, most likely a lot less than you paid out of pocket. Do you have anything in writing to prove that you were told by DME provider you WOULD get reimbursed? They are knowingly lying to you and can get get in serious trouble from ht emedicare/medicaid system. If not you are screwed, if you do, threaten to turn them in and sue. Had same thing happen to me. Contact states attorney consumer affairrs division if you have proof, they will look into the case so you don't need to hire a lawyer, although this will take longer. There is no way to find out from medicare if they filed, I even had a lawyer trying to get that info for my case and he got nowhere.
    What I have found out since then, if they did in fact actually submit to medicare, you WOULD HAVE gotten a letter reguarding wether it was approved or not. This usually never takes longer than a month if the dealer is legit.
    Good advice. Thanks for posting these useful places to file complaints.

    You bring up another problem of paying up front...... Medicare will NEVER agree to pay the full price for anything. Providers are forced to accept whatever Medicare will pay. But if you pay up front, then Medicare reimburses YOU (if the provider filed the claim...).... they would only pay like half of what you got charged. Do you think the provider will reimburse you the other half? No way. Once they have your money, they will never pay it back. Sometimes they are up front about it.... they are not willing to accept Medicare's low price for payment.

    We have had such difficult ordering ANY DME that is not the simple, basic models that Medicare routinely pays for. If we want ANYTHING higher end or even slightly less typical - the provider makes us pay up front. The problem is that it often winds up costing more for us then if we just bought it ourselves online....

    I have to admit, I also feel sorry for the good providers. They get paid so poorly by Medicare that their profits are ultimately quite low. And since many Medicare transactions recover multiple phone calls/refillings (often due to poorly trained DME staff), the providers often lose money on us.

    But one additional thing - after the > 1000 phone calls I have made to providers/Medicare/other insurance companies, I have learned a few things about working through the system. You can always find out if a claim has been filed by a provider to Medicare. You sometimes need to get to the correct department at Medicare to find this, but you can. Be persistent. I always ask for a supervisor almost immediately when I call Medicare... but politely... as many of their first line customer service reps don't know what they are doing. It may take me an hour on the phone though....

    Our lawyers were terrible at navigating Medicare, so it does not surprise me yours couldn't find out if a claim was filed. They didn't believe me that they should never accept "no" for an answer, and to always push things up the ladder. Our lawyers were so useless that I ultimately did all the communication with Medicare ourselves when we were struggling with our initial settlement/accident related issues, and literally just called the lawyer when it was done.... and told them where to fax the final forms.

  8. #8
    UPDATE..

    I called Medicare and surprise they are not a authorized supplier. I contacted my secondary insurance and they said they will cover it if I have a denial letter from Medicare. Not sure how much or what they will cover but now I need to see how to file it with Medicare so I have the denial letter. Anybody have any idea how to go about that?

  9. #9
    Senior Member jschism's Avatar
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    If you have proof they did say you would get re-imbursed, sue them and get a free chair. Idiots like that shouldn't be doing this kind of business anyway.
    I would also send copies and notify TiLite, maybe they pull the dealers status as a seller.
    Last edited by jschism; 05-11-2012 at 03:22 PM. Reason: add

  10. #10
    Senior Member ~Lin's Avatar
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    Quote Originally Posted by jschism View Post
    If you have proof they did say you would get re-imbursed, sue them and get a free chair. Idiots like that shouldn't be doing this kind of business anyway.
    I would also send copies and notify TiLite, maybe they pull the dealers status as a seller.
    Ditto this! I'm sure you're not the first person they've done this to, or the last if you don't make a big stink about it.
    Board Member of Assistance Dog Advocacy Project working in Education. Feel free to ask me any service dog questions!

    I am not paralyzed. I have a genetic connective tissue disorder with neuro complications and a movement disorder.

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