Print Page   |   Sign In   |   Join
Page 1 of 1
Thread Actions

5/21/2014 at 1:35:48 PM GMT
I just got word from two different manufacturers reps that BCBS will soon be implementing even more stringent compliance measures for pap patients. 

The following is the e-mail that was forwarded to me from my rep.

PAP Device Data Required for Ongoing Sleep Therapy Treatment Requests


There is growing industry concern regarding patient compliance with PAP treatments used to treat obstructive sleep apnea (OSA).  Poor compliance can lead to serious health issues and result in wasted dollars spent on equipment and supplies.  For this reason, BCBSGa is introducing an enhancement to our sleep testing and treatment program, administered by AIM Specialty HealthÒ (AIM), which will allow us to support your efforts to encourage patient compliance. 


AIM Sleep Disorder Management Diagnostic and Treatment Guidelines provide that ongoing treatment is indicated only for patients who demonstrate compliance with therapy. In order to satisfy the medical necessity of ongoing treatment, demonstration of compliance is required every 90 days for the first year of therapy and annually thereafter. Beginning July 1, 2014, patient attestation of sleep therapy compliance will no longer be required to support a preauthorization request.  Instead, AIM will be requiring DME device data to confirm compliance with therapy. 


In order to facilitate the submission by your practice of DME device data, AIM has implemented a direct link with the following manufacturers who will automatically provide device usage information to AIM about a particular patient when you make a request for on-going therapy.  

•              Philips

•              Fisher and Paykel Healthcare

•                ResMed

•                DeVilbiss Healthcare


To take advantage of the convenience of these arrangements,  you should register each patient in the appropriate DME manufacturers’ web-based software, per the training materials provided to you by each manufacturer.  We also recommend that you perform periodic downloads of member device usage data before contacting AIM for review requests so that you can determine if the criteria for ongoing treatment are met. 


For patients with devices manufactured by other companies, you will need to manually enter compliance data from their devices into the AIM system. 


We are pleased that this enhancement to our sleep management program will:


·         Help you more easily identify patients who may need help using their PAP equipment

·         Promote more accurate clinical appropriateness determinations from actual compliance data

·         Save you time by streamlining the approval process


For more information, please contact your Provider Relations representative.  

5/22/2014 at 6:24:29 PM GMT
GAMES members that are contracted with BCBS of GA and provide PAP devices and related supplies need to consider NOT accepting any future patients with this payer. Why would BCBS of GA continue to add more stringent compliance measures after:
1) Requiring there patients to have home sleep testing - SAVES BCBS OF GA MONEY,
2) Not requiring/ or allowing the patient to a have titration study - SAVES BCBS OF GA MONEY,
3) Requiring the DME company to provide AUTO type PAP devices that increase equipment acquisition costs for the DME company and not paying more for this type of therapy - SAVES BCBS OF GA MONEY,
4) Requiring the DME company to have to request authorization through AIMS Specialty Website, which adds administrative cost for the DME company- SAVES BCBS OF GA MONEY,
5) Now requiring the DME company to track "recorded" compliance every 90 days for the first year, increasing the DME administrative cost - SAVES BCBS OF GA MONEY,
6) DME company has to obtain recording devices (modems) with no reimbursement, again increasing the equipment cost for the DME company - SAVES BCBS OF GA MONEY,
7) The DME company has to request "re-authorization" through AIM's Specialty website and make sure that the DME company uses one of three manufactures (Resmed, Fisher/ Paykel, or Respironics) to tie the compliance together with the patient and the DME company, this limits the DME company ability to use any other manufacture and possibly pay more for the AUTO type PAP devices - SAVES BCBS OF GA MONEY....

On top of all of this....We had a fee schedule reduction in November of 2013.

Are you seeing a theme yet?????

Who is saving money from every direction - - BLUE CROSS / BLUE SHIELD OF GA .
Who is having there cost increase in every direction - - THE DME COMPANY.

Are we, the DME companies in the state of GA, willing to stop accepting BCBS of GA patients? I'm not sure if I can even financially make it make since to continue accepting them?

5/28/2014 at 3:23:04 PM GMT
Well said.

6/3/2014 at 2:54:04 PM GMT
Problems with BCBS
I hope you are all well aware of how BCBS of GA is attempting to destroy our State Health Benefit, I have heard from several members on the subject as well as members of the BOD, state health journalists, and others in the healthcare field (Docs and Labs) and wanted to "list our grievances" so that we as individual companies that make up GAMES can decide how we wish to approach BCBS. Barring individual action with BCBS, GAMES is unable to instruct or encourage our membership on how to proceed with BCBS, due to antitrust laws, we can however, openly discuss individual strategies and ideas on how we can as an orginazation deal with "Big Blue". 

The majority of the issues I am hearing backlash on are as follows (I will address each in more detail):

1: reduction in reimbursement
2: increased compliance/paperwork load to get the reduced reimbursement
3: unnecessary recoupments/zero transparency in the recoupment process.
4: lack of interaction/education with providers and beneficiaries.

To begin we must start at the beginning, BCBS made some shady deals to get the state health benefit plan (SHBP), this is well known and was even garnered a lawsuit from United Healthcare, which proved unsuccessful (oh how i miss the good old days of UHC!!!).  BCBS used its leverage of the SHBP to hold all providers int he state hostage, and slash reimbursement (by up to 50% in some cases) guaranteeing the savings that they promised the state to backdoor their way into the plan. Once the plan and the network of providers was secured, BCBS has systematically begun to dismantle the SHBP.  
With their latest announcement of how they will handle CPAP resupply and monitor ongoing compliance, BCBS is now the most stringent insurance that my organization has to deal with, even more stringent that the highest authority in the land Medicare. With the number of patients that are covered under the SHBP that fit the demographic of CPAP customers, BCBS has officially made it completely unprofitable to service SHBP CPAP patients.  
Sadly, this is not the end of the BCBS's atrocities against Ga providers. Most recently BCBS has announced that they will begin recouping money from providers. Why are they recouping this money? They wont tell us. How much can we expect to pay back? They wont tell us. When will these recoupments end? They wont tell us. What they will tell us is HOW and WHEN we can pay back this money, and that we can actively chase the difference down from the customer.  Based on my conversations with labs and Physicians, (NOT BCBS BECAUSE THEY WONT RETURN MY CALLS OR ANSWER E-MAILS) it seems that BCBS has paid some claims in error. Rather than upset their beneficiaries in this turbulent time (See the following articles) they are taking back from us and forcing us to go after their beneficiaries, essentially making us the bad guys in our customers eyes...


OF course this is all speculation, I have no way of knowing that BCBS's goal is to pass the buck onto GA providers to avoid any further embarrassment /beneficiary  backlash, what I do know is that at this point, in the point of declining reimbursement, shady dealings with DCH, increased difficulties with paperwork/documentation, and lack of communication with providers; I am not longer able to assume BCBS has anyone's interests at heart but their own bottom line. 

So, what is the solution? Do we light a fire under our beneficiaries? Do we band together with the hospitals and labs to send a message to BCBS? Do we organize like the teachers (Teachers Rally Against Georgia Insurance Changes)? Some of our own membership suggest that we retain attorneys and sue BCBS or DCH or both?

I am extremely interested in what each of you think, so much in fact that I am begging your for comments, ideas, anything... If you have contacts at BCBS that answer their phones or return calls, I need them. Email addresses, mailing addresses etc... If you know people in the media now is the time to get this story out, reach out to your physicians, write letters to your customers... anything you can do will help.

The danger we all face is one that we've all been hearing for some time now. If BCBS breaks us, it will not be long before the other third party insurers follow suit. and in this increasingly hostile environment for our industry, WE CAN NOT AFFORD a loss like that. 

I welcome any and all comments from every one of you, please e-mail me at or, attached is a copy of the letter that I have been sending to my BCBS rep every single day with no response.

Tyler Riddle

 Attached Files: 
BCBS LETTER.docx (14.24 KB)

Contact Us
2700 Cumberland Parkway ▲ Suite 570 ▲ Atlanta ▲ GA ▲30339 ▲ phone: 404.299.7700 ▲ fax: 404.299.7029▲