Simon Sinek’s book “Start With Why” says to be successful, you must start with your why when creating a business. I started The Compression Closet to help those without insurance obtain the garments they need for lymphedema. When I was working in a durable medical supply company that served women who needed bras and prostheses due to breast cancer, there was also the need for compression for lymphedema. Time and time again, I heard women complain about insurance not covering these products and how difficult it was to obtain them. At this time, you could not bill Medicare for garments. I sympathized with this woman who had struggled to beat the battle of breast cancer just to be left with a new disease, a chronic disease. To make matters worse was the challenge of trying to obtain these garments, and thus, I started The Compression Closet.
BILLING MEDICARE FOR COMPRESSION GARMENTS
So now, some twelve years later, Medicare has begun to cover many of these garments. Therefore, I am faced with deciding whether to jump on that bandwagon. I have been doing much research and given this decision much thought. And at this time, I’ve decided that it is not feasible for me to bill insurance. There are many hoops I must jump through to become a Medicare-approved provider of compression garments. Along with that, a great deal of cost is involved, which would then have to be passed on to my customer. This would negate my original intention of helping those who do not have coverage.
BECOMING A LICENSED DMEPOS
To bill Medicare, I must become a licensed DMEPOS Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. There is currently no license for being a compression fitter and garment provider. However, they are working on a program to create a license and accreditation for eligibility in this area. Then, there is the expense of becoming accredited and obtaining a $50,000 surety bond on top of business insurance. Finally, I would need accreditation and have to pass all the government inspections and procedures. The cost, time, and inability to get a license at this time are all significant hurdles for me.
Additionally, my markup is so low currently that I would have to raise all my pricing to compensate for all the additional costs of billing insurance. This is one of the most significant drawbacks for me. Returning to my original reason for starting this business – “my why.” I wonder how many people will be left without a place to get affordable, high-quality compression garments.
Although some new Medicare reimbursement rates are reasonable, some are not! For instance, Medicare coverage for knee-high compression stockings 20-30mmHg is only $36.93. This reimbursement rate is less than the wholesale price of any major manufacturer for knee-high compression stockings that I know of. I have to caution my therapist, as well as my customers, that there are no compression garment regulations. Therefore, anyone can put the word compression on a garment. So you might be able to find a compression stocking out there for this price, but you have no guarantee as to what you are purchasing. There are many garments out there marked compression garments that will do no good for lymphedema and possibly cause additional issues.
QUALITY OF THE PRODUCT I SELL
The bottom line is that I will not compromise my selection of product offerings to provide a stocking to fit the Medicare price range. I cannot imagine any stocking for $36.93 that would benefit the lymphedema condition. There are a lot of stockings out there that might worsen the condition. Buyer beware. If you go shopping, I suggest you stick with the major manufacturers, Jobst, Juzo, Mediven, Sigvaris, L&R, and Therafirm. I have had many customers spend hundreds of dollars on compression garments they could not use because they worsened their condition. And could not return because they had worn it.
Another consideration is the out-of-pocket cost that you might have to pay. For instance, if you choose a custom compression knee high instead of your Juzo Dynamic over-the-counter stocking, your 20% co-pay would be at least $85.60 and probably a lot more for the pair. Which is more than a pair of Juzo Dynamic stockings would cost you. By no means am I suggesting that you not take advantage of the Medicare coverage! I’m just saying beware of co-pays, upgraded pricing, and what you will be paying. The insurance game can be a tricky one!!
As I initially said, I have done much research into this. Furthermore, I will continue to attend all the classes provided on this subject by the government and private entities. I have updated my website’s HCPC coding to correlate with the new Medicare guidelines. So, all your receipts will have the necessary coding if you want to submit them to your insurance company for possible reimbursement. So the short answer is no, I am not billing insurance now. However, this may change if I logistically find a way to bill Medicare for compression garments and maintain my company’s integrity and “my why.”
Disclaimer – This post is for general information. Furthermore, the information contained in this blog is not a substitute for medical advice. Always consult a licensed healthcare professional for advice on your specific condition.