Changing DMEs: PCP Referral Required, per Insurance?

[Kiralynx]

In the thread about Apria and the Headrest Mask (viewtopic.php?f=1&t=47581&st=0&sk=t&sd=a), I commented,

Probably a thought for another thread, but my insurance is presently insisting that I'm not permitted to change DMEs without a referral from my primary care physician.

Rested Gal said, "A-M-A-Z-I-N-G....wow. I hope you do start a thread about that. Simply amazing. "

So, here I am, starting the thread.

The genesis of this astonishing email from my insurance had to do with the above referenced thread about trying to order a new mask from Apria, the authorized DME for my insurance.

Every single time I try to order supplies, the order gets screwed up. Nasal pillows tossed in a plain manila envelope and sent regular post, arriving crushed and unuseable, and then Apria insisting I must bring them the ruined set before they would reorder. (Turns out they didn't have the order number for CL2 direct seals on file, and wanted to get it off the package they'd screwed up. But they couldn't just ASK me for the number. Guess they did not want to admit they didn't have it.) Wrong length hose sent. Refusal to quick order a full-face mask.

Apria has also refused to fill two prescriptions from my doctor on the grounds that "your insurance won't cover that." "That" was additional data cards for my machine, and the full-face mask I needed just about the time I was due for a new mask. Apria refused to honor my PCP's prescription for an additional mask of my choice, and instead made the full-face mask my replacement mask.

Apria wanted me to sign a contract stating that I would pay the full, billed amount, on any item for which my insurance denied coverage. Not the negotiated rate -- the full, exhorbitant, billed rate. Needless to say, I declined. I was still pretty sleep deprived, back in April, but I wasn't THAT sleep deprived!

I know that I have seen people posting about getting reimbursed by their insurance for products purchased from CPAP.COM and other on-line DMEs, but I had no idea how to do about it. (The insurance manual we received is remarkably unhelpful about these things.)

So, I wrote to the Insurance, and (a) placed a formal complaint against Apria for the latest fiasco, and (b) asked how I could submit claims for supplies purchased, since Apria was incompetent.

I received a boiler-plate on how to find an approved DME, which contained an intriguing statement:

As your plan requires a referral from the Primary Care Physician (PCP) for all services not rendered by the PCP, should you change DME providers, a referral from the PCP to the new DME provider is required. If a referral is not obtained, no benefits are available for the services.

My return inquiry asked two questions: (1) Why my PCP should give a darn where I got my prescriptions -- medical or equipment -- filled as long as they were filled, and (2) Why did I need a referral in order to change DMEs when I had not needed a referral to GET one in the first place (the sleep center where my study was done faxed my test results and the doctor's prescription to Apria) brought the following boiler-plate:

Do you need a referral?
Yes, your primary care physician (PCP) is responsible for coordinating your care. Your PCP will authorize required referrals to specialists and facilities, as needed. The referral requirement is a provision of your
plan, which does not apply to your prescription coverage.

Additional information you should know
1. The first visit authorized must be within 90 days of the date the referral is issued.
2. If the referral is for multiple visits, the first visit must be within 90 days of the referral date and the remaining visits must be used within one year of the date the referral was issued.
3. Your PCP determines how many visits are authorized on the referral.

The information provided above is not a guarantee of coverage. Coverage is based on all the terms and conditions of your plan as well as eligibility at the time services are received.

And that is where the matter stands. It's patently obvious that the reply is (a) boiler plate, (b) sent by someone who has no idea what CPAP is, or what a DME is, or even that DMEs fill prescriptions.

And I have no earthly idea what I'm going to reply to this.

[LSAT]

Interesting...I was on Medicare when I first started on CPAP and I used Apria. Last year I switched to a Medicare Advantage plan. When I called and asked them if I was required to use a specific DME, I was told NO...I can go anywhere that accepts Medicare. I found what appears to be a great DME that just opened near me. I stopped in and had a 30 minute discission with a consultant. We discussed the two machines that I had and she invited me to come in and have them pressure tested. I had some questions and she said she would give me some pointers when I stop in with the machines. We discussed masks and she had almost every one on display. I left with a goods feeling and I didn't spend a dollar. I'm going to take her up on her offer to check out my machines in January and at the same time...order a new mask. (They also carry mask parts).

[sronsen]

That is surreal! A DME provides equipment prescribed by a physician, just as a pharmacist dispenses medications likewise prescribed, except a pharmacist sometimes does some work. What does your DME have to do with your treatment? Most of them do not provide data-capable machines, so they have no role to play in your treatment. If there's any role, its for a RT, who has a conflict of interest if he or she works for a DME.

I'll stick with submitting my on-line receipts to my insurance company and receiving 70% reimbursement! I had a DME once, 10 years ago who provided my cheap CPAP (no humidifier) and mask at hugely inflated cost to me, despite insurance reimbursement. I haven't needed one since and will never in the futire! With my savings, I have several masks in the closet and a complete backup CPAP and humidifier. Several hoses too. I have my own 24/7 support at the lowest possible cost.

[Kiralynx]

Interesting...I was on Medicare when I first started on CPAP and I used Apria. Last year I switched to a Medicare Advantage plan. When I called and asked them if I was required to use a specific DME, I was told NO...I can go anywhere that accepts Medicare.

Alas, I don't qualify for Medicare yet -- or maybe I'm lucky I don't, since if I'd had to wait another eight years for my Bipap, I might not have made it.

Can you be reimbursed by Medicare if you choose to order on-line from, say, our good hosts?

[Kiralynx]

That is surreal! A DME provides equipment prescribed by a physician, just as a pharmacist dispenses medications likewise prescribed, except a pharmacist sometimes does some work. What does your DME have to do with your treatment? Most of them do not provide data-capable machines, so they have no role to play in your treatment. If there's any role, its for a RT, who has a conflict of interest if he or she works for a DME.

I was told by my insurance that the services provided by a DME (filling prescriptions) is not the same as those of a pharmacist (filling prescriptions), and I must therefore have a referral any time I want to order supplies or change DMEs.

I'll stick with submitting my on-line receipts to my insurance company and receiving 70% reimbursement! I had a DME once, 10 years ago who provided my cheap CPAP (no humidifier) and mask at hugely inflated cost to me, despite insurance reimbursement. I haven't needed one since and will never in the futire! With my savings, I have several masks in the closet and a complete backup CPAP and humidifier. Several hoses too. I have my own 24/7 support at the lowest possible cost.

Well, all I was trying to do was to find out how to submit on-line purchases for whatever reimbursement I could get. I have several back-up masks and a back-up Bipap.

I find myself succumbing to conspiracy theory -- I complained about Apria to Aetna, and now Aetna's going to make sure I cannot change from Apria. Man, I could spin a great yarn from that notion!

[6PtStar]

Can you be reimbursed by Medicare if you choose to order on-line from, say, our good hosts?

I am on Medicare at this time if this new bill does not mess everything up!!!!!!!! I have talked to the Medicare people three different times and according to them there ain't no way in He** that they will reimburse for purchaces made by me internet or otherwise. It does not matter how much money I can save them they will only pay someone that is registured with them as a Provider or Contractor. I know some rules are different in some states but I would bet this is a firm rule.

I do buy some things out-of-pocket just because it is easier and less frustrating. Sometimes it is either buy it myself or do without.

Jerry

[Kiralynx]

I have talked to the Medicare people three different times and according to them there ain't no way in He** that they will reimburse for purchaces made by me internet or otherwise. It does not matter how much money I can save them they will only pay someone that is registured with them as a Provider or Contractor. I know some rules are different in some states but I would bet this is a firm rule.

I do buy some things out-of-pocket just because it is easier and less frustrating. Sometimes it is either buy it myself or do without.

Jerry,

That's dismaying. Especially considering how much trouble it is to order from the registered Probiders and Contractors sometimes.

[Kiralynx]

bumping

[Guest]

The insurance companies love it when they frustrate you sooo much that you buy out -of-pocket and don't bother them even though you've paid their premium.

[rested gal]

The insurance companies love it when they frustrate you sooo much that you buy out -of-pocket and don't bother them even though you've paid their premium.

Yup. There's method in their madness.

[Patrick A]

Interesting...I was on Medicare when I first started on CPAP and I used Apria. Last year I switched to a Medicare Advantage plan. When I called and asked them if I was required to use a specific DME, I was told NO...I can go anywhere that accepts Medicare. I found what appears to be a great DME that just opened near me. I stopped in and had a 30 minute discission with a consultant. We discussed the two machines that I had and she invited me to come in and have them pressure tested. I had some questions and she said she would give me some pointers when I stop in with the machines. We discussed masks and she had almost every one on display. I left with a goods feeling and I didn't spend a dollar. I'm going to take her up on her offer to check out my machines in January and at the same time...order a new mask. (They also carry mask parts).

I was on BC/BS FEHB when I started CPAP, now that I am on Medicare (soon to be Obamacare) I was told by my Secondary insurance BC/BS FEHB that I can use any "DME" and they would pay what Medicare doesn't. Go Figure.

[leejgbt]

I believe your insurance might be violating an insurance regulation. You need to call your insurance commissioner as this type of "captive referral" system is prohibited in Montana (so I suspect elsewhere also). While "in-network" physicians are routinely required to refer to "out-of-network" physicians and labs this provision has never included DME providers and is used to have the "out-of -network" provider treated as if they are "in-network". At most you would have a separate deductible and separate co-pay for your "out-of-network" services. I have never heard of an insurance making this a non-covered service. Someone at that insurance is misinterpreting their own rules I think.

As for Apria asking you to sign something making you responsible for the entire billed amount you were right to decline. Also, Apria does not have the right to tell you which mask you can order. If you have an RX for two different masks they have to honor this RX. The replenishment rules for payment are the only guidelines they are held to, not the type of mask.

[Gerryk]

Kiralynx who is your insurance company? I do believe most states have a department that covers insurance and regulations. I would look it up in your state and give them a call. Explain what has happened and even fax or email a copy of the response from your insurance company. I do not believe what they say is true or legal. I wouldn't argue with the insurance company, rather go find out if what they have done is legal in your state or if the state will get involved. I would bet all you need is a letter from the state that what they are doing is illegal and they will change their mind real quick.

All it takes is a phone call.

Gerry

[Kiralynx]

The insurance companies love it when they frustrate you sooo much that you buy out -of-pocket and don't bother them even though you've paid their premium.

Unfortunately, yes, you're right. Which is why I'm trying to work this out.

[Kiralynx]

Yup. There's method in their madness.

Yes, so the question is -- what to reply to THIS bit of madness.