DMEs asking for physician notes

[Janknitz]

If you are on Medicare (and some other insurances) they are asking for the physician notes to make sure that there was follow-up and documentation of adequate compliance within the first 90 days of using CPAP. Otherwise, their submission of charges may be denied.

So while HIPAA does protect your privacy, if you don't provide adequate documentation to meet the criteria of your insurer, then the DME may not be willing to provide you with the necessary equipment.

If you are not on Medicare, call your insurance company and find out what documentation the DME must submit to be reimbursed. If you are on Medicare, you need to meet the DME halfway at least, by providing the documentation that meets Medicare criteria. If your insurer does not require such documentation, then you have to decide how hard you want to argue with the DME in order to get your supplies from them. Are there other DME's covered by your insurance? Will your insurer reimburse your expenses if you go out of network (ie. buy from an online supplier like our hosts)? Is it worth all the trouble to you, or is it affordable and easier to just take care of things on your own. Only YOU can answer these questions.

[49er]

If you are on Medicare (and some other insurances) they are asking for the physician notes to make sure that there was follow-up and documentation of adequate compliance within the first 90 days of using CPAP. Otherwise, their submission of charges may be denied.

So while HIPAA does protect your privacy, if you don't provide adequate documentation to meet the criteria of your insurer, then the DME may not be willing to provide you with the necessary equipment.

If you are not on Medicare, call your insurance company and find out what documentation the DME must submit to be reimbursed. If you are on Medicare, you need to meet the DME halfway at least, by providing the documentation that meets Medicare criteria. If your insurer does not require such documentation, then you have to decide how hard you want to argue with the DME in order to get your supplies from them. Are there other DME's covered by your insurance? Will your insurer reimburse your expenses if you go out of network (ie. buy from an online supplier like our hosts)? Is it worth all the trouble to you, or is it affordable and easier to just take care of things on your own. Only YOU can answer these questions.

I don't have medicare and yes, I did ask a member services rep what documentation DMEs were allowed to require. He told me they could ask for anything they wanted but he gave me wrong information on another issue per a supervisor so I may call again and ask to speak to someone else about this.

Regarding going out of network, the supervisor didn't know if I would be reimbursed by cpap.com or any other out of network provider and I couldn't tell from reading my benefits. She told me the only way to find out would be to submit a claim. I should have been more persistent about getting an answer but I had been on the phone nearly an hour and was worn out. I think if I can;t find a DME to do business with, I will submit the claim and see what happens.

You're asking some good questions at the end of your post that I need to address.

[Janknitz]

You can request the "Evidence of Coverage" which is the actual contract between you and your insurer. You will not have seen it unless you specifically request it. That document should spell out the DME policy.

[49er]

You can request the "Evidence of Coverage" which is the actual contract between you and your insurer. You will not have seen it unless you specifically request it. That document should spell out the DME policy.

Great advice, I will definitely ask for this.

Thanks!

49er