$$$ issues DME Compliance Monitoring and Insurance

[anakinskywalker]

Can anyone explain how it is that a sleep center in a hospital is allowed to refer you to their own affiliated DME provider? Isn't that a conflict of interest? As an ignorant first time CPAP user I allowed this to happen to me. The DME provided absolutely no choice in machines and required the compliance monitoring even though my high deductible insurance paid absolutely nothing for either the testing at the hospital or the DME fees for the machine or the compliance monitoring. I have read that hospitals are somehow exempt from some of the conflict of interest rules regarding DMEs but that loophole should be closed for sure.

What I now realize is that I should have purchased my machine from an independent DME like CPAP.com and paid less than half of what I was charged but I was too sick and tired to really figure that all out at the time. Now I am stuck with HUGE bills that I cannot pay. I am going to post separately about the cost of the sleep study dx and titration, but for this post I want to hear from others on how the DME and compliance monitoring charges work. From what I've been able to figure out, the charges are somehow bundled into the machine itself, so there is no way to figure out exactly how much extra they are charging for this "service" apart from their profit on the machine. The markup was just incredible -- my charges are over $2000 from the DME alone (and counting now that it has gone to collection) for a System PR One Auto with humidifier (non-heated tubing). The tech only spent about 10 minutes with me to dispense the machine - certainly not enough time to justify such a markup. The sleep study and titration charges were nearly an additional 3000, counting the dr charges for reading the report and ordering the CPAP tx -- I've been paying a little each month and have barely made a dent in the bill.

Essentially, even when there is no hope of insurance covering anything, the DME is allowed to force compliance on you and get you to pay them for the "privilege" of this invasive and totally unnecessary "service." They even automated their end of compliance by having an autodialer do the follow up phone calls to my home - no human being involved at all. I am sure they make a huge profit on this dubious service. I can certainly see if I were a truck driver or something which would require evidence of monitoring, but for the typical patient it seems a terrible invasion of privacy and all for nothing if you don't have insurance coverage to pay for it once you've demonstrated "compliance."

The other thing that I am now realizing is that I was never given a prescription. I asked the pulmonologist about this recently and the claim was that they don't really write a prescription, but rather write a "requisition" that they send to the hospital's affiliated DME provider. So I never saw exactly what the prescription was -- just had to take whatever was offered at the DME and assume they got it right. Not good at all -- kind of like sending you home with pills but not telling you the dose. Of course, I think now that the DME doesn't want you to know how to program the machine and set up the "dose" of pressure, since that would make you realize how little they are actually doing to set up the machine and justify their huge markup. The machine was pre-set when I got there to pick it up -- I'm sure they do that on purpose to keep the programming a big secret.

Anyway I ended up getting a machine off of Craigslist that works great -- identical to the machine the DME uses -- and I learned how to program it using the web using the settings that were on the DME machine. I even monitor myself with sleepyhead. I was nervous about going through Craigslist -- who knows where that machine has been -- it could even be stolen property I suppose. But the seller seemed genuine. Anyway, am sending back the DME machine to the DME to try to mitigate my losses and fighting the collection. Now that I know all of this I am dumbfounded by what a racket the DME (and the sleep study center) are running.

Interested in how others have experienced this.

[JScottEvans]

They can refer you wherever they like, but the choice is yours. If you are unsatisfied with the service you are receiving, then you definitely need to find another DME company. If you're paying out of pocket with no insurance involvement there is no need for you to show compliance. Compliance downloads are generally not billed and are a part of the monthly rental price.

[bwexler]

The best answer is everyone with a diagnosis of OSA should be required to come to this forum and others to learn what they need to do before they meet the DME, maybe even before the sleep study.

Laking advance knowledge you are doing what I would probably do. I think the hospital is entitle do regular payments from you of about $2/month until paid in full.
After you graduate and start earning a living, maybe a final settlement payment totaling about $800, which is what one of my sleep doctors charges for a sleep study in his office.

[xyz]

a
> Can anyone explain how it is that a sleep center in a hospital is allowed to refer you to their own affiliated DME provider?

It depends on the state.

> Isn't that a conflict of interest?

That's why it's outlawed in some states.

j
> They can refer you wherever they like

See above.

> but the choice is yours.

True. The problem is that new users don't understand all the ins and outs.

For those who have insurance, they should usually go with an in-network provider. But even that depends on the details, such as amount of co-insurance and co-pays.

Not only can they not depend on the DME to give them the straight story, but even worse, when they call the insurance company the odds of getting someone who is knowledgeable (and helpful) about DME issues is small.

[gomer]

My fam doc sent me to our local horsepital's sleep clinic. I had the Dx testing and titration study done there as well. Everything was done properly and great results. In my case there was a script, but I used the hospital's DME by choice.

I came here early on when the OSA issue came up and LEARNED a lot even before my sleep study, so I was prepared.

I like to LOOK before I LEAP....(& that goes for lab tests as well).

[anikinskywalker]

I did ask the insurance company about the cost before proceeding -- the testing part anyway. I was considering a home sleep study which I thought would be more affordable and easier to arrange to avoid overnight childcare expenses. But the insurance company told me that the hospital overnight testing would cost the same as the home testing -- that it was all billed as a sleep study so no different. So I went with the hospital testing since I thought I would be more apt to sleep longer there than at home with all the usual child-related interruptions. I now believe that the insurance company response was incorrect -- my research shows there are different billing codes for unattended sleep studies, so presumably the charges are different (less). I did not occur to me to ask the insurance company about the machine or the compliance monitoring since I did not even realize that compliance monitoring was something I had to purchase. I think there is a lot of deceptive practices with regard to the dispensing of the equipment as well as the way the sleep studies are conducted. I plan to file a complaint with my state's AG and consumer protection/health care quality agencies.

[anakinskywalker]

Just reposting the below paragraph under my correctly spelled username (still getting the hang of posting here). I would add to below that I agree with the leap before you look idea, but as someone was had undiagnosed OSA for a number of years, I was way too sick and tired, and relied on my local provider that I did not realize would take advantage of me the way that they did. Providers should not be in the business of looking at patients as opportunities to make as big a profit as possible they way that Best Buy and user car dealers do. Now I am much more jaded by this experience.

I did ask the insurance company about the cost before proceeding -- the testing part anyway. I was considering a home sleep study which I thought would be more affordable and easier to arrange to avoid overnight childcare expenses. But the insurance company told me that the hospital overnight testing would cost the same as the home testing -- that it was all billed as a sleep study so no different. So I went with the hospital testing since I thought I would be more apt to sleep longer there than at home with all the usual child-related interruptions. I now believe that the insurance company response was incorrect -- my research shows there are different billing codes for unattended sleep studies, so presumably the charges are different (less). I did not occur to me to ask the insurance company about the machine or the compliance monitoring since I did not even realize that compliance monitoring was something I had to purchase. I think there is a lot of deceptive practices with regard to the dispensing of the equipment as well as the way the sleep studies are conducted. I plan to file a complaint with my state's AG and consumer protection/health care quality agencies.

[Guest]

Do read this thread also "Process of Contacting DME and Requesting Data Capable Machine"

[jencat824]

I've never heard of a charge for 'compliance monitoring'. This is absolutely a case that needs the attention of your state AG. Unless someone else has info on this I'm unaware of, most of us that need to show compliance for insurance purposes, do so by various methods. The most common are taking the SD card to the DME or a dialing device attached to the unit. Both are done for a short period of time, usually 30 to 90 days. You are the first I've ever heard say they were charged for compliance monitoring, since its in the DME's best interest to show compliance to get paid. Since your insurance isn't paying, compliance monitoring isn't necessary.

Now many Drs want to see your data & request that you bring your SD card with you IF you continue to see your sleep Dr regularly. In many cases that isn't necessary, especially if you follow your own data & use this forum to learn how to interpret it.

I am angry that this outfit took such advantage of someone without insurance involved. If you need a sleep Dr in the future, you might want to switch.

Also, you have a right to a copy of your sleep study & a prescription. If you want to order a new mask, you will need this, so its very important to get this, otherwise getting replacement masks can be difficult. Call your Dr & insist that you are aware you have a right to your records - the sleep test results & any other medical records you have with them. Also insist for a mask prescription too, & make sure its general in case you want to try a different mask. These should be free, at least I think so, in my state the first copy of any medical record, including the sleep study is free, additional copies are charged at $x.xx per page. Keep that copy in a safe place, I have a friend who recently lost a rather long medical record & had to pay a bundle when she required another copy.

Let us know what happens with all this. This outfit has ripped you off. If you must pay, try to get all charges for compliance monitoring removed. Then set up payment arrangements for $5 per month - unless they charge a fee for billing and/or a finance fee, then paying it off quickly would be in your best interest. Otherwise, stretch it out a looooong time to make them suffer a little for what they put you thru.

Jen

[Thewino]

Anika,

Rereading your initial post, I did find a couple of troubling aspects. First, you have a absolute right to itemized billing from any hospital that accepts Medicare monies. Secondly, if you went through the expense of the sleep study, were told you have sleep apnea, and were offered an overpriced machine without being given an Rx, is fairly problematic.

You could contact JCAHO, who oversees healthcare organizations, especially hospitals. I believe they would be concerned if you asked for an itemized bill but were told one isn't available and were never given the opportunity to seek equipment elsewhere.

Simply look up: jointcommission.com on the Internet. Once there, look at the box on the right and click 'How to make a complaint about a Healthcare organization.' JCAHO is a really big deal for hospitals and can now show up unannounced at any hospital that receives federal funding. They frequently go to hospitals to look into egregious complaints.

If a complaint is made, they will always follow up with you.

Be well,
TheWino

[jencat824]

Anika,

Rereading your initial post, I did find a couple of troubling aspects. First, you have a absolute right to itemized billing from any hospital that accepts Medicare monies. Secondly, if you went through the expense of the sleep study, were told you have sleep apnea, and were offered an overpriced machine without being given an Rx, is fairly problematic.

You could contact JCAHO, who oversees healthcare organizations, especially hospitals. I believe they would be concerned if you asked for an itemized bill but were told one isn't available and were never given the opportunity to seek equipment elsewhere.

Simply look up: jointcommission.com on the Internet. Once there, look at the box on the right and click 'How to make a complaint about a Healthcare organization.' JCAHO is a really big deal for hospitals and can now show up unannounced at any hospital that receives federal funding. They frequently go to hospitals to look into egregious complaints.

If a complaint is made, they will always follow up with you.

Be well,
TheWino

Excellent approach!

[hello_its_just_me]

I can explain this to you. I am a CPAP user as well as a Respiratory CSA who works with PAP. The insurance requires the compliance. Your insurance may not have contributed to your cost due to a high deductible, but the cost of your equipment will be deducted off of that. (so if you need other medical procedures or equipment, you will be closer to meeting that threshold amount where they will start covering something) You could have informed them that you did not want to use your insurance for the purchase, but most likely the cost would have been somewhat higher. You are usually given the "insurance rate" on any portion that you are responsible for, which is less then the "list price" This "compliance monitoring" is not charged to you. It is just part of the rental of equipment. As to a choice of machines, (example: brand etc) most companies only carry one or two of the most common brands : Usually Respironics or ResMed. Some may use Fisher & Paykel or Devilbiss. All the machines function the same way. The Dr is ordering this as a treatment for your condition. Just like you don't go to pharmacy requesting which manufacturer you want your medication to come from. As long as the machine has the features that the Dr is ordering..ex: if it reads out the AHI, or if its an auto-titrating device, then that is all that is required.

[Julie]

You're responding to an out of date post.