Insurance/Billing Question

I have a question regarding the way cpap/bipap machines are billed with insurance. Here's the scenario I've encountered and I'm wondering how it should be handled by the DME.

I got a cpap machine on 11/20/09. So, they billed my insurance with a service date of 11/20/09, planning to bill monthly during the rental phase. So, they billed my insurance again on 12/20/09.

On 12/23/09, I was switched to a bipap machine. But they had billed my insurance for the cpap 3 days beforehand. Then they billed my insurance for the bipap on 12/23/09.

I'm not sure right now what has happened with my insurance, but isn't this kind of double billing? This kind of thing has to happen a lot -- how are DME's supposed to handle insurance billing in situations like this?

I guess the best way to phrase this is that a patient is on a machine and their insurance requires a monthly rental for a specified period of time. What happens when in the midst of this, the patient requires a change in equipment?

And my situation forces this to happen again!! My switch to the ventilator came mid February. My billing/insurance is so confusing and messed up now. It's a nightmare. I need to know how DME's SHOULD be handling this so I know if I'm being billed correctly.

Gosh the fun just doesn't stop for you, does it?! Sorry, I have nothing useful to add to this conversation besides wise cracks. Good luck!!!!

echo wrote:Gosh the fun just doesn't stop for you, does it?! Sorry, I have nothing useful to add to this conversation besides wise cracks. Good luck!!!!

LOL -- Thanks!! Even wise cracks are appreciated right now.

This whole thing stems from that nasty bill I got a couple weeks ago. We're trying to figure everything out and my DME's billing is so messed up I'm not sure any of us are going to get it totally figured out.

I have a stack of insurance statements and my head just about exploded trying to sort it out. They've got the billing situation I mentioned, but we've also got billings for supplies (masks) that I never kept, dates of service that don't match up, and on and on. Plus, they sent in a bill to my insurance for the bipap that I got as a test that I didn't even keep overnight!! But they billed my insurance for it --

Oh, this is just an awful situation.

I can only speak for what I have heard - don't know how accurate it really is

you get billed for a whole month for each month and portion there of even if it was only one extra day - months are not prorated - and when I was on O2 and switched locations- same national DME they switched the contract date to reflect the date for the new location (as if it was NEW contract) not just a month after the date the last bill where I was before was entered

so it appears they are following that (as was done with my O2)

jules wrote:I can only speak for what I have heard - don't know how accurate it really is

you get billed for a whole month for each month and portion there of even if it was only one extra day - months are not prorated - and when I was on O2 and switched locations- same national DME they switched the contract date to reflect the date for the new location (as if it was NEW contract) not just a month after the date the last bill where I was before was entered

so it appears they are following that (as was done with my O2)

Gosh, I really hope it doesn't work this way! That would double my co-pays in December and February since I changed equipment in both those months. I would think that the insurance companies would have a fit paying twice in a month.

it is like

you get an Rx for an expensive drug - you take it, you react and have to toss out the rest and your doctor writes another Rx for another expensive drug -- you get stuck with both copays, the insurance pays for both meds and hopefully the second one works

jules wrote:it is like

you get an Rx for an expensive drug - you take it, you react and have to toss out the rest and your doctor writes another Rx for another expensive drug -- you get stuck with both copays, the insurance pays for both meds and hopefully the second one works

I see what you're saying and I understand the logic behind it. But still -- wow.

I was lucky in that I only had my original apap purchased by my insurance company. It was on rental for approximately August to December and then purchased. The rental amount was applied to the purchase price. Since I had my max out of pocket expense met, I never was billed a co-pay -- so have absolutely no experience with your type of situation.

It seems that you catch it coming and going!! It is not fun dealing with all the hassle and having to worry about making the payments.

I feel for you Madalot and wish there was someway to make things smoother for you.

The statement was made that the billing was confusing. I would suggest that from the DME's point of view the billing is very effective. They get paid more money.

In order to keep overhead costs low the insurance company pays as long as the right code is used. The DME understands this and plays loose with the logic knowing that they will not be challanged in most cases.

One thing to appreciate about insurance companies is that they operate like the casinos in Los Vagas. They dont care as much about reducing the total payout as they do about maximizing the difference between what they take in and what they payout. Thus it is not cost effective to closely monitor the individual bills submitted.

Kevin G. wrote:The statement was made that the billing was confusing. I would suggest that from the DME's point of view the billing is very effective. They get paid more money.

In order to keep overhead costs low the insurance company pays as long as the right code is used. The DME understands this and plays loose with the logic knowing that they will not be challanged in most cases.

One thing to appreciate about insurance companies is that they operate like the casinos in Los Vagas. They dont care as much about reducing the total payout as they do about maximizing the difference between what they take in and what they payout. Thus it is not cost effective to closely monitor the individual bills submitted.

This is interesting. I have to admit that had my DME not sent me that huge bill, I probably would NOT have looked so closely either. If I had received bills from them that appeared to be in line with what my co-pays should have been, I probably would have just paid them. Once I received a bill for almost $3,000, it made me look REALLY closely at my insurance statements. Had I not looked, we never would have determined that a significant payment WAS made by my insurance, yet they never posted it to my account.

I was just curious what the standard was for situations where a patient switched machines mid rental.

sleepycarol wrote:It seems that you catch it coming and going!! It is not fun dealing with all the hassle and having to worry about making the payments.

I feel for you Madalot and wish there was someway to make things smoother for you.

Thanks Sleepycarol! Luckily I have a husband that doesn't get upset about much of anything and takes most of this in stride. He helps keep me calm and grounded when I'm just about to go ballistic! But he did say he was proud of me for having all my insurance statements AND using them to prove that the DME HAD been paid for things they claimed they hadn't.

But I tell you -- I sure could use a little break from all this. I'm a little weary of having so many problems and issues.

I'm bumping this in hopes of getting a bit more input -- perhaps from some of the sleep lab or DME people here. I believe that I have been told correctly, but just want a bit more first-hand experience on this.

IF this is the standard (that insurance/patient frequently gets charged for two, different pieces of equipment in one month), I have to accept it. But I sure don't like it.

Thanks everyone.

yep, they bill for the entire month; it's 2 seperate bill codes so most insurances don't catch it. I would take it up with the DME company.

lovecpap wrote:yep, they bill for the entire month; it's 2 seperate bill codes so most insurances don't catch it. I would take it up with the DME company.

Thanks for this. I've asked the DME about it and they are "looking into it" -- Are the insurance companies okay with this OR is this something the DME's do that they shouldn't, but usually get away with?

I'm in a position right now that I can negotiate my outstanding balance with my DME. IF this is an industry standard AND the insurance companies know about it and pay it, then I have to keep that in mind during my talks with my DME. But if they do it, but aren't supposed to, I need to know that as well so that I can use that to my advantage.

Madalot wrote:
Thanks for this. I've asked the DME about it and they are "looking into it" -- Are the insurance companies okay with this OR is this something the DME's do that they shouldn't, but usually get away with?

.

This has me very curious as well. ARE the insurance companies fine with this or would they prorate if they knew the situation? Does anyone out there know or does it depend on the insurance company?

Jeanette