Insurance / DME

So this weekend I received a letter from my DME which provided my original CPAP machine requesting that I pay them $2,200 for my CPAP machine. Apparently, they received notification from my Insurance company that pre-approval was not required. So they gave me the machine and I used it religiously for 5 months. However, my insurance company BCBS denied the claim they made saying it could not be made without pre-approval. Apparently BCBS admits they were incorrect to suggest pre-approval was not required in the first place. And since the submission for the machine was after I started using it.. they would not accept the documentation al. la. sleep study that it was a medical necessity. So the DME appealed and BCBS denied the appeal. Apparently now I must appeal this personally and until it is resolved I am on the hook for the $2,200 for that machine. To make this even more crazy about 5 months after I was given that machine I decided to establish a backup machine; so I bought a PR which is newer, better and much quieter -- and it's my primary and only machine I have used in the last 10 months. I packed up the old machine in case my PR broke.

So I'll know more of the details soon. But right now I can say...

1. If I must pay $2,200 for a machine that costs 1/4th of that online. That is crazy; what is their overhead.
2. I should have been more suspicious when they gave me the machine. I assumed they had the pre-approval completed. I should have asked for documentation. What if that machine would cost $20,000... I guess my bill would be $200,000.
3. Looking at the paperwork it appears BCBS actually did pay the DME a fraction of the amount the DME requested. About $400 of the $2,200 they originally billed. For some reason the DME hasn't subtracted that from the $2,200 they are saying that I owe.
4. I guess I will need to speak with the Maryland sleep commission.

I'll update this thread later next week once I know more about what happened.

Be careful out there, CW

Welcome to the dark and dangerous world of insurances and local DME providers. I'm sorry you've been caught in the middle of such a frustrating, tangled web. Don't pay anyone a penny yet until you can get the issues straightened out.

Did you satisfy the first 30 days of compliance on that CPAP they provided you with? Why not check the compliance on it? Maybe if the compliance data is less than required you can get out from under it at no cost to you? None of them need to know about the xPAP you purchased out of pocket and are actually using.

I don't have BCBS insurance, so I'm not sure how your particular insurance works. Here is how the CPAP machine billing worked in my own case:

• Amount that DME (durable medical equipment provider) billed insurance for CPAP machine: $1,400

• Amount that insurance company allowed for the machine: $842.10

• My share of cost (20% of allowable amount): $168.42.

• My insurance company paid $673.68. This is $842.10 (allowable amount) minus $168.42 (my share).

• The DME wrote off the $557.90 difference between the billed amount ($1,400) and the "allowed" amount ($842.10) because they "accept assignment."

If your DME normally "accepts assignment," meaning they would write off the difference between the amount they billed insurance and what insurance actually "allowed," perhaps they would be willing to accept that "allowable" amount as full payment. They should subtract the $400 that BCBS paid and also any money you have already paid. Perhaps you can negotiate this with the DME. If you need to, show them printouts of what this equipment costs online so they know you're not a dummy.

I hope this all works out for you!

Wow, this sure sucks. I wonder if the fact that BCBS paid anything at all will work in your favor? If they made the mistake it should be on their nickel. Of course, this might be far too reasonable an argument for anything involving insurance, but it might be worth a try. Also, it might help to get in touch with the insurance regulators in your state, and your own attorney. Sometimes just a request from an attorney for copies of paperwork is enough to convince folks to act reasonably, as in you could take the machine back to them and they can eat the $ they claim is still due. Good luck, and let us know what happens.

Newbies, listen up! This situation points out the fact that many of us need to change the wording we use with ourselves about our therapy. No DME "gives" a client a machine. They provide one for a fee. The client pays the fee out-of-pocket or through insurance premiums or taxes or whatever. It is NEVER a gift. Whatever your money situation DO THE MATH before you accept any equipment because the money isn't always the way it first appears.

CiresWrossed wrote:3. Looking at the paperwork it appears BCBS actually did pay the DME a fraction of the amount the DME requested. About $400 of the $2,200 they originally billed. For some reason the DME hasn't subtracted that from the $2,200 they are saying that I owe.

What paperwork, from BCBS or the DME?


I have BCBS and this is how it works, at least for me. Every time BCBS pays a provider, they send me an EOB statement (explanation of benefits). On that statement it clearly spells out how much the original charge was, how much BCBS allowed, how much BCBS paid, and most importantly, HOW MUCH YOU OWE.

If you cannot find the EOB statement, call BCBS and request a new one. Or better yet, go online, set up an account, and look at the statement now.

If BCBS is saying you own anything less than $2200, call up BCBS, ask them to call the DME with you on the line, and get an explanation.

CiresWrossed wrote:So this weekend I received a letter from my DME which provided my original CPAP machine requesting that I pay them $2,200 for my CPAP machine. Apparently, they received notification from my Insurance company that pre-approval was not required. So they gave me the machine and I used it religiously for 5 months. However, my insurance company BCBS denied the claim they made saying it could not be made without pre-approval. Apparently BCBS admits they were incorrect to suggest pre-approval was not required in the first place.

Hi,

There is a simple solution for this problem. Sue the DME in small claims court for $2200. If the judge asks you why you are suing, tell the judge that it was "detrimental reliance". You relied on the statement that the DME made that pre-approval was not needed. Of course, you will need this statement to be in writing or the DME will deny that they said it. Then the DME will probably try to point out some contact language somewhere that states that they do not guarantee reimbursement, and that they only submit the claim as a convenience to you. The judge will then flip a coin, and your fate depends on whether or not the judge has had any insurance hassles recently. If he or she has, then he or she will probably stick it to the DME. If not, then it depends on what the contract says.

-john-

Guest wrote:

CiresWrossed wrote:3. Looking at the paperwork it appears BCBS actually did pay the DME a fraction of the amount the DME requested. About $400 of the $2,200 they originally billed. For some reason the DME hasn't subtracted that from the $2,200 they are saying that I owe.

What paperwork, from BCBS or the DME?


I have BCBS and this is how it works, at least for me. Every time BCBS pays a provider, they send me an EOB statement (explanation of benefits). On that statement it clearly spells out how much the original charge was, how much BCBS allowed, how much BCBS paid, and most importantly, HOW MUCH YOU OWE.

If you cannot find the EOB statement, call BCBS and request a new one. Or better yet, go online, set up an account, and look at the statement now.

If BCBS is saying you own anything less than $2200, call up BCBS, ask them to call the DME with you on the line, and get an explanation.

I have BCBS FEHB every time they spend a penny they send me EOB, being as they are now my secondary insurance and Obamacare is my primary it's an even bigger mystery. I went to the hosp. a couple of weeks ago. There should be a code of 303 or 310 which says the provider accepted assignment. If it's there the DME is trying to shaft you call your insurance and tell them what they are trying to pull, good luck.