HELP!!! I think the DME is lying to me again!

[cowlypso]

The other funny part is that the RT was kind enough to set the new machine to my prescribed CPAP pressure of 10. Which he did by setting it on Auto, min 10, max 10... No worries, though, I'll be changing that anyway, back down to 8.5.

[J-Mac]

Yes, they want to replace it with a used machine. A visibly worn, dirty, used machine. But they had no problem with replacing it. I could have walked out of their office today with the "new" machine.

I called my insurance company, and they said that they have no directive as to whether the DME is required to provide me with a new machine or a used one. Which means that it's the DME's policy that they don't give out new machines.

I asked my insurance company about changing DMEs mid-rental, and she said that she couldn't find anything in the contract that specifically addressed this. All she could tell me is that the follow medicare guidelines.

I also asked about reimbursement if I purchased from an online supplier. She said that they would reimburse at a monthly rate. Meaning that I'd pay out of pocket up front, and then get reimbursed by them over the course of 12 months. I'm not sure about how that works with participating providers, networks, preauthorizations, etc. But it's an option I might explore. I'd definitely need to get something in writing from the insurance company about that before I did it, though. I'm currently living off of student loans and can't afford to purchase a machine myself.

This is exactly why I have purchased all of my own equipment, supplies, etc. at my own expense since my first dealings with a DME assigned by the health insurance company. First machine was new but a discontinued model from a back shelf in their storage area. No help with mask fit or selection; only one "breathing circuit, consisting of mask, tubing, and any fittings required" beyond the first setup. Oh, just a whole lot of joy from them! That was in January 1999 and I have purchased all of my CPAP needs ever since. I guess that someday I may not be able to do this anymore, but so far I am disabled and have no other income than disability income and I still manage to buy all my own equipment and supplies. I refuse to let a DME dictate my treatment.

Thanks!

Jim

[LTTS]

Wow, there is a TON of misinformation here. I've been doing DME insurance billing for 25 years and I'd like to clarify a few things for all of you reading here.

1. If your insurance payer only pays for a rental you are not entitled to a new machine - even if the rental is a "rent to purchase." There are a few exceptions to this, for instance certain MediCaid contracts in some states require that new equipment be provided, but that is rare. Medicare and the vast majority of insurance contracts with DME providers do not entitle to the patient to a new rental item. The reason for this is very sound. The vast majority of insurance payers require a compliance audit before they will pay for the rental beyond 2-3 months. If the patient does not demonstrate, through the data download, that they have been compliant with the usage of the PAP device the insurance company will not continue to pay subsequent rental months.

Many patients are not compliant with the use of the device, and it must then be paid for by the patient or returned. If insurance payers required a DME provider to provide a new device to each patient what would they do with all the used devices returned from non-compliant patients? The insurance payer cannot have it both ways -- insist that new devices be provided, and insist that DME providers take them back and dispose of them if the patient is non-compliant. So if this upsets you, your beef should be with the insurance company rules.

Rest assured, all DME providers must be accredited. And those accrediting organizations do routine inspections of cleaning and disinfecting procedures and the function check of used items that are required before the device is passed on to another patient. Basically the equipment is refurbed. In most cases the equipment will appear brand new, even if it is not. If it doesn't look clean don't accept it. If you get a new one, count yourself lucky. The DME provider either does not have any used devices in stock, or is just being really nice to you. They do compete on service rather than price because they don't get to set their prices -- the insurance payers set the rates. So a new machine is a bonus, and not something you're entitled to.

2. No insurance company, and certainly not Medicare, will allow any DME provider to start a new rent to purchase from month 1 if you change providers in mid-stream. Any provider that takes a patient when several months of the rental have already been paid to another provider is either doing it out of ignorance because they did not check your insurance and previous claims carefully enough, or is simply trying to make a doctor or sleep lab happy so that they will send them more referrals. The bottom line is that it's not so easy to switch DME providers once you have had several months of rental paid to the first DME provider. So don't do it on a "whim."

3. Your warranty does not entitle you to a new machine either. If it's under warranty you can get a refurb or a repair. The provider can elect to give you a new machine, but in no way are they obligated to do that.

4. Lots of commercial insurance payers pay less than Medicare pays. If the provider has a contract with your insurance they will take what the fee schedule of that insurance payer pays - that's in their contract with the insurance payer. If they are not contracted with your insurance then the insurance payer may refuse to pay anything. And just to clear up one more misconception -- it is the INSURANCE PAYERS who refuse to contract with the DME providers in most cases, not the other way around. The large insurance payers make deals with national DME providers at rock bottom prices, and will not pay any other DME provider for DME products. So you're stuck with whomever they negoiated the rock bottom prices. And in that situation, you're a captive to the DME or DMEs that your insurance payer will allow in network. Unfortunately rock bottom prices can (but don't always) mean rock bottom service.

The bottom line is you get what the insurance payer pays for.

[jedimark]

What's the matter, are you in damage control or something? You seem to be making a lot of noise today.

I won't speak much on Insurance companies, as we both seem to agree they are evil.

Wow, there is a TON of misinformation here. I've been doing DME insurance billing for 25 years and I'd like to clarify a few things for all of you reading here.

Congratulations on screwing and being screwed by the insurance companies for that long.

1. If your insurance payer only pays for a rental you are not entitled to a new machine - even if the rental is a "rent to purchase." There are a few exceptions to this, for instance certain MediCaid contracts in some states require that new equipment be provided, but that is rare. Medicare and the vast majority of insurance contracts with DME providers do not entitle to the patient to a new rental item. The reason for this is very sound. The vast majority of insurance payers require a compliance audit before they will pay for the rental beyond 2-3 months. If the patient does not demonstrate, through the data download, that they have been compliant with the usage of the PAP device the insurance company will not continue to pay subsequent rental months.

We are quite well aware of the consequences of what happens with incompliance. Stop trying to FUD it up.. The cost always comes back on users.. You don't have to absorb jack over it..

Many patients are not compliant with the use of the device, and it must then be paid for by the patient or returned. If insurance payers required a DME provider to provide a new device to each patient what would they do with all the used devices returned from non-compliant patients? The insurance payer cannot have it both ways -- insist that new devices be provided, and insist that DME providers take them back and dispose of them if the patient is non-compliant. So if this upsets you, your beef should be with the insurance company rules.

Seriously, companies like yours are dumping 10 year old pieces of crap on users..
And for the more recent cases, the fact you accepted data incapable machines in the first place when other options were available was incredibly douchey.

Rest assured, all DME providers must be accredited. And those accrediting organizations do routine inspections of cleaning and disinfecting procedures and the function check of used items that are required before the device is passed on to another patient. Basically the equipment is refurbed. In most cases the equipment will appear brand new, even if it is not. If it doesn't look clean don't accept it. If you get a new one, count yourself lucky. The DME provider either does not have any used devices in stock, or is just being really nice to you. They do compete on service rather than price because they don't get to set their prices -- the insurance payers set the rates. So a new machine is a bonus, and not something you're entitled to.

We care more about data capabilities than whether or not you managed to clean it properly.. Whether it's "new" is irrelevant.

It's a one way fan.. Cleaning a CPAP unit is not rocket science.. Wipe down, sterilized humidifier, new filters, new hose, and most of us wouldn't give a crap. I'm sure your procedures are far more involved..

But if it hasn't got full data capabilities.. Recycle the heap of crap. WE DON'T WANT IT!!!

2. No insurance company, and certainly not Medicare, will allow any DME provider to start a new rent to purchase from month 1 if you change providers in mid-stream. Any provider that takes a patient when several months of the rental have already been paid to another provider is either doing it out of ignorance because they did not check your insurance and previous claims carefully enough, or is simply trying to make a doctor or sleep lab happy so that they will send them more referrals. The bottom line is that it's not so easy to switch DME providers once you have had several months of rental paid to the first DME provider. So don't do it on a "whim."

If a user drops a dodgy unprincipled DME who supplied them with shoddy equipment, why should they a) be punished for it, and b) even care remotely?

3. Your warranty does not entitle you to a new machine either. If it's under warranty you can get a refurb or a repair. The provider can elect to give you a new machine, but in no way are they obligated to do that.

Doesn't change the fact you shouldn't have off-loaded those 10 year old heap of crap non-data providing machines in the first place.

4. Lots of commercial insurance payers pay less than Medicare pays. If the provider has a contract with your insurance they will take what the fee schedule of that insurance payer pays - that's in their contract with the insurance payer. If they are not contracted with your insurance then the insurance payer may refuse to pay anything. And just to clear up one more misconception -- it is the INSURANCE PAYERS who refuse to contract with the DME providers in most cases, not the other way around. The large insurance payers make deals with national DME providers at rock bottom prices, and will not pay any other DME provider for DME products. So you're stuck with whomever they negoiated the rock bottom prices. And in that situation, you're a captive to the DME or DMEs that your insurance payer will allow in network. Unfortunately rock bottom prices can (but don't always) mean rock bottom service.

The bottom line is you get what the insurance payer pays for.

Yes, insurance companies suck.

This is where users need to be given the choice of outright purchase.. Nobody seems to bother to tell users it's a practical option.

[ltts]

What's the matter, are you in damage control or something? You seem to be making a lot of noise today.

I won't speak much on Insurance companies, as we both seem to agree they are evil.

Wow, there is a TON of misinformation here. I've been doing DME insurance billing for 25 years and I'd like to clarify a few things for all of you reading here.

Congratulations on screwing and being screwed by the insurance companies for that long.

1. If your insurance payer only pays for a rental you are not entitled to a new machine - even if the rental is a "rent to purchase." There are a few exceptions to this, for instance certain MediCaid contracts in some states require that new equipment be provided, but that is rare. Medicare and the vast majority of insurance contracts with DME providers do not entitle to the patient to a new rental item. The reason for this is very sound. The vast majority of insurance payers require a compliance audit before they will pay for the rental beyond 2-3 months. If the patient does not demonstrate, through the data download, that they have been compliant with the usage of the PAP device the insurance company will not continue to pay subsequent rental months.

We are quite well aware of the consequences of what happens with incompliance. Stop trying to FUD it up.. The cost always comes back on users.. You don't have to absorb jack over it..

Many patients are not compliant with the use of the device, and it must then be paid for by the patient or returned. If insurance payers required a DME provider to provide a new device to each patient what would they do with all the used devices returned from non-compliant patients? The insurance payer cannot have it both ways -- insist that new devices be provided, and insist that DME providers take them back and dispose of them if the patient is non-compliant. So if this upsets you, your beef should be with the insurance company rules.

Seriously, companies like yours are dumping 10 year old pieces of crap on users..
And for the more recent cases, the fact you accepted data incapable machines in the first place when other options were available was incredibly douchey.

Rest assured, all DME providers must be accredited. And those accrediting organizations do routine inspections of cleaning and disinfecting procedures and the function check of used items that are required before the device is passed on to another patient. Basically the equipment is refurbed. In most cases the equipment will appear brand new, even if it is not. If it doesn't look clean don't accept it. If you get a new one, count yourself lucky. The DME provider either does not have any used devices in stock, or is just being really nice to you. They do compete on service rather than price because they don't get to set their prices -- the insurance payers set the rates. So a new machine is a bonus, and not something you're entitled to.

We care more about data capabilities than whether or not you managed to clean it properly.. Whether it's "new" is irrelevant.

It's a one way fan.. Cleaning a CPAP unit is not rocket science.. Wipe down, sterilized humidifier, new filters, new hose, and most of us wouldn't give a crap. I'm sure your procedures are far more involved..

But if it hasn't got full data capabilities.. Recycle the heap of crap. WE DON'T WANT IT!!!

2. No insurance company, and certainly not Medicare, will allow any DME provider to start a new rent to purchase from month 1 if you change providers in mid-stream. Any provider that takes a patient when several months of the rental have already been paid to another provider is either doing it out of ignorance because they did not check your insurance and previous claims carefully enough, or is simply trying to make a doctor or sleep lab happy so that they will send them more referrals. The bottom line is that it's not so easy to switch DME providers once you have had several months of rental paid to the first DME provider. So don't do it on a "whim."

If a user drops a dodgy unprincipled DME who supplied them with shoddy equipment, why should they a) be punished for it, and b) even care remotely?

3. Your warranty does not entitle you to a new machine either. If it's under warranty you can get a refurb or a repair. The provider can elect to give you a new machine, but in no way are they obligated to do that.

Doesn't change the fact you shouldn't have off-loaded those 10 year old heap of crap non-data providing machines in the first place.

4. Lots of commercial insurance payers pay less than Medicare pays. If the provider has a contract with your insurance they will take what the fee schedule of that insurance payer pays - that's in their contract with the insurance payer. If they are not contracted with your insurance then the insurance payer may refuse to pay anything. And just to clear up one more misconception -- it is the INSURANCE PAYERS who refuse to contract with the DME providers in most cases, not the other way around. The large insurance payers make deals with national DME providers at rock bottom prices, and will not pay any other DME provider for DME products. So you're stuck with whomever they negoiated the rock bottom prices. And in that situation, you're a captive to the DME or DMEs that your insurance payer will allow in network. Unfortunately rock bottom prices can (but don't always) mean rock bottom service.

The bottom line is you get what the insurance payer pays for.

Yes, insurance companies suck.

This is where users need to be given the choice of outright purchase.. Nobody seems to bother to tell users it's a practical option.

Let me see if I can clear up some of your misconceptions.

1. I'm not a DME provider. I consult with DME providers and my company manages the billing process for some of them. Unfortunately the rules are so damn complicated that some providers feel the need to outsource the process. So I'm actually smart enough NOT to screwed by them. Perhaps that indicates you should pay attention to my guidance.

2. The cost to DME providers for non-compliant users is actually quite enormous. Costs to the DME provider are very much front loaded and they do not make them back if the machine doesn't complete to a purchase. With that one comment you have demonstrated that you don't understand a thing about the cost incurred by DME providers in providing PAP products.

3. Well it appears to me that a "dodgey, unprincipled" DME provider is defined a provider that won't give you a free upgrade or a new machine because your insurance payer won't cover the cost. Might that be because you can't get the owner of the insurance payer on the line to browbeat into submission, and the insurance reps have no power to authorize the deluxe features you want that they won't pay for BUT you can harrass the DME provider or its staff into it? Just asking.

And, as I have explained and contrary to the post in this thread stating otherwise, you are not entitled to the start of a new capped rental period simply because you decide to change DME suppliers. Any supplier with half a brain will check if your insurance has already paid toward the rental cap. If they can't get the information from the insurance company they will ask the patient. And if the patient lies about that, they get to pay the bill for the months outstanding once the capped rental period ends. So no, not a good idea to change providers on a "whim" unless you have several hundred dollars to spare.

And might I add that no one is giving patients 10 year old equipment. The blowers rarely last that long and as long as its under rental the provider is responsible for repairs, so it's not cost effective to keep old machines around. Exaggerate much? Bottom line again is that you get what your insurance company pays for. Anything above that is a bonus and nothing you are entitled to.

4. Insurance payers can certainly elect to purchase rather than insist on an interest free loan from the provider in the form of rental payments. But the vast majority of payers don't permit it, which is why it is not offered to you by the DME provider. DME providers would LOVE, LOVE to bill the insurance company once rather than 10, 12, or 13 times. Again, turn your ire in the correct direction. Your DME provider doesn't get to make the rules.

[snuginarug]

Perhaps that indicates you should pay attention to my guidance.

Soooo.... your "guidance" is that cowlypso should have just shut up and bent over? Instead of talking to the supervisor, who sounded helpful and contrite? Instead of advocating for herself? I'll pass on your "guidance." Thanks though.

[jedimark]

LTTS, let me make this crystal clear to you, as you obviously have a listening and learning disability:

NOBODY WANTS THESE WORTHLESS NON-DATA-CAPABLE MACHINES

1) Most of us don't care if they are second hand.. we get how the system works..
2) Most of us don't really care if they are Auto or not.. (It's very cool to have, and most would be willing to pay extra for one)
3) Yes, it sucks that insurance companies cause these problems and don't listen... Just like you!!

No one is trying to cheat you, DME's or their insurance companies.. They are angry because they were given CRAPPY USELESS machines..

WE ARE THE ONES PAYING FOR THESE MACHINES
WE ARE THE ONES DEALING WITH THE SLEEP DISORDERS

You're beef is with the insurance companies, not us.

[ltts]

Perhaps that indicates you should pay attention to my guidance.

Soooo.... your "guidance" is that cowlypso should have just shut up and bent over? Instead of talking to the supervisor, who sounded helpful and contrite? Instead of advocating for herself? I'll pass on your "guidance." Thanks though.

I wouldn't define not browbeating someone into giving you something for free as "bending over." There was absolutely no reason for the supervisor to be contrite. She obviously just caved into the browbeating. That does not make the customer right. But again, you don't have to believe me. Call your own insurance provider and ask. Insurance payers have an upgrade rule for a reason -- because patients sometimes want upgrades. But they are supposed to pay for them. Not expect them for free.

[snuginarug]

She obviously just caved into the browbeating.

That's her problem, not yours. Why do you care about cowlypso or anything she does?

[ltts]

LTTS, let me make this crystal clear to you, as you obviously have a listening and learning disability:

NOBODY WANTS THESE WORTHLESS NON-DATA-CAPABLE MACHINES

1) Most of us don't care if they are second hand.. we get how the system works..
2) Most of us don't really care if they are Auto or not.. (It's very cool to have, and most would be willing to pay extra for one)
3) Yes, it sucks that insurance companies cause these problems and don't listen... Just like you!!

No one is trying to cheat you, DME's or their insurance companies.. They are angry because they were given CRAPPY USELESS machines..

WE ARE THE ONES PAYING FOR THESE MACHINES
WE ARE THE ONES DEALING WITH THE SLEEP DISORDERS

You're beef is with the insurance companies, not us.

No one wants them? Actually most patients don't have a clue about the deluxe features posters here think they need, and they do just fine with the basic machines that are covered by their insurance payers.

And you are not paying for the machines. The insurance company you freely elected to engage with is paying. That is why they call the shots. If you were paying you could call the shots. But you're not.

What is mind boggling to me is that you seem to think DME providers should just pay the difference out of their pocket because you are engaged with an insurance company that finds no medical necessity in these added features. I do tend to believe that a PAP patient's pressure level does change over time, mostly because they continue to gain weight, so autoset is helpful. And guess what? It saves the insurance company money in that you don't have to have a repeat study every few years to ascertain that.

But when did that become the DME provider's problem and why? Can anyone here explain why a DME provider should continue to provide more expensive machines even as insurance payers markedly decrease their reimbursement rates when the payers themselves don't require the DME to provide these more expensive features? I'd love to hear the rationale for that.

You can get as angry as you want, and scream to the high heavens, but that doesn't make your argument rational.

[ltts]

She obviously just caved into the browbeating.

That's her problem, not yours. Why do you care about cowlypso or anything she does?

I actually don't. I'm just responding to your comment. You asked, I answered with my opinion on the issue. She browbeat the DME provider into providing a product that they were under no obligation to provide under any insurance coverage that currently exists.

[snuginarug]

You must care or you never would have posted anything at all, right back to your very first post. Posting at all indicates you care. Why do you care?

[ltts]

You must care or you never would have posted anything at all, right back to your very first post. Posting at all indicates you care. Why do you care?

So that's a different question. Why do I care about this issue? Because I have spent the last 5 years of my 27 year career in the field of DME watching DME providers being beat down, and put out of business by politicians and greedy insurance companies.

Every single day of my life I see DME providers advocating for patients to insurance companies. Every single day of life I see payers that weasel out of paying an entire capped rental period for things as silly as the payer saying the signature on the order was illegible or the physician didn't sign the download report. Every single day I see DME providers make 2nd, 3rd, and even 10th requests to physicians to send the documentation the insurance companies require, only to be told, when they finally get it, that it's not good enough.

You know what I seldom if ever see? DME providers coming to the patients and repossessing their rental items. The DME providers know you need them, even if the insurance company is finding new and creative ways not to pay on a daily basis. This is rampant with Medicare and many large insurance payers. Just out of control. And it's putting your DME out of business. Take two seconds the next time you are at your local DME and ask for the owner or manager -- just ask them what is going on.

So it's bit off putting to come here and find that so many of you villify these same people and think they are obligated to provide you with deluxe equipment that your insurance company would tell you flat out is not covered by your policy. Have any of you that advocate "demanding" this from DME providers ever once bothered to call your insurace company and ask what they cover or what the DME provider is obligated to provide under the terms of their contract? Clearly not. Clearly not.

So yes, I care. And the responses to this thread have truly disgusted me. The posters in this threads act like they have no obligation beyond browbeating the DME provider, and frankly at least some of you do not even know how to read the EOB your insurance company sends you. If you believe you need these features
then mount a campaign with insurance providers. Trust me, we'd really love for you to join us in advocating for you rather than have you blame the DME provider for something that is completly out of their control. Yes, I know it's easier to chew out the DME. After all, the insurance company is going to do nothing but give you the runaround individually. But you're still barking up the wrong tree.

[snuginarug]

So it's bit off putting to come here and find that so many of you villify these same people

Well, this is a forum for patients, not billing company employees. We are not here for the benefit of the insurance companies, DMEs or the people who go back and forth between the two. I suggest that you start your own forum for people who work in the industry. If you are put off by what people say here, maybe you should go away. That's what I do when I go somewhere people are not friendly to me.

[ltts]

So it's bit off putting to come here and find that so many of you villify these same people

Well, this is a forum for patients, not billing company employees. We are not here for the benefit of the insurance companies, DMEs or the people who go back and forth between the two. I suggest that you start your own forum for people who work in the industry. If you are put off by what people say here, maybe you should go away. That's what I do when I go somewhere people are not friendly to me.

I'm not a billing company "employee" - you can really tell that you haven't read a word of this thread, just as you claimed. Ignorance is bliss for some people. Others might appreciate the real story. And I have been proud to report it. As I have said in numerous posts (that you admit you have not read) there is no need to take my word for it. I would advise people to call their insurance providers to verify information about the obigations of a DME provider, particularly as to the products and feature sets that are covered instead of relying on this forum.