Possible Insurance Fraud?

In searching for a new DME, I've been told several times by several online and local B&M suppliers that even though they are not "in-network" with my insurance, they can get me my equipment annually at little or no cost to me.

When I inquired about how that would be possible when I have deductibles and co-insurance, their response is that even thought they are out of network, they don't bill me for the difference if my insurance doesn't pay them.

This makes no sense and would appear to be fraudulent behavior. If my insurance believes I'm paying a certain amount and bases their future billings to me over the year upon these incorrect assumptions, that stinks of fraud to me.

I'm sure my insurance carrier would love to know that I actually didn't pay that out of network deductible if I suddenly have a $20,000 bill for out of network services due to an auto accident a few months from now. And I have no idea why a vendor would do this if my insurance only paid a small portion of the claim submission...they could potentially be losing money.

Is this rampant in the CPAP world? This isn't coming from those "Hello, This is Peggy" operators...this is coming from vendors recommended by others here and by two different doctors.

Am I missing something?

If "Peggy" calls; hang up!
That is, if they are contacting you initially, somebody's paying plenty moolah for it--probably you.
Do not believe any promise not available in writing.
All promises are void at the end of the plan year.
You have no way of knowing which plan year it is.

I don't think this is insurance fraud...If they are willing to accept what your insurance co. pays them without any payment from you...it is their loss. I'm sure that your insurance company doesn't care whether you have to pay or not. They have agreed to pay XX amount for an item. I certainly would test them out. Buy something and see what the end result is. If you would buy a mask for example and the retail oprice was $200...the agreed upon insurance amount might be $150. If you have a 20% co-pay, you would be responsible for $30 and the insurance company would pay $120. The insurance company pays $120 whether you pay the DME $30 or not. It is the DMEs loss if they agree to accept only what the ins. co. pays.

LSAT wrote:I don't think this is insurance fraud...If they are willing to accept what your insurance co. pays them without any payment from you...it is their loss. I'm sure that your insurance company doesn't care whether you have to pay or not. They have agreed to pay XX amount for an item. I certainly would test them out. Buy something and see what the end result is. If you would buy a mask for example and the retail oprice was $200...the agreed upon insurance amount might be $150. If you have a 20% co-pay, you would be responsible for $30 and the insurance company would pay $120. The insurance company pays $120 whether you pay the DME $30 or not. It is the DMEs loss if they agree to accept only what the ins. co. pays.

The issue is that BCBS believes I've paid out of pocket on a deductible for the year. It simply wouldn't be true...I would deem this equivalent to having secondary insurance and I'm sure BCBS would definitely want to know about that. One purpose of deductibles is to make people think twice about whether they really want to get that treatment and incur an associated expense. If I can simply and magically eliminate that deductible and not tell my insurance carrier, that would at the very least seem to me to be dishonest. I'm betting that if I mentioned it to BCBS they would consider it fraudulent, especially since I'm annually asked to confirm whether I have any additional insurance. I define insurance as someone else paying what I'd otherwise owe...I'm fairly confident BCBS would see it the same way.

So, who gives a squat how BCBS feels?

chunkyfrog wrote:So, who gives a squat how BCBS feels?

I do.

I have to look myself in the mirror and since I've entered into a contract with my insurance carrier, I'm honor bound and legally obligated to stick to it.

If I expect my carrier to honor their end of the deal...I'm expected to honor mine.

I'm not sure if it's insurance fraud or not, but it does happen sometimes.

I had a therapist that I was seeing regularly. My insurance company changed their policies and I went from no copay to a $20/visit copay to see her. She said that she would accept the insurance payment as payment in full, and not bill me for the copay.

I'm sure the DME will be VERY HAPPY to accept your co-pay.
Let your conscience be your guide.

chunkyfrog wrote:So, who gives a squat how BCBS feels?

Here's a quote from the 2011 BCBS Federal benefits booklet.

Note: If your provider routinely waives (does not require you to pay) your applicable deductible
(under Standard Option only), coinsurance, or copayments, the provider is misstating the fee and
may be violating the law. In this case, when we calculate our share, we will reduce the provider’s
fee by the amount waived.
Example: If your physician ordinarily charges $100 for a service but routinely waives your 35%
Standard Option coinsurance, the actual charge is $65. We will pay $42.25 (65% of the actual
charge of $65).

This is specific to one plan only, but I'll bet similar words are in most every BCBS plan booklet for every plan they have.

Another quote from the booklet.

Non-participating providers. These Non-preferred providers have no agreement to limit
what they will bill you. As a result, your share of the provider’s bill could be significantly
more than what you would pay for covered care from a Preferred provider. If you plan to use a
Non-participating provider for your care, we encourage you to ask the provider about the
expected costs...

Cotay, the two greatest risks one is faced with if you go with a DME supplier who says they will not bill you for the difference. One, your insurance company very well may be aware of their practice and so reimburse a lot less than you are expecting. And two, the person you are talking to may well be lying through their teeth and after you have the equipment and they have the insurance payment in hand start coming after you for the difference. In this case you would have NO recourse to avoid paying their demanded price. You have no way to enforce an illegal agreement.

Years ago a chiropractor in Illinois advertised NOOPE, no out of pocket expense. He would bill the ins co his fee, get their payment, and write off the copay. Well, it didn't take long for the insurance companies to adjust their reimbursement to 80% of 80%, or whatever their % pay was, or refused to pay for his services. Plus they threatened him with legal action for fraud. He changed. No insurance reimbursement, no business. Simple business model.

Cotay wrote: chunkyfrog wrote:So, who gives a squat how BCBS feels?



I do.

I have to look myself in the mirror and since I've entered into a contract with my insurance carrier, I'm honor bound and legally obligated to stick to it.

If I expect my carrier to honor their end of the deal...I'm expected to honor mine.

I admire you for your honesty, maybe if we had more of this the medical problems would be less. I have federal BC/BS and I watch my EOBS and if there is any hanky panky I'll call and let them know about it. Insurance premiums are high enough.

idamtnboy wrote:And two, the person you are talking to may well be lying through their teeth

That IS what I am thinking.

idamtnboy wrote:and after you have the equipment and they have the insurance payment in hand start coming after you for the difference. In this case you would have NO recourse to avoid paying their demanded price. You have no way to enforce an illegal agreement.

The only way to find out is to read & re-read the agreement they will have you sign. You may also be responsible for any legal fees.

This is a rough business - the sleep business.

Here's another bit of info from a web site for medical billing professionals.

In general, waivers of co-payments and deductibles are permitted only if they are not advertised, not routine, and are granted only to
financially needy patients or where a reasonable collection effort has been made. (See below for addt'l info. on this issue).

Here's the link where I find this: http://medicalassociationofbillers.yuku ... yMu-4GwX0Q.

If Medicare is involved it is against federal law to waive copay except as stated above. Apparently there are no state laws on the subject. It may be a muddy situation IF the DME supplier has no contract with the insurance company and does not receive the insurance payment directly from them. In this case you would pay for the device, submit the claim yourself and get the insurance company reimbursement directly. Then if you take that check and give it to the DME supplier and they then revise their bill to you to bring the price down to the ins company amount, you might be in the clear. But I cannot imagine any DME operating on solid business footing doing things this way other than on an exception basis.

Cotay wrote:When I inquired about how that would be possible when I have deductibles and co-insurance, their response is that even thought they are out of network, they don't bill me for the difference if my insurance doesn't pay them.

This makes no sense and would appear to be fraudulent behavior.

Remember the saying "IF it sounds to good to be true...."?

How long could a company stay in business giving away FREE machines?

idamtnboy wrote:In this case you would pay for the device, submit the claim yourself and get the insurance company reimbursement directly. Then if you take that check and give it to the DME supplier and they then revise their bill to you to bring the price down to the ins company amount, you might be in the clear.

Why would anyone pay twice for one machine?

I had a dentist who gave a 5% discount for payment in full at time of service.
He would not deal directly with any insurance company; only worked on folks with no insurance.

Yes, it's usually insurance fraud.

I can't tell you how likely you are to get caught.

I'm not quite sure how I feel morally about accepting the deal if you don't end up with any kind of kickback out of the deal.