DME antics

Dear Hubby just diagnosed couple weeks ago. Doctor wrote order for Autopap pressure range 5-20, humidifier and mask of patient choice and sent over to a local in network DME. DME called us to say they checked our benefits and we can have that machine but will have to pay $250 above and beyond our insurance copay for the Autoset. Since I have already been through this song and dance and have read Janknitz blog when I was diagnosed this summer, I called the insurance company and they confirmed the DME should not balance bill and should accept the reimbursement for the E0601. I called the DME to tell them I called insurance company and that if they won't give the S9 Autoset for the reimbursement arrangement allowed with our insurance we will walk to another DME, we will tell the doctor's office they will not fill the doctor's order as written, and I will let my insurance company know they are not in compliance with their contract with them. The DME insisted they are allowed to charge extra for the Autoset and they do not care if we take our business elsewhere. My husband went to the doctor's office this morning, told them what happened, they are not happy with the DME company, they promised to call another in network DME to get the machine he wanted and gave my husband a copy of his order in hand.
What is the deal with these DME's anyway? On line, there is only a $50 difference between the S9 Elite and Autoset. I checked with insurance company, if we buy on line we are subject to a $3000 out of network deductible and then 60/40 benefit.

Keep looking for an in network DME who will supply as prescribed without the upcharge. They are out there. You should be able to get a list of in network providers of DME equipment from your insurance company.

I know Pugsy. Some of these DMEs are a racket and it is so frustrating. I doubt the second DME will do this to us after the doctor's office gets on the phone with them. Also, it is a local DME that gets a lot of business from this doc. She wasn't sure why the office gave the referral to the other company to begin with. She said she will handle it. Let's hope we get what we need today. Hubby is much improved after using my backup machine. We didn't even realize he had sleep apnea til mine was treated. He used to blame his poor sleep on my snoring. Now that I am quiet as a church mouse with an AHI <1 every night, he realized that his not resting properly may have something to do with him!

apneawho wrote: He used to blame his poor sleep on my snoring.

Don't you just love it?

Seriously, I am glad he quickly accepted what is going on. Since your doctor's office is willing to do the leg work to find suitable DME then by all means, let them. DMEs (most of the time) will stand up and pay better attention when dealing with doctor's office. We are just little peons to them. The first DME has apparently set up house rules about doing the upcharge thing. They do it because they can get away with it and no one challenges them. Unless someone challenges it like you did, the insurance company never knows it is happening. Most people don't know and never think to challenge... they think that the DME is doing what the doctor ordered and if the doctor ordered something special above normal...then they should pay the difference. It's a racket, plain and simple.

Since I am such a calm collected individual when I am getting screwed (Not)... Even if they had come around to not pushing the upcharge..I would probably still have told them to go screw themselves and found another DME. I simply couldn't stomach doing business with people like that. Zero tolerance for people like that.

Part of the issue seems to be that Resmed doesn't discount to DMEs as generously as the other manufacturers, so DMEs don't make a lot on a Resmed machine, generally. They are probably happier to supply a PR System One. And the insurance reimbursement is not based on the higher end of the spectrum.

Still, even if they don't do as well on the machine, they should know that if they make you, the customer, happy they will get your repeat business and make $$$ on masks, cushions, hoses, etc.

I hope you will send a letter to your insurance company's fraud unit explaining how the DME attempted to practice balance billing and make sure to cc the DME. If you have anything in writing from the DME, that will help.

They do this because they get away with it more often than not, and the poor people who don't know their rights get played as suckers.

Unless we speak up, this will never stop.

Janknitz wrote:I hope you will send a letter to your insurance company's fraud unit explaining how the DME attempted to practice balance billing and make sure to cc the DME. If you have anything in writing from the DME, that will help.

They do this because they get away with it more often than not, and the poor people who don't know their rights get played as suckers.

Unless we speak up, this will never stop.

Already done. Also spoke with insurance company on phone and they have sent the complaint to the Provider Relations Rep who will make a call to the DME to inform them they are not in compliance with contract.

WTG Apneawho! I'm glad you're not letting the DME get away with this!

Apneawho is really cool and a lot prettier than her avatar. Next month we will be married for 13 years. She's been a huge help getting me used to the CPAP and mask.

snoringshrink wrote:Apneawho is really cool and a lot prettier than her avatar. Next month we will be married for 13 years. She's been a huge help getting me used to the CPAP and mask.

Hi Snoringshrink...welcome to the forum. You have a great asset there in Apneawho but then I don't need to tell you something you already knew. Hope you have an easy adjustment to all this cpap stuff with only minor little bumps along the way.

A "his and hers" cpap family...that's cool.

Welcome to the forum, snoringshrink. Your wife has been helping people here. Glad she's helping you, too!

She really is. Right now, the biggest problem that I'm having is that I'm getting a pretty high level of leak out of my nasal pillows (average 22.6 last night alone). I'll keep playing around with the mask for a few days and call the RT if the numbers don't improve.

Thanks for the welcome. It's great to be here and great to be sleeping better.