Insurance company and DME, an illuminating experience

I am going around and around in the circles between the two above mentioned entities regarding the finances of my desired equipment. My insurance company rents for 2 months, then another 10 months on a rent-to-own plan if all is going well. They have a single billing code for the machine, hoses and mask regardless of which equipment is supplied. The contract the insurance company has with the in-network DME states that the DME can only bill for about $154/mo for the machine, hoses and mask regardless of which equipment is chosen. The DME gets 80% of that figure from insurance, I pay the other 20%. If I want a REMStar Auto w/C-Flex, my DME wants to pass along to me another $350-400, but my insurance says that the contract states that the DME isn't allowed to do that and can't refuse to serve me. So now I am trying to find a DME that wants to honor my insurance company's contract. This situation is blamed on Medicare reimbursement rates by my insurance company. ARRGGGHHHH! I am beginning to think the plan is to wear me down until I can't fight them anymore...they all know I am sleep-deprived already. I have already gone through billmyinsurance.com and my insurance company doesn't want to deal with me purchasing and then directly seeking reimbursement from them.

I know a great company that does just DME supply, you can email me and I can send you the information. My email is jkennedy@orbitmedical.com They might be able to help.

from your post I see you've already read the posts below about insurance and etc.

on my second coffee, so let me play with the calculator----$154x12= $1848. ins. co. pays 80%=$1478 and you pay 20%=$368. "DME wants to pass on another $350-$400 to me (for Remstar)". so, all of a sudden, your looking at $368+ $350-$400= $718-$768.
then you go to one of the online CPAP stores you googled and find the REMstar Auto C-Flex CPAP, REMstar Heated Humidifier with bag, hose and manuals=
$725.99.
Nothing clears out the airway like a good, hardy laugh! go for it.

See, here's the problem, this site shouldn't be here and we shouldn't be talking about this. Healthcare is not just another "service industry" and we are not "customers"---we are "patients", doctors are "gods" and DME's are "gods helpers".
"Patients" are supposed to get a prescription for a CPAP machine(make, model, pressure settings, etc.) from the doctor and then get this equipment from the doctor recommended, "in network" DME. the "patient"(see: sheep, lemmings, fish in the barrel) then breathes deep and pays the bills.
For even more laughs, call your insurance company and try to explain that your trying to get the equipment you want and save them some money.
Call your insurance company and challenge the "Rep" to use the words, "customer" and "service" in the same sentence. that's a real knee slapper.....

investor60 wrote:Call your insurance company and challenge the "Rep" to use the words, "customer" and "service" in the same sentence. that's a real knee slapper.....

Investor60, good attitude. Documenting the paradoxes in the healthcare industry would fill many volumes. Hope to see more of your posts.

Regards,
Bill

investor60 wrote:the "patient"(see: sheep, lemmings, fish in the barrel) then breathes deep and pays the bills

I was almost laughing too hard to read the rest of your cool post, investor. Veryyy good!

Sad, ain't it.

This situation is blamed on Medicare reimbursement rates by my insurance company.

Sad but true, I had a link to the files in which the government basically said: An automatic machine does what a simple machined does - pump pressure - therefore the request for a separate code is denied.

They moved the file.... but this is where it was -
http://www.cms.hhs.gov/medicare/hcpcs/dme.pdf

O.

Respironics charges an additional $300 to DMEs for the Remstar Auto over a basic Remstar Plus. The billing code is the same for any model CPAP whether it has C-flex, is auto-titrating, or is just a basic blower. When DME companies negotiate with insurance companies or medical groups, I've found very few of them really care about patients needs. It's all about money so they negotiate for the least expensive equipment and masks. If your DME company didn't agree to their terms, another DME company would have.

It sounds like your DME is trying to pass along their extra cost for the machine to you. My advice is to call your DME company, ask for the manager and negotiate a better upcharge. DME companies can't compete with Internet companies pricing. The business models and level of service is totally different. A DME company has a much larger overhead and is heavily regulated where an Internet company is not.

Excellent post Investor!!!

JohnBob, my suggestion: Dump the local yocal DME, go to cpapforseniors.com and buy your machine on-line they will do your medicare billing for you. Get the machine you want, if the Remstar Auto w/Cflex is what you want, use your existing prescription and order it on-line nothing special for that machine is needed.

ozij wrote:

Sad but true, I had a link to the files in which the government basically said: An automatic machine does what a simple machined does - pump pressure - therefore the request for a separate code is denied.

They moved the file.... but this is where it was -
http://www.cms.hhs.gov/medicare/hcpcs/dme.pdf

Ozij,

I think this is the link you were refering to:
http://new.cms.hhs.gov/MedHCPCSGenInfo/ ... #TopOfPage

about the middle of the page under "Downloads" where it says "Durable Medical Equipment"

Lyn

Thanks for the link, Lyn!

Here's the text, where the government again turned down (as it has in past years) using a separate billing for autopap.

On page 21 of http://new.cms.hhs.gov/MedHCPCSGenInfo/ ... agenda.pdf
__________________________________

Meeting Agenda Item #16
April 25, 2006
HCPCS Request #06.23

Topic/Issue:
Request to establish a code for self adjusting sleep apnea system, trade name: ResMed S8 AutoSet Advantage.

Background/Discussion:
According to the requester, select payers consider APAP technology medically necessary as a second or third line alternative therapy for obstructive sleep apnea when documentation of failed CPAP is an issue. Patients may experience difficulty in using positive pressure therapy if the pressure is equal to or greater than 10cms of H20 as evidenced by an in lab technician attended CPAP titration during polysomnography. Also if the patient is intolerant of high fixed CPAP pressures despite appropriate patient education and interventions to improve comfort and compliance, APAP may be deemed medically necessary. APAP addresses issues such as positional and sleep stage induced apneas. The technology has also been reviewed as appropriate for pre and post management of bariatrics patients where dramatic changes in weight over time have a profound effect on the pressure needs of the patient once looking at long-term compliance and providing efficacious therapy to offset complications associated with apneaic patient.

CMS HCPCS Workgroup Preliminary Decision:
Existing code E0601 CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICE adequately describes a category of items by that perform the same or similar function as the item in this request. Clinical information included with this application does not demonstrate a superior clinical patient outcome when this device is used, when compared with other CPAP devices categorized at code E0601.

Medicare Payment:
Fee schedule and payment rules associated with existing code apply to this product.
Pricing = 36