Insurance deductible question

[HP]

I recall a post or two sometime ago about this, but I haven't been able to find it via the search function.

I purchased a cpap and filed a claim with the insurance company. The company paid a smaller reimbursement than I expected, because they said that cpap.com was not an in-network provider. Out of network provider claimes are serviced under an additional and separate deductible.

I recall seeing some advice posted here that one should appeal the decision on the basis that since I purchased the device and submitted the bill to the insurance company, I became the "provider" and normally "I" am an in-network provider, and I should win the appeal.

Can anyone confirm this and provide any additional clarity for me??


Thank you!

[mattman]

Hiya HP.

There is someone here who has had success with this, I don't remember who. Wulfman maybe?

This is the only case I know of though where someone has been able to do this. Now - I have not gone LOOKING for people who have done this though, so it's possible they were just going under my nose.

Typically though, and why it doesn't seem very likely, is that what makes a provider "In Network" is that they have signed a contract and agreed to be bound by the prices set forth by the insurance, they have agreed to documentation requirements and agreed to the standards and practices set forth by the insurance company (Things like record keeping, patient data tracking, care guidelines, etc).

Obviously, these are things that you may well be willing to do but you haven't signed a contract and therefore wouldn't (normally) be considered "In-Network".

Now, that being said it certainly can't hurt to try the appeals process. Just be aware that it's an insanely long process. We often fight these for 6 months or more. It can be a very time consuming process.

mattman

[bookwrm63]

Hi HP,

I myself have been checking out insurance questions lately regarding cpap purchases. Did you call your insurance company first to verify your benefit? Were you quoted a different benefit rate than what you received? If you did call, perhaps if you have that persons name and the date you spoke with them, it might help in your appeal. When I called yesterday to mine, I was very specific in mentioning in-network vs. out of network and the different benefits they provide. Good luck and I hope you get the resolution you want.

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[Wulfman]

HP,

Yeah, that would have been me.
Did you make out an invoice to your insurance provider FROM YOU? (as the billing party)
Also, as far as a lesser amount that they paid......were there any deductibles taken into account by them?

When I went through this process, they initially issued me a check for 60% of the amount that I had submitted......which represented an "out-of-network" payment. When I brought it to their attention and questioned them about it, then then issued me another check for the remaining 20%.....for a total of 80%......which is all our plan reimburses on DME purchases. FWIW, I hadn't actually received the check, yet, when I questioned them......I had been on the phone with them inquiring about the reimbursement because I hadn't yet received any payment for the invoice I had sent them. When I questioned them, the gal I was talking to went to her supervisor and then came back and informed me that they had made a mistake and that another check would be sent.

Den

[HP]

Wulfman,

I did not write up a separate invoice from me to them......Is that the mistake I made?

Is the appeal opportunity now gone, since I sent them a copy of the cpap.com paid invoice along with my claim form?

I did not phone them in advance, since it takes forever to get someone live on the phone there.

I purchased a second portable cpap about six months after I bought my first machine, and I doubted that they would even cover a second machine purchased so close to the first one.

I believe I will submit a formal appeal anyway using the logic of buying the machine myself and submitting the cpap.com paid invoice as evidence of the original purchase.

I suppose the same will also apply to replacement masks, hoses, etc.

Thanks for your response.

[onecoknower]

Per insurance appeals regs, you have 180 days from the time your claim was denied to appeal. If you're planning to, you need to include ALL the documentation you think is relevant to your appeal, because if it's denied, the only way you'll be able to get it paid is via winning a lawsuit.

Just thot you'd want to know...

[Wulfman]

Wulfman,

I did not write up a separate invoice from me to them......Is that the mistake I made?

Is the appeal opportunity now gone, since I sent them a copy of the cpap.com paid invoice along with my claim form?

I did not phone them in advance, since it takes forever to get someone live on the phone there.

I purchased a second portable cpap about six months after I bought my first machine, and I doubted that they would even cover a second machine purchased so close to the first one.

I believe I will submit a formal appeal anyway using the logic of buying the machine myself and submitting the cpap.com paid invoice as evidence of the original purchase.

I suppose the same will also apply to replacement masks, hoses, etc.

Thanks for your response.

HP,

Probably was.

And....they like communication (read that "pre-authorization") about stuff like this, too. They may very likely tell you how to go about doing this.
I even jumped through those hoops and they still (momentarily) shorted me 20% till I questioned it. For a minute, I thought they had sent MY check to CPAP.COM.....
I also enclosed a copy of my CPAP.COM invoice to show them that I wasn't doctoring any figures.
It kind of throws them for a loop when we do things out of the norm like this.

You can still try to appeal it....??? (I sure as Hell would!) I think you get two or three tries at appealing their rulings.

I never did actually get a definite answer from mine as to when (or IF) they would be willing to help me buy another machine. Since I was already prepared to buy the first one completely out-of-pocket (to get a better machine and one that would work with software), I was pleasantly surprised that they agreed to reimburse me for a good chunk of the one I bought. I'm sure that it would be around 5 years or more. In any case, I think I'm stocked up now.

Best wishes,

Den