Update: The DME worked me over

[Slinky]

OF COURSE THEY DIDN'T GIVE YOU ANY ARGUMENT - "THEY" DID 'NOT' SUPPLY THE MACHINE YOUR DOCTOR SPECIFICALLY ORDERED!!!! YOU have THEM by the short hairs. IF you plan to continue doing business w/them for your masks and supplies via insurance MAKE SURE that they are aware that if you encounter ANY MORE hanky panky from them you will not only notify their head honcho but also your state licensing bureau AND your insurance.

[TXKajun]

This is allllllll just so damn WRONG!!

Kajun

[linuxgrl]

Just needed someplace to rant.

I submitted a claim to my insurance - Excellus BCBS for the CPAP that I purchased from cpap.com, after dumping my rotten, rotten DME. I used wulfman's advice and made up my own invoice with myself as the billing party. I included my prescription and a copy of my bill from cpap.com.

And today, my christmas present came early... My claim was rejected with a code "258 - claim submitted to Blue Cross / Blue Shield plan where service were rendered."

UGH. Obviously I will be calling them first thing in the AM. Does anyone have any advice for me before I have a stroke?

[Slinky]

Well, all insurances have to have an appeal process. And there is always a complaint to your state insurance division. Hopefully, you have all the paperwork from the snakey local DME, you should be able to get a copy of your script from your doctor. That is your proof that the DME didn't supply you w/the equipment as scripted. While you might not have something in writing hopefully you have the date and time of call and who you spoke to when you were promised the Pro by this DME and the date, time and name when the Plus was brought out instead. Use it all. Keep copies. Keep proof of submission of the complaint and proofs sent.

Hopefully, others here can better advise you.

[sleepycarol]

When you took the plus back did you sign any papers? What were the papers you signed?

When I took my Plus back they wanted me to sign a waiver that I was essentially giving up on CPAP and was NOT going to use a cpap. I refused to sign that. I did sign where I turned the CPAP back in to them but not the other form that said I wouldn't be compliant with therapy.

They even called my doctor and wanted her to fax a script stating that I would not be using a cpap. I had already talked to her and she knew what was going on and so after a discussion with them -- she simply hung the phone up on the woman.

Have you talked to the insurance company about why you ditched the DME? Unless you communicate with the insurance company they may not know why you returned the DME and who knows what the DME told them. My insurance company even paid for a full month of rent at the first DME (I had the machine 2 weeks) and then turned around and paid ANOTHER month a the second DME. I thought that was generous on their part.

Take a deep breath BEFORE you talk with them. Stay calm, think things through prior to talking, and be firm!!

[linuxgrl]

When you took the plus back did you sign any papers? What were the papers you signed?

No, they never asked me to sign anything. Yikes. That is horrendous what they did to you though! Sounds completely illegal to me!

Have you talked to the insurance company about why you ditched the DME?

Sort of, not really. I did tell them that I was no longer going to be doing business with the DME, and they told me the whole process I would need in order to start up with another one. And then I chose to go the cpap.com route because I was going out of town for thanksgiving, and needed a new cpap in a hurry.

I've calmed down now, thanks to some classical music and hot cocoa and I will definitely be giving them a call in the morning when they're open.

Thanks SleepyCarol and Slinky for the support!

[sleepycarol]

Just remember to keep a calm voice (even if you are shaking on the inside) and be firm as to why you feel that you have a good claim.

Tomorrow is Friday and lots people are looking forward to the week-end and many have Monday off due to it being Christmas Eve and then of course Tuesday is Christmas. Do NOT be discouraged if you do not get the answers you want!! It may have nothing to do with you and everything to do with THEM wanting out of there!! Take notes of your conversation -- who you spoke to, the time, and major points of the conversation. Try (and this can be hard for me) really hard not to argue with them.

If you do not get what you want, sit down take a deep breath and compose a letter to the supervisor stating all of the facts as it pertains to your treatment. Set it aside for a couple of hours and then reread it in case you left anything out it can be added. It is important you put it in writing so that you have proof in case it goes to appeal. When you mail it you will want a signature delivery confirmation in order to proof they received your letter.

[mindy]

Hi linuxgirl,

In addition to Slinky's excellent advice, I'd like to add one thing from personal experience. I had to go the route of an appeal a number of years ago. It was a claim that should have been a slam dunk and I was floored that it was denied (reviewer was an RN). Upon appeal, it was sent to a regional specialist type of doc and he immediately approved it. The whole thing was very frustrating and a lot of hassle but most definitely very well worth it since it avoided continuing problems.

Since that time I've learned that some insurance companies take the path of least resistance and deny the first time around -- they know that lots of folks won't go to the trouble of appealing or don't realize that they may stand a good chance of succeeding.

Consumer Reports at one time had an article on the same thing and also advised appealing. They even had an example letter to send.

I'd try something like the following:

1. Make up your mind whether or not you're willing to stick it through and if so, then settle in for a longish haul

2. Take deep breaths whenver you start to feel yourself getting mad ... and stay as cool as a cucumber. The calmer you can stay, the better off you will be.

3. Document everything - if you call, note the name of the person you talked to, the date and time, and what was said. If you didn't catch their name, ask specifically (and they will know you are keeping track).

4. Follow the 2 P's: persistence and politeness

5. Document what happened with the DME and send a letter to your insurance carrier .... it may be easier for them to say "no" over the phone. If you take the trouble to send careful documentation, they may be more likely to take you seriously.

And know that I'll be thinking of you and hoping that this will turn out well!!!

Mindy

[mindy]

ps and sleepycarol had some great comments, too!

m

[milkman]

And today, my christmas present came early... My claim was rejected with a code "258 - claim submitted to Blue Cross / Blue Shield plan where service were rendered."

This is nothing to worry about. The claim just needs to be sent to the proper office. I have Highmark BCBS, which is in Pennsylvania. I live in Portland Oregon. If my claims get sent to Highmark I get the same code. My claims need to be sent to Regents BCBS in Portland where I get the service. Regents verifies the claim locally and then forwards it to Highmark for payment. The Excellus BCBS office can tell you where to send the claim.
Maybe it should go to the BCBS office nearest cpap.com in Texas. Excellus should forward it and probably will, but I would send in another to the office nearest where the service was rendered, that way you know you are covered. If the claim is submitted twice, one will simply be denied with a code for "already processed with another claim".

[linuxgrl]

Thanks Mindy, for the great advice! I had a feeling I was in for a fight when I got started with all of this but the stress of the holidays, plus a huge, huge test coming up tomorrow... It just couldn't possibly be worse timing. I wish the letter would have just come a few days later so I could have gotten it after the holidays.

[linuxgrl]

This is nothing to worry about. The claim just needs to be sent to the proper office.

Milkman, I love you. I had no idea what the code meant and I thought that they were denying it because I'd already had CPAP service provided by the DME.

Why do they have to use such confusing language! Well, I know why. So the frazzled customer will beat their head against the wall.

THANK YOU!

[GeneS]

Since that time I've learned that some insurance companies take the path of least resistance and deny the first time around -- they know that lots of folks won't go to the trouble of appealing or don't realize that they may stand a good chance of succeeding.

We had an experience similar to Mindy. Our group insurance in 2006 did everything they could to not pay a claim. They rejected the first submittal almost always, they said a secondary insurance was primary etc. It went on and on. People kept spreadsheets, thick notebooks etc. to track every claim and to pester the agent and insurance co. until they paid. We did research and found that they had lost a class action suit in Arkansas for the same thing. We sent the agent copies of this that we downloaded from the Internet and they knew we could do the same thing in our state. People eventually got their claims paid and we got a new Insurance Co. the next year. Their CEO and founder took huge sums of money out of the company instead of paying claims. He retired with the money and to avoid problems. It was just in the paper that he had to pay back quite a few million I think because of Stock Option Violations.

I agree that you cannot always accept what the insurance company does without standing up for your rights or you will be taken advantage of. We have also have had very good insurance companies so you have to keep track and stand up for yourself.

[KansasRT]

Just a word of advice, when ever you return something to a DME you should INSIST to have a signed (By you and them ) pickup ticket. Without a valid pickup ticket the DME can continue to bill the service. Most won't, and it is illegal and if caught they can be fined and made to return the money. Also any other supplier that you use (B&M DME or submitting claims yourself) would have their claims denied. It would eventually be fixed, but not without a headache. This happens alot around here with A**** and L****** . Mostly with Oxygen, but *PAP as well. I really can't comment on the BCBS issue because I don't know. But thought I wuld add the other info.

[Wulfman]

Just needed someplace to rant.

I submitted a claim to my insurance - Excellus BCBS for the CPAP that I purchased from cpap.com, after dumping my rotten, rotten DME. I used wulfman's advice and made up my own invoice with myself as the billing party. I included my prescription and a copy of my bill from cpap.com.

And today, my christmas present came early... My claim was rejected with a code "258 - claim submitted to Blue Cross / Blue Shield plan where service were rendered."

UGH. Obviously I will be calling them first thing in the AM. Does anyone have any advice for me before I have a stroke?

Did you have communications with your insurance provider BEFORE you did what you did? I always try to include that step in my recommendations.

viewtopic.php?p=223818

It's been reported on the forum that BCBS has been excellent about this type of thing with users buying out-of-pocket. And, like the others said, it needs to be appealed through the proper channels and all the former paperwork un-done. Otherwise it'll look like they're paying more than once for the same or similar stuff.

Den