Yup--I may now be paranoid with DME's

[Paul56]

We have boards up here where folks can post used items for sale. "Used Ottawa" is the one in my area.

Someone has this unit up for sale at the link below. Perhaps there is a similar online "used" facility for your area. Not sure I would consider purchasing a machine from a smoker... the smell may be impossible to get out. <shrug>

http://www.usedottawa.com/classifieds/a ... ption=cpap

[lovey]

I had, before the bipap, used a cpap for 17 months, with great compliance from day 1. When I questioned the 3 month rental for bipap with BC/BS, I didn't get anywhere. I kept saying I had been compliant, that this was a 2007 expense, etc. Luckily for me it did work out all in the end. Please people don't give up though, if enough people fight this, we have possibilities for change.

Medical costs are the reason now I am on Medicaid and COBRA health insurance and Social Security disability. It costs so much when I work to pay the copayments. Illnesses shouldn't be allowed to bankrupt people or have them live in extreme poverty like I do right now. We need change...now..

[DreamDiver]

... I really am wondering if the DME will now be able to bill me for that outrageous amount?

The DME will bill your insurance. It's unlikely you'll have to pay the entire amount since it is contracted through the insurance company as Rested Gal suggests. Since you've already done the PSG and a first month with the rental, the insurance company will tell you what's left for you to pay for that month. If you have already gone over your $1000 out of pocket for the year, you probably won't owe anything for the month. However, it's still a good idea to talk to the human resources person in your company or the Insurance sales rep who sold you the insurance to find out what options are right for you. There may be options - as I said - proving compliance prior to the end of the year and making them pay for the entire machine before then so you don't end up Write to your health insurance company with your concern and copy it to your state's insurance fraud bureau. In a very matter-of-fact, non-threatening way, let them understand that you're angry and upset at the system and that you will be making a lot of noise. Write your governor and your congress members/senators. Let them know this is not a matter of compliance, but rather a glitch in the system that makes it unreasonable for you because you end up paying more than the machine is actually worth, not even counting what the insurance company also is paying to the DME.

@MichelleFL - there is a compliance number on the readout of your machine. It's a 'code' used to establish whether your hours are appropriate for the number of days you've had the machine. You can call this in to the DME and they can call in compliance to your Insurance. You shouldn't have to pay for this particular service. Again, contact either human resources or the person who sold you your insurance to find out your full options.

[WNJ]

If your DME has an agreement with BCBS, then probably they will only bill you for the “allowable” amount.

Most medical providers have one rate they charge individual customers, and another (lower) rate they negotiated with insurance companies. You should get the benefit of the lower negotiated rate.

If not, you should be able to negotiate a lower rate yourself, if you are in a position to immediately pay the lower rate in full.

Wayne

[plr66]

The "billed" amount and what the DME expects to get and is perfectly willing to accept from the insurance company is very different. The billed amount can look ridiculously high....

Sigh--Had to go to bed last night before a I could read a bunch of these responses. Thanks one & all--will get back to the board tonight after work. But RG, I do want to just ask again, following on this statement, which I was aware of. That "ridiculously high billed amount" that is now being denied by BCBS.....can that amount be now forced upon me as a consumer since it is clearly and known-to-everyone universally as an absurd billing amount?

[rested gal]

That "ridiculously high billed amount" that is now being denied by BCBS.....can that amount be now forced upon me as a consumer since it is clearly and known-to-everyone universally as an absurd billing amount?

I have no idea. I'd find out exactly why BCBS is denying the DME's claim. Might be just some bit of paperwork that was not filed and can be cleared up fairly easily? I don't have insurance at all, so I really don't know how it might work in your situation.

[WNJ]

....can that amount be now forced upon me as a consumer since it is clearly and known-to-everyone universally as an absurd billing amount?

Well . . . there is a rational basis for that difference. I won’t say it is fair, but it is rational.

For individual patients without insurance, the medical provider will collect less than the full billed amount, maybe nothing at all, from a percentage of patients. They factor a degree of non-payment, plus a healthy margin for the expense of trying to collect from patients. Over a period of time, providers can forecast the amount they will collect vs. the amount they bill. They will adjust their billing to a higher number to reflect the amount they need to actually collect to remain in practice.

Insurance companies offer providers the following bargain: We will put you on our “preferred” list and send our subscribers your way. This will help insure you a steady stream of patients for whose services you will be paid. In exchange, you grant us (as the principal payer) a price that discounts the margin you have to build in for collecting and for “deadbeats.”

Wayne

[Paul56]

Talking about deadbeats and payments...

My DME wanted me to provide a credit card number as security against the trial machine they gave me. I suppose they have some "customers" they provide a trial machine to and never hear from again.

My experience is the following... "Respiratory Therapist"??? Naw! More like "Sales Agent". I'm sure they are not all like that... but mine was.

It has to be one of the easiest sales jobs on the planet.

[Insomniyak]

Try Craigslist (Craigslist.org) and look for the local or surrounding areas where you live. If you do find one, Please open up and clean it or have someone technically versed clean it and make sure to change the filter and buy your own hose and filter. I have seen CPAPs for $50--$100 on Craigs so they are out there.

[lovey]

I think they can try to charge the full amount. I had a problem in that I had 3 more physical therapy visits than allowable. I had asked them repeatedly when I was covered to, but they don't care. For the 3 visits, they are trying to charge me $900. After I told them I was on Medicaid, Food Stamps, etc. and couldn't pay, they have given me the "discount" rate of $130 a visit. This is the same amount that they regularly received from insurance for each visit! I didn't like how they worded everything and threatened me with collections (without even a bill yet), so I have been refusing to pay now. They were the ones who messed up by repeatedly telling me I was covered for the visits. And I've added it up that they have received over $8k for 6 months of therapy for me, so it is not like they didn't get any money over me!

It is all a scam. Greedy, horrible people. I had one lady from a doctors office threaten to "mess up" my insurance if I didn't pay the $25 owed to them...gee, the $12k I paid for medical last year wasn't enough????

Uggh.. Please don't vote for McCain. I'll never be able to get insurance again under his plan. Good luck..

[DreamDiver]

I had one lady from a doctors office threaten to "mess up" my insurance if I didn't pay the $25 owed to them...gee, the $12k I paid for medical last year wasn't enough????

No doubt, the entire healthcare system needs reworking. It's interesting she said that. People don't realize how easy it is today for patients to keep an audio or even visual record of what's happening around them. Many popular MP3 players can be set to record before you even enter the billing office. It would be interesting to see how they might fare if that kind of nastiness showed up on your blog or myspace.

I guess I shouldn't advocate that. But we do live in big brother times. I wonder of little brother and little sister shouldn't listen back.

[jnk]

Yup--I may now be paranoid with DME's

My opinion is that we are NOT paranoid. They ARE out to get all they can get. The game is called "buyer-beware," and this is one instance where assuming that life is fair, honest, and being played on a level field can get you into a lot of trouble financially.

The assumption of the insurance companies and the DMEs is that most people do what they're told and are afraid to be considered rude by being assertive. That means we all have to do our homework and be very firm, not rude, about what we will and will not accept, what we will and will not pay for.

We can't do that effectively without doing our homework first, though, or it will be clear we don't know what we're talking about, which gives them license to walk all over us. Polite questions that let people on the phone know that we know what we're talking about are our best weapons of defense.

The deals between DMEs and insurance companies happen behind closed doors. So it's only by learning the ins and outs of how things work, from places like this forum, that any of us can be armed with enough facts to wade through all the, uh, let's call it 'obfuscation,' being thrown at us by DMEs and insurance. And it is best to learn all we can BEFORE dealing with any DME or insurance company about this stuff, instead of watching it all go bad as we are systematically victimized. But we have to know going in that no one actually considers it his/her assigned job to be helpful to us. That means that we individually have to be helpful to ourselves by working the phones and figuring out what is best for our health and our wallets.

And I say that If we find someone helpful at a DME or insurance company, thank them profusely, write in to their companies commending them, and post the name of that company here. That way we can turn our non-paranoia into action and steer some money toward companies who deserve it.

That's my rant. Now back to our regularlly scheduled forum.

[plr66]

Regardless of what your insurance is paying to the DME, if you find your out of pocket and deductibles are more expensive because of the January restart of deductibles, turn the box back in tomorrow and buy a new one from cpap.com. Do the math so you won't fall prey to what happened to me..

Yes, Diver, that's what I was saying my situation was...$1000 deductible now, and then again starting over with another $1000 deductible on Jan. 1st....so I'd have been paying $2000 out of pocket just toward deductible, and still wouldn't own the machine. Needless to say that it at least seemed to be a no-brainer that I needed to just buy my own cpap online. I just did not anticipate that I might get billed for that huge amount by the DME with possibly zero insurance coverage. I do admit that my cognitive functioning is at times impaired!

I will add here, that it is just not usually possible from what I have read, to just convince the insurance company that because you've been compliant for a couple of months, they should now change their rules and buy the machine for you. Not gonna happen in most cases. BCBS told me this as well.

It amazes me how many people get diagnosed in September so they get their machines in October. If I believed in conspiracy theories, I'd say this is one set to help the DME's and Insurance companies wrest more money from patients than from their plans.

Okay Diver, I think you just beat me on the paranoia scale!!

[MichelleFL]

Okay Diver, I think you just beat me on the paranoia scale!!

Same here plr66. I am glad that you started this thread as I had no idea nor thought about January.. I have my mind focused on getting the machine right now and not worrying about too far ahead in the future.. The future I did see was myself paying to rent the machine for 10 months then they will buy it for me, totally forgetting my deductable! ahhhhhhhhhh! Now I don't know what to do. I unfortunately cannot buy one outright, don't even have credit cards to put it on. I guess that I will have to try craigslist or cpap auction and pray there is someone out there who can help me and they are not looking to get almost full price for it.. My main concern though.. Buying something used, how long is it going to last???

[plr66]

My opinion is that we are NOT paranoid. They ARE out to get all they can get....
The assumption of the insurance companies and the DMEs is that most people do what they're told and are afraid to be considered rude by being assertive. That means we all have to do our homework and be very firm, not rude, about what we will and will not accept, what we will and will not pay for.

We can't do that effectively without doing our homework first, though, or it will be clear we don't know what we're talking about, which gives them license to walk all over us. Polite questions that let people on the phone know that we know what we're talking about are our best weapons of defense.

Nicely said, jnk. Even though it was only in August when my PCP sent me for a sleep study due to alarming oximeter data, it seems like eons ago in terms of "what I knew then and what I know now." I was SO anxious to do whatever I was instructed to do to start my recovery as quickly as I could do it....and it was a totally new world I'd never been in. Heck, I've hardly had any MD appts at all in my adult life until the past couple of years (all of which now seem amazingly and probably related to this undiagnosed OSA)--and I am in my late 50's! So I went into this with naivite, and driven by a desire to do what I needed to--worry about the financial part later. And I bet there are tons of other folks here who followed that same pattern.

Yes, I intend to pursue this through our state insurance commissioner, if necessary, and informed BCBS of that in my 1st Appeal letter. But Diver, I doubt I'll take it to the governor or legislators....I'll leave that to you, since we live in the same area. I have really appreciated everyone's input to this thread. Thanks, as usual. You all are terrific!