what is going on?? lost in the catch 22

kenrose · Post by **kenrose** » Sat Sep 17, 2005 11:02 am

Hi everyone
heres my latest tale of woe. my orig DME is totally insane (wanted $1100 for encore software) and dumped a refurbed G and el cheapo comfort select mask, no travel bag no filters etc. My sleep doc (he who is known as Quite Possibly Retarded) is useless. (doesn't believe in auto pap etc).

Now, I called the people at bill my insurance.com and a woman there told me that since I had already gotten equipment from my local DME I probably would be unable to get equipment from Bill my insurance and to go back to my DME. I tried that and of course got no where. Since I have already been ripped off I have to go back?????? My insurance carrier is excellent and in network I only have a 10% copay (out of network 30%) and my yearly deductible is $250.00 They have no time constraints, only a letter of medical necessity (not a case where you can only get a new mask once a year or whatever)
If I have to buy equipment on my own I will but what is going on here? my next plan is to get a RX for new equipment from a different doc and just submit that and see what happens. any thoughts?

loonlvr · Post by **loonlvr** » Sat Sep 17, 2005 11:36 am

I have Blue Cross. I had a cpap, but wanted a Auto. My sleep doc refused so I went to my reg doc. I explained to him why I wanted the Auto, Did the research. I went online, printed out what I wanted, and then brought the printouts to him. He wrotes on Rx exactly what I wanted. I paid for it myself from an online store. Although my co-pay was higher, the whole works(including software) was 1/3rd the price. Just make sure you get something in writing thats states they will cover you. And it takes awhile to get re-emburshed.

TXKajun · Post by **TXKajun** » Mon Sep 19, 2005 11:08 am

ken, you might want to check with both your DME and your insurance carrier and see whether or not you are actually renting your CPAP unit or not. In my case, I got a rental from a local DME (at a totally outrageous rate, I might add, one that when I totalled up my "10%" copay, it was more than enough to justify me getting a brand new 420E with heated humidifier and software than to continue to pay the copay for another 11 months!!) which I kept for one month, then returned. In the meantime, I had ordered a new CPAP from johnny and company here at cpap.com and gotten it in. I made my insurance company aware of the incredible price difference and showed them, in writing via email, that we could save over $1000 by getting the CPAP machine via internet rather than renting from the DME.

I got preauthorization from my insurance carrier (be sure to keep notes and get names and phone numbers of EVERYONE you talk with!! And remember, patience, patience, patience. These folks are, for the most part, idiots! Ok, maybe not idiots, but they are inexperienced with: 1) folks that take an active part in their healthcare and 2) folks that actually know something and are willing to show them how to do things differently/cheaper/better and don't expect anything in return.). I had to pay out-of-pocket, but cpap.com sent a receipt with the proper billing code and it was faxed to insurance. They reimbursed me in about 1 week!

Give it a try.....after all, if you ask, they may say no, but if you don't ask, they NEVER have a chance to say yes.

This therapy WORKS!!!

Wulfman · Post by **Wulfman** » Mon Sep 19, 2005 1:30 pm

kenrose,

Along the lines of what TXKajun was saying, most insurance providers will reimburse you for out-of-pocket expenses. So, if you were to purchase the equipment youself and then submit a bill to the insurance provider, you would be considered "IN-network" and they would reimburse you at the higher percentage as opposed to an out-of-network entity. As was stated before, be sure to contact your insurance provider and get verification of procedures.

Good luck,

Den