Yet Another DME struggle

[PurpleSwan3033]

Something really needs to be done about these shady DME's and whatever ties they have to these doctors. They have too much control over our health issues in regards to cpap therapy yet they care too little about us and they demonstrate too little professionalism. My DME and my doctor are bouncing me back and forth like a ping pong ball, too. I won't go into details, "again", except to add my voice to those crying out and complaining because it just ain't right.

[Slinky]

AKCPAPGuy!!! Din't you momma tell ya, ya can't say nuttin' nice, don't say nuttin' at all??

Actually, thanks for that bit of news. So retirees are second class citizens w/Wells Fargo, eh?? I'm glad we pulled our business from them!!!

[cinco777]

akcpapguy wrote

Contrary to popular belief there are insurance companies who request the make model and serial number of the PAP unit given to a patient for prior approval. Recently our State employee insurance changed from BC/BS to Wells Fargo (yeah I thought they were just a bank too), they require the make, model, and serial number of the PAP unit given to a patient at the time of billing. What we found out in a very short time is while an active employee can get any PAP machine they want a retired employee can only get a basic model PAP machine, no exhale relief, no data, no nothing extra. Anything above and beyond a basic machine requires an approval by their medical review board upon a letter of medical necessity from their doctor, this is a 4-6 week process mind you.

We used to only issue M-series Pro's and Auto's to patients, but this policy has forced us back into carrying a stock of regular M-series.

So YES different insurance companies can and do specify which models their patients get, even with patients who have the same insurance, but different plans.

This just goes to show us who the real "Death Panels" are that the Republicans (Sarah Palin and all) keep talking about. It is not the Public Option - it is our current "we're in it for the money" Insurance Industry whose most recent endeavor seems to be to just give the retirees the basic stuff so they will remain uninformed and die sooner from ineffective therapy. I'm one of these second class patients as I am a retiree.

[mattman]

Just to help clarify one common issue...

Yes there is only 1 code for a CPAP. That does not automatically allow a DME company to bill for an autopap under that code. Yes there are cases where they CAN, but it's completely unfair to EXPECT them to, for a lot of reasons.

To further complicate things many insurance companies specifically prohibit providing one item while billing something different and even specifically mention providing a better item than what's being billed. This is somewhat understandable in that it means an insurance company won't have accurate information as to what the patient has though it can lead to problems when trying to get someone an item that they clearly want. That means going through all the pre-auth and fighting with review boards and all that. That often means 8+ hours of work over a 6 week process plus stacks of paperwork from patients, doctors, sleep labs and the insurance companies to try to get something approved.

Then add in that I personally think it's unfair to expect every provider to carry every model/brand/type of equipment and things can get really tough when a patient has a very specific item in mind. I'd rather know 2 brands and 6 models inside very well and carry the needed items to maintain them then to try and be ready for 5 brands and 6 models in each. This is easy for an online provider who carries only cpaps, especially since they don't even have to actually stock them but rather can use 3rd party warehousing (Which lots do. Hell I used to do it for them). Compare that to a brick and mortar provider who is not only providing those CPAPs but all the other equipment as well. Space issues often force you to focus on only a few options to cover the 99%+ patients you encounter.

One last thing on the bit about returning masks and other accessories. This is really doing you a favor more than anything. You do NOT want to get into a situation where you've got multiple billings from different providers, especially when just starting. All too often this causes headaches for months and months that can really foul up your billing. Since you're already returning stuff it just flat makes it easier for you - and them - if they collect everything and just don't bill anything for the whole encounter.

Anyways, just a few insights into the process that it sounds like you've run into. Sorry you're having hassles!

[Really]

Just to help clarify one common issue...

Yes there is only 1 code for a CPAP. That does not automatically allow a DME company to bill for an autopap under that code. Yes there are cases where they CAN, but it's completely unfair to EXPECT them to, for a lot of reasons.

To further complicate things many insurance companies specifically prohibit providing one item while billing something different and even specifically mention providing a better item than what's being billed. This is somewhat understandable in that it means an insurance company won't have accurate information as to what the patient has though it can lead to problems when trying to get someone an item that they clearly want. That means going through all the pre-auth and fighting with review boards and all that. That often means 8+ hours of work over a 6 week process plus stacks of paperwork from patients, doctors, sleep labs and the insurance companies to try to get something approved.

Then add in that I personally think it's unfair to expect every provider to carry every model/brand/type of equipment and things can get really tough when a patient has a very specific item in mind. I'd rather know 2 brands and 6 models inside very well and carry the needed items to maintain them then to try and be ready for 5 brands and 6 models in each. This is easy for an online provider who carries only cpaps, especially since they don't even have to actually stock them but rather can use 3rd party warehousing (Which lots do. Hell I used to do it for them). Compare that to a brick and mortar provider who is not only providing those CPAPs but all the other equipment as well. Space issues often force you to focus on only a few options to cover the 99%+ patients you encounter.

One last thing on the bit about returning masks and other accessories. This is really doing you a favor more than anything. You do NOT want to get into a situation where you've got multiple billings from different providers, especially when just starting. All too often this causes headaches for months and months that can really foul up your billing. Since you're already returning stuff it just flat makes it easier for you - and them - if they collect everything and just don't bill anything for the whole encounter.

Anyways, just a few insights into the process that it sounds like you've run into. Sorry you're having hassles!

Can ya hear the violins?

If the guy didn't lie to him it would not have happened. Really!!

[Patrick A]

My wife popped into another local DME (Lincare) and the rep there was very friendly, but said that UHC would not cover either the Elite II or Autoset II - no matter what the script said. I am changing group insurance at work in Jan to Anthem BC/BS and he said that they on the other hand do not have such restrictions.

She is off to try another this afternoon, but I guess worst case I can wait until Jan 4 and use the hand me down until then.

I have been having problems with APRIA RIPOFF I called my insurance who is my secondary BC/BS FEHB Medicare is my primary. I think that Lincare must be who BC/BS FEHB is going to dump APRIA RIPOFF for. Because the lady I talked to @ BC/BS FEHB Said that if I could not get any results from APRIA RIPOFF that she would call Lincare for me. Right now I am waiting for the clowns at APRIA RIPOFF to get me a new machine. ThanK God I bought one out right from CPAP.COM I could die before APRIA RIPOFF gets off their @$# and gets me a new machine.
Good luck.
Himself

[Slinky]

Thank you for your explanation and trying to clarify things for us from the local DME perspective, Mattman.

Just to help clarify one common issue...

Yes there is only 1 code for a CPAP. That does not automatically allow a DME company to bill for an autopap under that code. Yes there are cases where they CAN, but it's completely unfair to EXPECT them to, for a lot of reasons.

To further complicate things many insurance companies specifically prohibit providing one item while billing something different and even specifically mention providing a better item than what's being billed. This is somewhat understandable in that it means an insurance company won't have accurate information as to what the patient has though it can lead to problems when trying to get someone an item that they clearly want. That means going through all the pre-auth and fighting with review boards and all that. That often means 8+ hours of work over a 6 week process plus stacks of paperwork from patients, doctors, sleep labs and the insurance companies to try to get something approved. ...

HOWEVER, it still is NOT clear to me in any way, WHY, if CPAP and APAP are the same HCPCS code, there is ANY problem, except the DME's monetary one, that an APAP can not be provided.

Then add in that I personally think it's unfair to expect every provider to carry every model/brand/type of equipment and things can get really tough when a patient has a very specific item in mind. I'd rather know 2 brands and 6 models inside very well and carry the needed items to maintain them then to try and be ready for 5 brands and 6 models in each. This is easy for an online provider who carries only cpaps, especially since they don't even have to actually stock them but rather can use 3rd party warehousing (Which lots do. Hell I used to do it for them). Compare that to a brick and mortar provider who is not only providing those CPAPs but all the other equipment as well. Space issues often force you to focus on only a few options to cover the 99%+ patients you encounter.

I have at times explained that the local DME providers usually buy in bulk from one, maybe two, manufacturers and advised that the patient INSIST on a fully data capable CPAP but hang a bit loose on which brand and that if they are adamant they want a specific brand to shop their DME provider options for one that carried that brand. So I do understand some of the problem for a local DME provider in that respect. There aren't always local DME providers who specialize in "just" respiratory/xPAP equipment. BUT that still does NOT excuse the provider's RRT NOT reading thru the Clinicians Manual rather than just the QuickSet Up Guide when setting up an "off brand" (to them) xPAP for a patient.

[Llama]

Then add in that I personally think it's unfair to expect every provider to carry every model/brand/type of equipment and things can get really tough when a patient has a very specific item in mind. I'd rather know 2 brands and 6 models inside very well and carry the needed items to maintain them then to try and be ready for 5 brands and 6 models in each.

I agree, however in my specific instance the provider appeared to not know his product line, neither the Respironics he provided, the ResMeds he offered or the ResMeds I wanted. He was certain that any machine he was willing to give me would be sufficient, identified the Elite II as an APAP, etc. Either he was ignorant or he was lying to protect his bottom line.

I am *TOTALLY* cool with a business making money, but acting like a pharmacy when in essence it's a car sales lot makes it confusing for a consumer/patient.

[modistee]

OMG I have gone through the same thing. Except my ex DME brought me the same machine after she told me she was bringing the correct one. I took mine back and told them I found somewhere else that had the one I wanted. *blink* I felt like I was losing my mind with all this but it wasn't me after. Anndddd I have the machine I wanted now.

Modistee

[GumbyCT]

Then add in that I personally think it's unfair to expect every provider to carry every model/brand/type of equipment and things can get really tough when a patient has a very specific item in mind. I'd rather know 2 brands and 6 models inside very well and carry the needed items to maintain them then to try and be ready for 5 brands and 6 models in each.

I agree, however in my specific instance the provider appeared to not know his product line, neither the Respironics he provided, the ResMeds he offered or the ResMeds I wanted. He was certain that any machine he was willing to give me would be sufficient, identified the Elite II as an APAP, etc.

I think he knew - your request just did NOT fit his financial need.

Either he was ignorant or he was lying to protect his bottom line.

Either way how could you trust your help to him?

I am *TOTALLY* cool with a business making money, but acting like a pharmacy when in essence it's a car sales lot makes it confusing for a consumer/patient.

GREAT analogy - I think YOU will do well.

LMAO you are on to this money mill game.
Good Luck

[raggedykat]

I just opened my mail from yesterday and there is statement from my insurance company. It says that I owe my DME for the nasal mask that I tried when I got my cpap machine but returned to my DME because I went with the FFM. My DME told me that my insurance company would only pay for me to get one so I had to choose. Now I am going to have to pay for a mask that I don't even have!

[Patrick A]

I think we are all going to get ripped off by most DME providers. APRIA RIPOFF is one of the most notorious for bad customer service.

[peppi]

I'm sorry, we don't sell those models because they cost too much.

Man I can relate. I called Aetna and told them I wanted to buy my machine on line.
I have an in network deductible of $600 and out of network of $1500.00
So they referred me to three Orlando in network DMEs. I want an ResMed S8 Autoset II which my doctor finally agreed to after a 1/2 hour of my best salesmanship (my profession).
So armed with the scrip for an Autoset II, they try to tell me the thing is too much money.
How much? $1800.00!!! WHAT! I can buy it on line all day long on the Net for $588.00 and possibly cheaper on auction!

They suggested I do that. So I will.

I don't think I will ever deal with a DME, in the long run it will cost you more. Example, parts, the DME wants to sell the entire nasal mask , not just the pillows. This stuff all adds up.

Given the support here, I feel confident I can set the machine up myself and the DMEs can go pound salt.

[Wulfman]

You think dealing with the DMEs is bad NOW? Just wait.......

http://www.hmenews.com/?p=article&id=hm200911DxsXMa


Den

[Patrick A]

I'm sorry, we don't sell those models because they cost too much.

Man I can relate. I called Aetna and told them I wanted to buy my machine on line.
I have an in network deductible of $600 and out of network of $1500.00
So they referred me to three Orlando in network DMEs. I want an ResMed S8 Autoset II which my doctor finally agreed to after a 1/2 hour of my best salesmanship (my profession).
So armed with the scrip for an Autoset II, they try to tell me the thing is too much money.
How much? $1800.00!!! WHAT! I can buy it on line all day long on the Net for $588.00 and possibly cheaper on auction!

They suggested I do that. So I will.

I don't think I will ever deal with a DME, in the long run it will cost you more. Example, parts, the DME wants to sell the entire nasal mask , not just the pillows. This stuff all adds up.

Given the support here, I feel confident I can set the machine up myself and the DMEs can go pound salt.

My doctor wrote my prescription stating Respironics M-series BiPap Auto w/Biflex. Also it says with integrated humidifier. Then she checked the box on the prescription form that says do not substiute for generaic. So lets see what the clowns at APRIA RIPOFF do with that.