Insurance / DME

[Patrick A]

I went for a sleep study last DEC., needed a new machine. Any way the sleep center, said that even though Apria Rip off was a preferred provider for BCBS, being as my new study was for Medicare, they gave me a list of three DME's that they use.
They also said that Apria was really bad. I called BCBS and asked which one to go to Medicare paid most of the bill. BCBS allowed full pmt for the rest of the cost. I was really shocked that the machine is not a rental, but paid for in full. Maybe because it was a replacement machine for a machine that died and went to C-pap heaven? Go figure.

I am sure glad it's still Medicare and not Obamacare yet.

[GumbyCT]

4. I guess I will need to speak with the Maryland sleep commission.

I'll update this thread later next week once I know more about what happened.

Be careful out there, CW

You need to file a complaint with the Insurance Commissioner.

[CiresWrossed]

$400 is probably the amount the insurance company allows for that machine. They would never pay $2200. Call the DME and tell them the insurance company has already paid for the machine. Demand that they cancel the invoice and send you a copy of the credit or cancellation notice.

This billing could be the result of DME incompetence or it could be the DME wanting to see what they can get out of you. Don't take any s*** off of them and don't give them one penny.

Roster,

One confusing thing is the DME only established rental for 2 months at $250 per month. From what I have heard usually the insurance company requires rental for a lot longer. However, this DME billed billed BCBS for the entire cost of the machine after just a couple months. What I believe happened is when they got wind that a pre-approval was required. They immediately billed for the entire amount. But, I can't be certain because so far the DME has not returned my calls. When they finally do return my call my questions to them will be.

1. What is the contracted amount BCBS will pay for rental of this machine. I.e. the amount they pay for every other patient they have using BCBS.
2. Same question as #1 for the machine itself. What is the contracted amount BCBS will pay for it.
3. Have they ever seen a case where pre-approval was not required. If not, why the heck did they go forward without it in my case. That seems extraordinary.

I certainly have no intention of paying them $2,200.

Thanks, --CW

[CiresWrossed]

Are you saying you got the machine 15 months ago (5 months you used it, then you got the PR 10 months ago, that's 15 months), and NOW the DME is saying you weren't approved to have it? What took them so long to say so? (Was there a 13 month rental period?)

Yes, I got it from the DME 15 months ago but after 5 months the PR came out. And I personally felt I needed an Auto machine so I personally purchased it. Apparently they have been in the appeal process with BCBS NM for the past 13 months.

You say BCBS is admitting they made a mistake in saying pre-approval wasn't needed. Does the DME have documentation that BCBS said you do not need pre-approval?

Yes, they admit this in their correspondence with the DME. "The claim(s) did processed according to your contact benefits. However, it has been determined you were given incorrect information by Blue Cross Blue Shield of New Mexico prior to the services being rendered " (your contract benefits is referring to the DME)

If BCBS paid one red cent, that suggests they agreed to pay for it. It's almost like post-hoc pre-approval.

BCBS states the claim was adjusted as a one-time exception.

No one thinks to ask for verification that pre-approval is necessary--that's the DME's job, who contracts with your insurance, so don't beat yourself up about that. Someone screwed up, it's not you, but now you need to hassle with it.

Yes, I believe the DME actually also screwed up here. I suspect they know that BCBS and every other insurance company always needs pre-approval. If that is true, someone should have realized it and stopped until they got the pre-approval.

[CiresWrossed]

Isn't this the same post?
viewtopic/t54588/Insurance--DME.html

Wow, sorry -- I only clicked submit once. I'm not sure why it posted twice. Thanks.

[CiresWrossed]

I have BCBS and they have an excellent online presence. You can access your account and see all claims, payments, etc. right there.... I'd do that first before talking to anyone!

Emilia,

Yes, actually I have not had any real trouble with BCBS NM other than this. You are right their online presence is excellent. I regularly use the web site. Unfortunately this situation has been between the DME and BCBS so far. Frankly, I suspect the blame can be shared between BCBS and the DME but I'm still trying to figure that out.

=)

[CiresWrossed]

Just a heads up for everyone that is dealing with a DME company they are unhappy with:

3. Be very leary of anyone that tells you they are going to even swap your WORKING cpap machine for a much more expensive model 5 (or 15??? not sure) months after you rec'd the original. The only time we do an even exchange for a machine after any type of time is if A.) the machine is broken or B.) the physician has called and ask the patient to be transferred from a straight CPAP prescription to an AutoPap prescription. You shouldn't be charged in that situation (and it shouldn't be billed) because we know up front the insurance company (most) will not cover another machine for 5 years unless the upgrade is to bi-pap.

Thanks Sleepy.. actually I didn't swap the machine after 5 months. I personally purchased the PR machine after 5 months. Neither the DME nor BCBS were involved and no claim was made for it. My drama actually relates to the original machine I was given and the apparent mixup between the DME and BCBS about the pre-approval.

However, I do have a question since you deal with this. Is it normal for an insurance company to say pre-approval is not required for CPAP equipment? Do run into some very liberal insurance companies that would do this? I ask because it seems strange to me that the DME would not question this in the beginning -- i.e. nobody there said. "Hmm this is strange, no pre-approval necessary..."

I know its a lot but one of the key parts of successful PAP therapy is your DME provider. At least thats what I believe and I try to impress on everyone else here

I can see how the DME could be a valuable asset to this treatment actually. Until this situation; my DME was really very much out of the picture. I have not heard from them since they gave me the machine. Nobody has called and I have not received any correspondence from them about masks or anything. I didn't really mind since I know I can purchase supplies online. But, I suspect some CPAP patients can benefit from the extra support they could get from a competent DME.

[CiresWrossed]

4. I guess I will need to speak with the Maryland sleep commission.

I'll update this thread later next week once I know more about what happened.

Be careful out there, CW

You need to file a complaint with the Insurance Commissioner.

Haha yes, you are totally right. I was thinking insurance and I typed sleep. I've already looked them up.

[chunkyfrog]

---so far, so good. My RT is very helpful, so far.