Discovered my DME is Out of Network-Losing my PR System One

[Cotay]

This morning I checked my deductible usage with my medical insurance and much to my surprise they listed that I am responsible for nearly $2,100 in charges for my APAP, mask and consumables for one month’s service. Well, since I can obtain 2 or 3 systems myself for this price I called my DME to find out what gives.

The DME originally quoted me $50 as my total cost for the APAP….which would have been consistent with an in-network provider on my plan. Well it turns out they are out-of-network after all! YIKES!

To the credit of my (now former) DME, they are refunding me what I’ve already paid, paying for me to return the equipment, and then backing the claim out from my insurance. I’m actually really disappointed since these folks were responsive and friendly. I didn’t have to wait to have my calls answered and they resolved several issues immediately. They are letting me hold on to the unit untilI get set up with a new machine.

Now I have to visit my doctor on Saturday and possibly have a new sleep study done for a new DME. Apria was mentioned as my other option…darn.

I suppose the moral of the story is to check with your insurance even if the DME says they are in network. I'm so glad I ordered that DeVilbiss IntelliPAP backup!

[Cotay]

Does anyone have any feedback on SleepQuest in California?

I have BCBS of Texas for insurance....do any folks in Texas have a local DME they recommend? Maybe I can be sure to find one in-network if it's in TX.

[GumbyCT]

Now I have to visit my doctor on Saturday and possibly have a new sleep study done for a new DME.

I need to ask why? Why won't your current sleep study do?

[Kairosgrammy]

How long ago was your study? The sleep doctor should be able to just write a new prescription for an in network DME. I don't even see why you have to visit. You should be able to call for a new prescription and go pick it up. In fact, I'd go so far as to say if your study has been in the last few months, the only reason he would make you go back for another study is for the extra money. Your insurance won't pay for an additional study unless there is a reason the initial study wasn't accurate. Just saying.

This morning I checked my deductible usage with my medical insurance and much to my surprise they listed that I am responsible for nearly $2,100 in charges for my APAP, mask and consumables for one month’s service. Well, since I can obtain 2 or 3 systems myself for this price I called my DME to find out what gives.

The DME originally quoted me $50 as my total cost for the APAP….which would have been consistent with an in-network provider on my plan. Well it turns out they are out-of-network after all! YIKES!

To the credit of my (now former) DME, they are refunding me what I’ve already paid, paying for me to return the equipment, and then backing the claim out from my insurance. I’m actually really disappointed since these folks were responsive and friendly. I didn’t have to wait to have my calls answered and they resolved several issues immediately. They are letting me hold on to the unit untilI get set up with a new machine.

Now I have to visit my doctor on Saturday and possibly have a new sleep study done for a new DME. Apria was mentioned as my other option…darn.

I suppose the moral of the story is to check with your insurance even if the DME says they are in network. I'm so glad I ordered that DeVilbiss IntelliPAP backup!

[Cotay]

I'm just going off what my doctor's office told me yesterday. Hopefully he has a copy of the study we can use for a new DME.

I had an "at home" sleep test that was conducted by a field rep of the original DME. I assume he provided it to my doctor, but for all I know they have a deal where the test can't be used for another provider. I simply don't know more than I was told yesterday by my doctor's assistant. She had me make an appt for this Saturday and mentioned I may have to do a new test. I agree it makes no sense, but it wouldn't surprise me in the least.

I'm going to call some DMEs if I find some time today. If anyone has any suggestions on a good DME that offers good and personal service, let me know. Thanks!

[purple]

Texas is a pretty big place, where are you in Texas? I live in East Texas and think very highly of my DME, which is small, and my home office is in Longview, but is part of a much larger association of DME's which I would hope have similar outlooks about patients.

Might be better if your current DME, if they it is still possible, to simply re-bill your insurance company. In the last few years insurance companies have taken to denying claims which they should truly have paid, and will pay the second, or third time they are billed. Now there are insurance companies, and Medicare which will not pay if the correct box is not checked on the form. My doc told me he gets refusals, then has to look through the form, figure out how it should have been filled out and reapply to get paid. This is the result of regulation, and why docs are furious with Medicare, insurance companies as it takes away from treating patients and wastes their time and resources.

I hope your doc did not say Apria. Usually sleep docs have a list of DME's and add to that list an order according to what they hear back from their patients. I would bet that your doc's office would say not to get things in the wrong order, they will help you find a useful DME after they are ready to write the script. I would also feel a sleep doc will not accept a home study, as a properly administered sleep titration probably includes a lot things not in a home study, and might reveal another medical condition a home study does not.

You could run into the issue that your insurance company might not want to accept a particular DME that you would like to try. Perhaps ask the DME if they might apply to be part of that network, if they actually pay by Medicare rules and payment size, then it should be easy for them.

The DME I have in Longview is an extension of Taylor Home Health, in Tyler Texas, 903-535-8245 Like I said, it is an part of a network and they may have an affiliate office in your area.

Keep in mind you must be driving distance to their office, they will not simply ship you things, they will insist on providing the kind of service a DME is supposed to provide, altho, they are also very friendly folk. Either they can drive to your home or you can make an appointment and drive to their offices. Which, in my opinion and experience, is the way it should be for a newcomer. After you get started they will simply ship you supplies; filters, masks, cushions, hoses, and so on.

I would not recommend for a newcomer to just order off the internet.

If your problem is the size of your (as yet unpaid), yearly deductible, then I am not sure how changing DME's will help much.

[Cotay]

Thanks purple on the DME suggestion. I will check into them.

I am actually in California...but I have BCBS Texas through my employer. My in-network deductible is very good, while my out-of-network deductible is huge. It just doesn't make sense to go with an out-of-network DME when I can get the equipment myself on the open market for much cheaper.

My current DME is only out-of-network (despite what I was originally told). BCBS was correct in the way they paid the claims, so BCBS isn't at fault.

Thanks again!

[SleepyInIndy]

since the doctor had to write a perscription for the first DME, they should be able to provide a copy of that perscription. You can then take that script to any DME you choose. That should not require a new sleep study nor for the original sleep study to be provided to another DME.

[Pugsy]

If you have to start all over now..does your deductible start all over? How much is the in network deductible? How does it compare with just getting a copy of your prescription and buying online?
How does your in network out of pocket expenses compare to online purchase..especially if you have a copay needed with another sleep study?

[Cotay]

since the doctor had to write a perscription for the first DME, they should be able to provide a copy of that perscription. You can then take that script to any DME you choose. That should not require a new sleep study nor for the original sleep study to be provided to another DME.

I believe my Doctor didn't specify the pressure range with the original DME (who also performed the sleep test). I asked my Doctor for a copy of my prescription when I ordered my backup and all I received was the standard form he uses to dispense medication with "Auto PAP for sleep apnea" written on it.

I recall that the gentleman that ran the home study stated that my doctor didn't specify a range so they set the machine for the default on the PR S1 (4-20). My actual average is about 10.8.

If my doctor has a copy of the study that would be fine...his assistant that set my appt may not know what she is talking about.

[GumbyCT]

I had an "at home" sleep test that was conducted by a field rep of the original DME.

And why don't you get your own copy from this DME?

fwiw - I tend to think that anyone selling equipment would be biased about the outcome. Could that also be why they told you they were "in network"? They had nothing to loose and only money to get - for the PSG. Am I making sense?

[Cotay]

If you have to start all over now..does your deductible start all over? How much is the in network deductible? How does it compare with just getting a copy of your prescription and buying online?
How does your in network out of pocket expenses compare to online purchase..especially if you have a copay needed with another sleep study?

Pugsy, my in-network deductible is $250 for the year and 10% of the value of the services/equipment after that up to another $1,000 (max out of pocket is $1,250). Out of network it's $500 and 40% up another $4,000 (max oop is $4,500). So it does make a big difference...especially considering that as of December I was only required to pay 10% of the value of the APAP in-network since I had already hit the deducible. Now that we've missed the boat on last year I will be paying $250 plus 10% on any new machine. It's still cheaper than going into the market directly, but it would've been nice. I suppose technically I would have paid it this year anyway with consumables so it's not such a big deal...as long as it's in-network.

I had an "at home" sleep test that was conducted by a field rep of the original DME.

And why don't you get your own copy from this DME?

fwiw - I tend to think that anyone selling equipment would be biased about the outcome. Could that also be why they told you they were "in network"? They had nothing to loose and only money to get - for the PSG. Am I making sense?

Gumby- Good question. I just assumed the original DME wouldn't want to part with it...can't hurt to ask. I'm not inclined to think the DME intentionally was trying to lie...I believe they made a mistake on this point. I agree that people tend to be motivated by their own pecuniary gain, but so far I've been happy with their response. I may change my mind (and divulge their name for all to see) if any shenanigans begin.

[BlackSpinner]

Gumby- Good question. I just assumed the original DME wouldn't want to part with it...can't hurt to ask. I'm not inclined to think the DME intentionally was trying to lie...I believe they made a mistake on this point. I agree that people tend to be motivated by their own pecuniary gain, but so far I've been happy with their response. I may change my mind (and divulge their name for all to see) if any shenanigans begin.

In the USA you have right to a copy of your medical records. They MUST give it to you if you request it. They can charge you by the page for it but they must give it to you.

[Cotay]

In the USA you have right to a copy of your medical records. They MUST give it to you if you request it. They can charge you by the page for it but they must give it to you.

You know...I hadn't considered that either. Thanks!

[Jason7]

Cotay,
Since you are in CA, you may want to try Classic Sleepcare, their HQ is in CA...I am on east coast and just started using them but am very impressed so far, they do only OSA and nothing else, if they are in your network, check out their website classicsleepcare.com.
Good luck,
Jason