DME Lies?

[Offerocker]

You have a lot of issues that have become complicated by ‘time’. You’ve also received a LOT of GOOD information:

Unfortunately, cpap.com is considered out of network to my insurance company.

Being ‘out of network’ means that you’d pay a higher co-pay (according to my insurance).

Most of all, get a hard copy of your prescription from your doc and hold it. It doesn't expire. Then you have options in the future. Get a copy of the sleep study too. It is yours you can file it for the future.

I learned to do this with EVERYTHING from my doc. NEVER give up the original copy of the Rx.

The bottom line is the RX rules. It is unethical for the DME to put out something other than what the RX says. DMEs are not Medical Doctors and they are not to over-ride what the Dr prescribes. They can refuse to do the order, but not change what the DR prescribed….

I agree, but I resent the fact that the DME calls the insurance company!! They are MY insurance company, and I pay the premiums! I talked to my insurance company, got the scoop, but was told a different story by the local DME!!! (THEIR story)

I contacted Billmysinsurance.com but they told me that I had already started the process with another DME and they couldn't intervene at this point.

This is the problem about the ‘timing’ of everything. Too bad we don’t know all of this information BEFORE we get involved with a local DME.

I learned too much too late. I ended up ordering an APAP through CPAP.COM and paying for it myself. I now also own a more-expensive (to insurance company) cpap pro c-flex (NOT the pro-2!!). Go figure.

It is all a matter of timing, unfortunately. That’s why we need written information disseminated to the sleep labs, in order for them to be more educated in our plight, and to provide the written information TO US before we ever get hooked up with a DME. The ‘automatic’ assignment of a DME is a big detriment to our being able to make our own decisions. They don‘t allow time for us to do any research.

In short: you’ll have to try your best at getting what you need, as your doc Rx’d. The fight will be with the DME, since you’ve already started with them. How much is your co-pay? Would it be worth it for you to stop dealing with them, pocket that money, and use it for a direct purchase from CPAP.COM? That’s what I would do. If you don’t have a lot of out-of-pocket money and still don’t get what you want, then you’ll have an extra machine like I have. Too soon old, too late schmart. That’s the purpose of this Forum, but we don’t get here until after we’re having problems. The way around that IS in the works, but will take time. Good luck to you; we’ve all been there, with different circumstances and results. Stick with bugging your DME.

[Arizona-Willie]

[quote="JayPSU"]So essentially there is nothing I can do? Is that what all of you are saying? I can only get a cpap even though my doctor prescribed an apap? Is there a way that I can get an apap and pay the difference in price between the cpap and apap? Please be patient with me as I have ZERO experience with insurance companies. All I have ever needed before this in the past is checkups, blood tests, and twice x-rays. I don't really have experience working with insurance companies.
===========
How about using a different DME? If there is only one in your area you could use an online DME. Just fill out their form and fax them the prescription and you should get what you want.

It sounds like your DME is trying to maximize his profit when your insurance says they will pay and the doc wrote the prescription ... your DME is the roadblock. Only one logical reason for that. Money for the DME.

I wonder if they don't give the person who handles your account a set amount per case. They guy who brought my machine and mask to the house gave me the Ultra Mirage II mask instead of the Activa specified in the prescription. A cheaper mask. I tried it and then called the DME office and they sent the right mask via UPS next day delivery. I figured the account rep was trying to save a few bucks out of what they pay him to deliver and set up the equipment because the company didn't argue at all.

[DME_Guy]

The bottom line is the RX rules. It is unethical for the DME to put out something other than what the RX says. DMEs are not Medical Doctors and they are not to over-ride what the Dr prescribes. They can refuse to do the order, but not change what the DR prescribed….

I agree, but I resent the fact that the DME calls the insurance company!! They are MY insurance company, and I pay the premiums! I talked to my insurance company, got the scoop, but was told a different story by the local DME!!! (THEIR story)

Everyone you get care from communicates with your insurance company, whether it's the local pharmacy, your Dr, or your DME. It's good business practice for a company or Dr. to make sure they're getting paid before providing the service.

[Rastaman]

I suspect that we're auto-linked to a DME (especially in house ones) because many or even most people prefer to be told what to do. They don't want to make choices. Then you have all of us who do. And we probably assume there are more of us than there really are. But take a look around you. I think you'll find lots of examples where people don't ever take responsibility for themselves, not even in their 30's, 40's or 50's. They just never grow up. And many are just confused if you give them 3 choices. The they have to research and many many many consider that a hardship. (Use my brain?!?!? Are you kidding? Many people can't even bother to read instructions on the a new electronic product they just bought. Also, many never read the terms of their auto insurance or even open mail from them when they send it.

I know we, who seeked out this message board, are in a statistical group. How big it is, I don't know. And I will admit that sometimes.....sometimes even I am slightly confused by choice. Quite frankly, they probably should've asked me this "Do you want to be involved in the selection of your xPAP machine or do you want us to select it for you." And leave it at that. People who like to pick things will speak up and those who don't won't.

[JayPSU]

It's just not in my nature to get any kind of expensive equipment, whether I'm paying for all of it or not, without doing research. I spent a lot of time doing research and came up with what I wanted. I explained what I wanted and hy I wanted it to my doctor, and she was completely fine with me getting the apap. Her only hesitation was the fact that they don't include an option to measure your desaturation. But otherwise she was fine with me using it so I could periodically make sure I didn't need any pressure changes.

The more I read people in this post, the more furious I get. I cannot believe there are people out there who would disobey a doctor's orders and lie to people about what an insurance company will and will not do. It makes me sick. As I said, I'm going to obtain a copy of my prescription from my doctor's office first thing monday morning. Then I'm going to call the DME' office and tell them that I want the equipment that my doctor prescribed, in the way she prescribed it or I'll go to a DME that WILL obey a DOCTOR'S orders. Man, it just makes me so furious! And I started the morning in a great mood after a so so first night on a machine last night!

[quote="Rastaman"]I suspect that we're auto-linked to a DME (especially in house ones) because many or even most people prefer to be told what to do. They don't want to make choices. Then you have all of us who do. And we probably assume there are more of us than there really are. But take a look around you. I think you'll find lots of examples where people don't ever take responsibility for themselves, not even in their 30's, 40's or 50's. They just never grow up. And many are just confused if you give them 3 choices. The they have to research and many many many consider that a hardship. (Use my brain?!?!? Are you kidding? Many people can't even bother to read instructions on the a new electronic product they just bought. Also, many never read the terms of their auto insurance or even open mail from them when they send it.

I know we, who seeked out this message board, are in a statistical group. How big it is, I don't know. And I will admit that sometimes.....sometimes even I am slightly confused by choice. Quite frankly, they probably should've asked me this "Do you want to be involved in the selection of your xPAP machine or do you want us to select it for you." And leave it at that. People who like to pick things will speak up and those who don't won't.

[snoregirl]

I am like you. I research stuff to death before making a move. I am one of those who found this site before I made any move with a DME. I guess that is just my nature. I talked to 2 DME's that were acceptable with my insurance, and Bill my insurance which wasn't as well as looked into direct purchase from Cpap.com (out of network with a much higher deductable that I would never meet...)

I had the worst time getting any real infomation out of anyone. One DME wouldn't quote me total prices that they would charge my insurance, kept telling me what I would pay by the month. Not what I wanted to know. I wanted total out of pocket from day one to the day my insurance co would purchase including copay on the final purchase. The DME acted like I came from outer space. Who on earth would want to know that? I would so I could compare against a non-insurance purchase Cpap.com machine.

I also couldn't get my insurance company to tell me what the contract price was (same info I asked the DME for but from a different angle). I asked how the insurance company could pay the bills from the DME if they didn't know how much was authorized. No intelligent answer from Insurance co.

The whole process is amazing and out of control. So hang in there.

My view was that since I pay for insurance, if at all possible and as long as it cost me less total out of pocket I wanted to make them pay, even if I had to use a brick and morter DME and go through the stupidity of them setting up my machine (wrong I might add). So I hung in there and pressed for what I wanted (what was on my prescription, and got it), however this was only one and one half months ago. So.... I am nervous as to whether anything can and will go wrong in the next month and a half before my insurance company will finalize the purchase.

The reason I am nervous is if anything goes wrong and they won't purchase the machine I now have then I will indeed buy from Cpap.com. I figured out at the start if this happens I am out $84 over 4 months. Ok with me. But with the price uncertainty I am very tempted to buy a backup machine now rather than wait until Sept for the purchase of my DME Auto to become final. I don't want something to go wrong then I have to pay 40% more for the same thing I could buy for $709 now if Resprionics follows Resmed and hikes prices.

Just something to consider in all this the potential for price increases and timing.

[Offerocker]

I cannot believe there are people out there who would disobey a doctor's orders and lie to people about what an insurance company will and will not do. It makes me sick. As I said, I'm going to obtain a copy of my prescription from my doctor's office first thing monday morning. Then I'm going to call the DME' office and tell them that I want the equipment that my doctor prescribed, in the way she prescribed it or I'll go to a DME that WILL obey a DOCTOR'S orders. Man, it just makes me so furious! And I started the morning in a great mood after a so so first night on a machine last night!

Re your mood: JOIN THE CLUB!

No matter what I did, I did NOT get the machine prescribed for me from the DME. The owner of the outfit said "She has what she needs". Well, who is he/she to determine that, vs. a Rx from a doctor stating I require an APAP with C-flex???? I only had 6 weeks left on the rent-to-own, so bit the bullet, and am pulling my rental of the oxygen contcenrator from them. I had already purchased the APAP anyway, since I pretty much knew that the fight with the _____DME would end up in a KO, and I don't need any more of that battling against a brick wall in my life - it would do me more harm emotionally. By the way, the ______DME NEVER came out to change/clean the filters in the concentrator!!! (Only THEY are supposed to do that).

If you have Central Medical Supply in your area, please take your business elsewhere.

I'm sorry that your day went downhill after a great beginnig. But be prepared for a good fight with your DME. There may not be one, however, because there have been SOME great reports here of great DMEs. I hope yours will be one of them.

Maybe we can get DME_GUY to do some training in this area? No, it wouldn't work -"policy is policy", and his clients are lucky to have HIM for a DME. I sometimes felt that the person I dealt with was OK with things, until I got a phone call later telling me "NO"...I believe that came from management. I could NOT work for a company that worked like that. The almighty dollar has bought some peoples' consciences - assuming there was one initially.

[Rastaman]

I just want to add to all of this that you can imagine the same things are going on each time you have a doctor's visit AND each time you go to the hospital. This is an amazing racket to be sure. I'm quite sure my doctor is making over $300,000 a year. Maybe upwards towards 1 million per year. Or more. One time within the last 7 years I felt against a marble table in my bedroom and didn't realize it but tore my pectoral muscle a bit. It was painful but seemed to go away until about 1 am two nights later. My heart-rate shot up and I'm only 36. I woke up my wife and had her drive me to the hospital. At the time I didn't have insurance. My wife even worked at this hospital at the time so she knew all the in's and out's of the insurance part of it. They thought I was having a heart attack. They kept giving me nitroglycerine due to my heart rate being like 200/100. I had hypertention back then and it was untreated, obviously due to no insurance.

I don't see how ANYONE can afford medical without insurance. They charged me $5,000 for an overnight stay. They kept me from 2am to some time that next evening. I wasn't even there 24 hours. Could I pay that? No way! And I never have. Even $500 would've seemed excessive to ME. But I know that's typical and in this case 10 times that amount. My wife informs me that if you have insurance you get a "contracted" rate, which is somewhat less.

My point is that this is only ONE aspect in life where people are money gouging us. It happens every day to most of us and we just chalk it up to "that's what they charge nowadays." I do believe there is a reasonable price for everything. A reasonable profit. But when a CEO makes 262 times the average paid employee, things are top heavy out there. Back in 1960 the average CEO only made about 10 times what the average employee made. Take cable. It's now $70 to $120 a month when just 15 years ago it was $19.99 a month. I don't see people's wages going up up up. I see inflation going up up up. Cars now cost what people bought their homes for in the 1980's. The whole thing blows my mind. And it doesn't seem like it's going to stop until the whole thing falls over on it's side. And that's going to take us consumer getting ANGRY and refusing to do business unless we absolutely have to.

Bottom line: Check consumerreports.org before you buy ANYTHING. And if what you're buying isn't on there, check buyer reviews at any place that sells stuff. Places like Amazon.com let the users/buyers give their ratings and experience. Even Cpap.com does too. Most people don't take the time to post their experiences or to even read others but it's a VERY useful tool as many have found here on cpaptalk.com Also, check with the better business bureau before you lay down your dollars. If they have complaints then you might want to go elsewhere. (If they were unresolved) It's not the same world it used to be.

[Lyn]

So essentially there is nothing I can do? Is that what all of you are saying? I can only get a cpap even though my doctor prescribed an apap? Is there a way that I can get an apap and pay the difference in price between the cpap and apap? Please be patient with me as I have ZERO experience with insurance companies. All I have ever needed before this in the past is checkups, blood tests, and twice x-rays. I don't really have experience working with insurance companies.

Yes, there is something you can do ... DON'T GIVE UP. And don't give in to the DME (or believe everything they say).

If they got the cpap approved, & you have a prescription for an apap, you CAN get an apap. Don't let them tell you otherwise.

I too have BCBS ins. I originally got a cpap with the sleep doctors prescription, but I wanted an apap. The sleep dr wouldn't approve one but my Internist did. I finally worked it out with the DME to pay $100 out of my pocket & got the machine I wanted.

Lyn

[Darth Vader Look]

The sleep dr wouldn't approve one but my Internist did. I finally worked it out with the DME to pay $100 out of my pocket & got the machine I wanted.

You shouldn't have to pay a bribe to your DME to get the machine prescribed by your doctor. That is just down right ridiculous. That is exactly why I dumped my DME and had my wife get her prescription from the doctor so that she could go else where to get her Auto.

[Lyn]

You shouldn't have to pay a bribe to your DME to get the machine prescribed by your doctor. That is just down right ridiculous. That is exactly why I dumped my DME and had my wife get her prescription from the doctor so that she could go else where to get her Auto.

I agree. But it was one of those situations where you just get so tired of all the hassle that you just want it over with. And, I felt that going to another DME would probably be a repeat of the first experience.

Also, considering that I went from a $325.00 cpap to a $635.00 apap (cpap.com prices) & paid less (even with the extra $100.00) than I would have had to if I purchased it on my own, I was still ahead.

Lyn

[JayPSU]

You're a lot nicer than I'm going to be. If my prescription was for an apap machine and it said nothing else, and the DME disobeyed this order, I am going to be EXTREMELY angry and I will be all over them. I will give them the chance to correct the problem and if they keep giving me problems, I will just keep hassling them about it. What has this world come to where you have to fight to get the equipment your doctor prescribed and your insurance carrier that you pay good money for says they will pay for it? I WILL get my machine, and I will NOT pay any more than the 20% I'm supposed to pay for equipment in my insurance plan.

You shouldn't have to pay a bribe to your DME to get the machine prescribed by your doctor. That is just down right ridiculous. That is exactly why I dumped my DME and had my wife get her prescription from the doctor so that she could go else where to get her Auto.

I agree. But it was one of those situations where you just get so tired of all the hassle that you just want it over with. And, I felt that going to another DME would probably be a repeat of the first experience.

Also, considering that I went from a $325.00 cpap to a $635.00 apap (cpap.com prices) & paid less (even with the extra $100.00) than I would have had to if I purchased it on my own, I was still ahead.

Lyn

[jkeene]

Jay,

I think a good line of attack might be the contracts that the insurance company has with the doctor and the DME. If they're in-network, as it sounds from reading this thread, then they are both under contract to provide services and equipment according to the terms and conditions they agreed to under the insurance company contract. Sounds like the doctor did his part, but the DME is balking. I'd start with a gentle reminder to the DME about "contracted items", and how an in-network doctor has written you a valid prescription for device the insurance company says it will pay for. Ask for a supervisor at the DME if you get stonewalled.

If that doesn't get you satisfaction, I'd call the fraud department at your insurance company, and repeat your story. While it might not be precisely fraud, they could at least route your issue to a group inside the insurance company that deals with contract enforcement.

Jeff

[dllfo]

JayPSU,
You have already taken the first step to getting your APAP. You are NOT settling for what they have done.

Medical Necessity is the key here, as mentioned above. If you can afford it, you can also buy an apap on the internet.

By registering, people can pm you. I have some comments I don't care to say
publicly, but you are already "doing good" by not accepting your level of treatment.

As inacpapfog said, call you dr. and tell him those things. You will find your insurance, my insurance...all of them have certain squares to fill. I got my
Auto Bipap in one day after I found the right person to handle it. PM me.