Is my local DME crooked or is this normal?

[Audio_mc]

I was diagnosed with Severe OSA in August 2017 and I purchased a CPAP machine with my DME through my Insurance (blue cross blue shields). I always buy my equipment such as filters, cushions, etc. from my DME through insurance and NEVER had a problem. I even purchased a cushion as recent as last month in the beginning of October and my insurance happily covered it with no problems. So here comes yesterday........

I went in to my DME yesterday to purchase the P10 nasal pillow mask because I was due for a full set replacement mask (every 6 months) and all of a sudden they said "Oh it looks like you haven't been seen in over a year and you will have to either schedule an appointment or pay for the mask full price without insurance". They are claiming that my supplies prescription expires after a year. However, I have a copy of my CPAP prescription and it says It is good for 99 (i'm guessing 99 months) and they are claiming that there are 2 separate prescriptions (one for supplies and one for CPAP) and t coincidentally did not have a copy of the so called 'prescription for supplies' and my guess is because they are full of s**** and IT DOES NOT EXIST!. They claim that insurance won't cover it if I don't do a follow up and said that they had a meeting in the morning about this topic but yet they couldn't explain why my insurance just covered my replacement cushion last month even though it's been a year since my last appointment. I even got a replacement cushion and filters in September with no issues so clearly it is THEIR POLICY and has nothing to do with insurance as they keep claiming.

I also called Blue cross and blue shields and they said that they do not require an annual follow up for Sleep apnea treatment in order to purchase supplies through insurance as long as my prescription says 99 or lifetime and I told this to my DME and they are still insisting that I have to do a follow up before I can use my insurance to purchase any equipment from them.

I'm going back there this morning with a copy of my prescription from them that says 99 on it (although they claim that they have two separate prescriptions for CPAP and supplies but couldn't prove it)

Any advice on my next step? Is there anywhere to file a complain against these type of practices from a DME or am I just out of luck and need to go to another DME?

[Pugsy]

Get another DME. You will need to check with your insurance company though and get a list of who in your area has contracts with your insurance.
Vote with your business and take it elsewhere.

I don't know if it is technically legally crooked when DMEs come up with their own in house rules like this but apparently a lot of them do it for some reason or other. It stinks though. They come up with stuff and blame it on "your insurance requires it" when obviously there is no such requirement and they get away with it because most people won't do like you do and question it because people are too darn trusting of doctors and DMEs.

[prodigyplace]

To answer the thread title, the answers are "Yes they are crooked" and "yes, this is normal".

I also have Blue Cross / Blue Shield and switched from Lin(don't)care to Roberts Medical. They are not much better, though

Ask your insurance company for a list of local DMEs or try shopping around yourself. For me, after the first year, I found it less expensive to get supplies elsewhere. My insurance only pays 80% and I have not met my co-pay limit for the year. That means I would need to pay the full amount of the DME's inflated prices.

Do you need just a pillow? I suspect only the cushion & headgear would wear unless there is physical hose damage.

I have a few spare medium pillows I could share with you.

[jimc2]

What does the P10 cost you with insurance? I stopped dealing with my DME years ago and just buy my stuff from Amazon and cpap.com. I wasn't saving much if anything dealing with insurance and the DME. Both of which were a pain to deal with anyway.

I know some people have really decent insurance and probably save enough to make it worth dealing with DME/insurance.

[Audio_mc]

Thanks for the reply guys. I figured that it was an unethical practice and just wanted to make sure. The p10 cost & 99 without insurance but for me it is worth going through insurance because I already met my deductible and don't have to pay a copay for equipment. My insurance covers 80% of the equipment which is a good deal.

[chunkyfrog]

In my experience, BCBS allows any damn thing the DME likes.
My first DME tried to charge me for an entire Quattro mask,
while only delivering the cushion- (the only item I needed).
BCBS was perfectly OK with that.
Of course this would only happen once every 3 months--
--those cushions do NOT last that long for me.
Go figure.

[D.H.]

You are not obligated to use this DME, especially if you're past your compliance period (and even if you're not).

Any DME that takes your insurance is fine. If you have a copy of the prescription, you can send it to them.

[Janknitz]

I believe there are some states that are requiring that prescriptions of CPAP machines and supplies be updated annually, but you'd have to check and see if that applies in your state.

Prodigy Place said:

My insurance only pays 80% and I have not met my co-pay limit for the year. That means I would need to pay the full amount of the DME's inflated prices.

You might check with your insurer to verify if this is true. My understanding is that even if you haven't met your deductible, DME's may not charge you more than the price they are contracted to provide for your insurer, that may be very much less than "the full amount of the DME's inflated prices", even though you have to pay the additional 80%. But you need to ask your insurer about this, not the DME. If they are trying to charge you the fantasy billing price instead of the insurer's contracted price, it may count as FRAUD. Don't let them get away with this!!!

[igotsuckeredtoo]

The place to report such things, you will actually have to file a complaint, is with the Attorney General of the state the business is in.

I had a horrible time with supplies,they never had any on the shelf though each of them promised they would if I became a customer. The first one made me use one filter for over a year before I finally found out I was entitled to filters every week! I saved it its grey they are blue and white new. Now I get all supplies online.

[prodigyplace]

I believe there are some states that are requiring that prescriptions of CPAP machines and supplies be updated annually, but you'd have to check and see if that applies in your state.

Prodigy Place said:

My insurance only pays 80% and I have not met my co-pay limit for the year. That means I would need to pay the full amount of the DME's inflated prices.

You might check with your insurer to verify if this is true. My understanding is that even if you haven't met your deductible, DME's may not charge you more than the price they are contracted to provide for your insurer, that may be very much less than "the full amount of the DME's inflated prices", even though you have to pay the additional 80%. But you need to ask your insurer about this, not the DME. If they are trying to charge you the fantasy billing price instead of the insurer's contracted price, it may count as FRAUD. Don't let them get away with this!!!

They were charging the contracted price which was still higher that purchasing/obtaining elsewhere for pillow, etc.

[Audio_mc]

I talked to the manager and doctor today who were so unprofessional even though I was calm the whole entire time to the point that he started making unprofessional comments like "I charge $400 an hour and your waisting my time" and also said "you just swing by here to pick up equipment. What do you think this is burger King". I was shocked by the unprofessionalism. I advised him that I'm recording the conversation and he said that's fine. Texas is a one party consent state so I have the right to record. I don't know the rules about uploading to YouTube to expose the unprofessionalism but I may take that route if I am able to legally.

[Pugsy]

Does the doctor have any sort of financial interest in the business where you get your equipment?

[Audio_mc]

Does the doctor have any sort of financial interest in the business where you get your equipment?

Yes he is the owner

[LSAT]

Personally, I would NEVER use a DME that was affiliated with my doctor...conflict of interests.

[Pugsy]

Does the doctor have any sort of financial interest in the business where you get your equipment?

Yes he is the owner

There's your explanation.
DMEs are free to setup their own in house rules (which they often will then blame on your insurance when it's a bold face lie) and in this case the doctor wants to see you so he can get another office visit out of you.
He can do that....it's legal but it stinks.

Now IF you happened to have Medicare as your insurance...the sleep doctor (or anyone in his family) is prohibited from having any financial interest in the place where the supplies are dispensed. Medicare is the only insurance that I know of that specifically addresses the potential conflict of interest....it's a big no-no.

Again...vote with your business dollars....find another DME. Ask ahead of time what their policy on supplies is with your RX.