Insurance va. DME vs. Me - what do you guys think?

[DawnTCB]

Hi everyone! Hope you all are doing well!

I am having a "disagreement" with my DME...

I started CPAP on 5-25-07. My insurance rents the machine for 1 month, and then, provided I am compliant, will buy it outright. I realize that many insurance companies require a longer rental period, and my insurance is NOT all that great overall, but I checked this before I agreed to the sleep test because I could not afford to be eaten up with co-pays.

I am 100% compliant, all night every night and have attended all follow-up appointments and compliance checks, etc. In July I asked my DME if the insurance had paid for the CPAP yet, because when my divorce is final (if ever! ) I will be changing insurance and I want to make sure that THIS insurance covers it so I don't have to hassle with trying to get a new insurance to cover it. My DME advised that just a couple of days before, they had sent the Letter of Medical Necessity to my insurance. He further said that he could NOT send the LMN before they asked for it, because they would turn it down as "unnecessary paperwork".

I got my first bill from the sleep clinic/DME last month (September), with my 10% or whatever of my sleep study and I paid it. This month I got a bill for a couple of copays, and the full rental costs for by CPAP for July, August, September, and October, at $130 apiece.

I called my DME who said "the insurance never paid for the machine". I called the insurance and they said, "the DME never billed us for the machine. We will deny the rental fees because we only pay one month rental. Please ask them to bill us for the machine." I called the DME back and they said, "well, most insurance companies require a longer rental period, so we didn't know to bill them so soon; we will bill them now." I asked if I could have a refund (or credit, really, since I have not paid it yet) for the rental fees that my insurance declined, and they said no, because they had rented it to me and have yet to be paid for the machine, so they are due the rental fees.

To my way of thinking, it is the DME's responsibility to check on the insurance THEY accept, and also I reminded them to bill my insurance back in July. The fact that they did NOT doesn't seem to say to me that I owe the rental fees, does it? This seems like a bit of a scam to me... I mean technically they could keep billing me for rental fees forever, and never charge my insurance for the machine, and my insurance would keep declining it and I would get more and more debt, right? Is there a reasonable way to get out of this? Has anyone else had this happen?

Thanks in advance!

[Slinky]

If you didn't handle all this in writing then do so now. Do NOT pay one red cent more than your insurance requires. Keep the equipment. IF the DME threatens or does try to turn it over to collection, ignore them. Get verification in writing from your insurance company of their CPAP reimbursement policy. Notify the collection agency of the issues - and then let them slug it out. As long as the issue is in dispute the credit agencies are NOT supposed to hold it against your record. You can insist that it be removed if it is.

It is always wisest when there is a dispute or one is anticipated to send all written correspondence via Certified Mail, Return Receipt Requested.

[KansasRT]

I would hope that when the insurance pays for the machine the rental fees would go away, but that would be in a perfect world. I have done three way calls with DME's and Ins Co and Patients before. The insurance company has the ability to do it if you don't.

[Sleepdeprived]

[quote="DawnTCB"]Hi everyone! Hope you all are doing well!

I am having a "disagreement" with my DME...

I started CPAP on 5-25-07. My insurance rents the machine for 1 month, and then, provided I am compliant, will buy it outright. I realize that many insurance companies require a longer rental period, and my insurance is NOT all that great overall, but I checked this before I agreed to the sleep test because I could not afford to be eaten up with co-pays.

I am 100% compliant, all night every night and have attended all follow-up appointments and compliance checks, etc. In July I asked my DME if the insurance had paid for the CPAP yet, because when my divorce is final (if ever! ) I will be changing insurance and I want to make sure that THIS insurance covers it so I don't have to hassle with trying to get a new insurance to cover it. My DME advised that just a couple of days before, they had sent the Letter of Medical Necessity to my insurance. He further said that he could NOT send the LMN before they asked for it, because they would turn it down as "unnecessary paperwork".

I got my first bill from the sleep clinic/DME last month (September), with my 10% or whatever of my sleep study and I paid it. This month I got a bill for a couple of copays, and the full rental costs for by CPAP for July, August, September, and October, at $130 apiece.

I called my DME who said "the insurance never paid for the machine". I called the insurance and they said, "the DME never billed us for the machine. We will deny the rental fees because we only pay one month rental. Please ask them to bill us for the machine." I called the DME back and they said, "well, most insurance companies require a longer rental period, so we didn't know to bill them so soon; we will bill them now." I asked if I could have a refund (or credit, really, since I have not paid it yet) for the rental fees that my insurance declined, and they said no, because they had rented it to me and have yet to be paid for the machine, so they are due the rental fees.

To my way of thinking, it is the DME's responsibility to check on the insurance THEY accept, and also I reminded them to bill my insurance back in July. The fact that they did NOT doesn't seem to say to me that I owe the rental fees, does it? This seems like a bit of a scam to me... I mean technically they could keep billing me for rental fees forever, and never charge my insurance for the machine, and my insurance would keep declining it and I would get more and more debt, right? Is there a reasonable way to get out of this? Has anyone else had this happen?

Thanks in advance!

[RosemaryB]

I recently had a debate with my DME. They claimed the ins. said that my ins. year started in September, not January (it's January). It was an automated system they got this info from and told me it was up to me to call the insurance company and straighten it out. They wanted to charge me a new deductible. I'm closely watching this and doubt if I'll be getting new supplies from them next year, unless it looks like I've maxed out my deductible elsewhere.

I despaired of trying to change the ins automated system, so I called our HR dept and asked them to straighten it out with the insurance company. They cleared it up more easily because it was coming from an organization. I don't know if that will work for you, but you could give it a try if you have a friendly HR depart ment where you work.

(Ins and DME: A pox on both their houses).

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): DME