DME Tricks

[early2rise]

This morning, as planned I picked up my updated prescription for the ResMed S9 Auto and started calling DME's. Finally decided on a small local company that had favorable return/exchange policies. I had my appointment all set up for next Tuesday the 5th when I decided to drop off my prescription in case they needed to order the machine hereby shortening any additional delays. The person I dealt with stated because my ins only pays X, they have to charge an additional $350.00 as an upgrade fee. At that point I was so glad that I found this forum and all the wonderful people who had prepared me and I knew that isn't the way the contracted rates work. So I very calmly gathered my prescription off the counter said you may cancel my appointment and left the office. I'm normally a fairly calm person until someone tries to take advantage of me. I surprised myself in how i handled the situation.

But I do wonder if a company has agreed to the ins reimbursements, why jeopardize the relationship with the ins and/or patient? I guess they think few people will have to wherewithal to complain and they can get away with it. Another major issue with the US healthcare system.

[Janknitz]

But I do wonder if a company has agreed to the ins reimbursements, why jeopardize the relationship with the ins and/or patient? I guess they think few people will have to wherewithal to complain and they can get away with it.

Exactly!

Sad, isn't it!

[BleepingBeauty]

This morning, as planned I picked up my updated prescription for the ResMed S9 Auto and started calling DME's. Finally decided on a small local company that had favorable return/exchange policies. I had my appointment all set up for next Tuesday the 5th when I decided to drop off my prescription in case they needed to order the machine hereby shortening any additional delays. The person I dealt with stated because my ins only pays X, they have to charge an additional $350.00 as an upgrade fee. At that point I was so glad that I found this forum and all the wonderful people who had prepared me and I knew that isn't the way the contracted rates work. So I very calmly gathered my prescription off the counter said you may cancel my appointment and left the office. I'm normally a fairly calm person until someone tries to take advantage of me. I surprised myself in how i handled the situation.

But I do wonder if a company has agreed to the ins reimbursements, why jeopardize the relationship with the ins and/or patient? I guess they think few people will have to wherewithal to complain and they can get away with it. Another major issue with the US healthcare system.

Good for you, early2! Kudos for being an informed and savvy consumer!

I trust you'll find another DME who wants your business and will earn it with good service and straight-dealing. Best of luck.

[ameriken]

Can someone fill us noobs in on what this is about?

[Otter]

Can someone fill us noobs in on what this is about?

Insurance pays DMEs (durable medical equipment providers) the same for a cpap machine no matter what make or model you get. Hence, the DMEs want to get you out the door with the cheapest unit available. Failing that, they try get you to pay for the "upgrade", but I'm told that's either against insurance regulations or against the law (I'm not sure which). Even if it were allowed, it's completely unjustified, as they'll bill insurance about twice the free-market retail rate for the most expensive machine.

When you go to pick up your first machine, make sure you know what you want and do not accept substitutes or excuses. Be aware that "fully data capable" may mean something completely different to your DME than it does to you, and that most of the machines come in several different versions with very similar names. If you don't know the exact name of the model you want, odds are very good you'll wind up with a less capable machine.

Early had done her homework, saw the con for what it was, picked up her scrip, and walked out.

[danshiplett]

When I first got my machine it was a brick, I talked with my doctor and he was happy to write me a new prescription. I called my insurance and discussed with them, they stated they would only pay for certain models because the fully data capable machines were not a necessity. I went to my DME and I did have to pay the additional charge of $150. To me it was worth it to be able to get something fully data capable.

[camman595]

Can someone fill us noobs in on what this is about?

... Even if it were allowed, it's completely unjustified, as they'll bill insurance about twice the free-market retail rate for the most expensive machine.

They may bill the insurance company but that doesn't mean they will get it. For example, my DME charged the insurance comany $300 for the Resmed H5i humidifier but the insurance only paid $177 and no additional monthly fee. And they are billing insurance $115/month to rent the S9 Autoset but the insurance company is only paying $65.65/month. After 10 months the unit is mine. So that being said, the total that insurance is going to pay for my Autoset + humidifier is $833.50. That is $263.50 less than I could purchase it for at cpap.com. That is why they try to give you a less expensive machine. They are not necessarily trying to rip you off as much as they are trying not to loose money.

I suggest that you decide on which machine you want before you go to the DME and be specific when you tell them.

[early2rise]

Can someone fill us noobs in on what this is about?

... Even if it were allowed, it's completely unjustified, as they'll bill insurance about twice the free-market retail rate for the most expensive machine.

They may bill the insurance company but that doesn't mean they will get it. For example, my DME charged the insurance comany $300 for the Resmed H5i humidifier but the insurance only paid $177 and no additional monthly fee. And they are billing insurance $115/month to rent the S9 Autoset but the insurance company is only paying $65.65/month. After 10 months the unit is mine. So that being said, the total that insurance is going to pay for my Autoset + humidifier is $833.50. That is $263.50 less than I could purchase it for at cpap.com. That is why they try to give you a less expensive machine. They are not necessarily trying to rip you off as much as they are trying not to loose money.

I suggest that you decide on which machine you want before you go to the DME and be specific when you tell them.

Camman595, how much do you think the DME pays the manufacturer for the machines? I'm an auditor and I have seen how little some companies pay for their inventory and the markup %. I don't think that by not charging an upgrade fee they would be in any danager of losing money. Its more likely just providing less of a profit.

[rested gal]

When you go to pick up your first machine, make sure you know what you want and do not accept substitutes or excuses. Be aware that "fully data capable" may mean something completely different to your DME than it does to you, and that most of the machines come in several different versions with very similar names. If you don't know the exact name of the model you want, odds are very good you'll wind up with a less capable machine.

Good point, Otter. The names of the machines can be confusingly similar.

The link below may be helpful to new people trying to figure out which machine does what.

My list of machines that record "full data" (AHI and leak info) and those that don't -- updated February 2011.
You'll want a machine that can record leak and AHI info. The ones in blue do that; the ones in red do not:
viewtopic.php?p=307168#p307168

Something else Otter mentioned is important. On this forum we talk about "full data" or "fully data capable" a lot, but that's not a phrase DMEs use.

"Compliance" (hours of actual use) is the only kind of information from a machine download that insurance or Medicare is interested in. So, it's understandable that most DMEs would think of data (even if you say "full data") as just being "compliance" data showing hours of use. That's all most DMEs are accustomed to looking at....proof that the person is using the machine long enough to get Medicare or insurance to keep pay the monthly rental.

Many (perhaps most) DMEs probably assume that if a machine has a Smart Card stuck in it, the machine records "full data." Not so.

If you want a machine that can record and show what we mean by "full data" (AHI and Leak info) better say "AHI and Leak data" specifically. Saying "full data" or "fully data capable" to a DME is likely to be meaningless to most of them.

Check out LinkC's post on page 2 of this thread:

LinkC's story of dealing with a clueless DME
viewtopic.php?p=342111#p342111

LinkC's topic includes a funny story by roster
viewtopic.php?p=344282#p344282

and

danw61's story
viewtopic.php?p=344299#p344299

[Otter]

They may bill the insurance company but that doesn't mean they will get it.

Good point. My understanding was that they did get the cash cow rates at least some of the time, but perhaps not. It never made the slightest sense to me that either medicare or insurance would pay that much. I paid out of pocket, so I really don't know anything about insurance.

[Otter]

Camman595, how much do you think the DME pays the manufacturer for the machines? I'm an auditor and I have seen how little some companies pay for their inventory and the markup %. I don't think that by not charging an upgrade fee they would be in any danager of losing money. Its more likely just providing less of a profit.

Also a good point.

Cpap.com, like all the other online DMEs, is limited by Resmed's minimum price. With Philips, the DMEs are allowed to show a "discounted" price after a trivial additional step, and hence there is competition and the market price is lower. Hence for the S9 Autoset and humidifier, cpap.com charges $1,072.00, and for the very similar PR1 Auto with its humidifer, only $635.00. If the DME pays about the same for both machines, then there is plenty of room left for profit on the S9 at $833. It would be interesting to see the wholesale prices for these machines. Do you know them, Camman?

[CruzTerri]

What I find very interesting is that I started CPAP therapy on 1/10/2011; however, neither my DME nor my MD have ever requested to see my data (full or otherwise).

[monarch22]

Early2rise, that must have felt so good to be in control of the situation and not let them take advantange of you or even waste your time arguing with them. You should be very proud of yourself!!

CruzTerri, I'm in the same boat as you. My doctor is clueless regarding cpap and apnea, and the DME only calls me every 3 months to try to get me to order supplies! DME seemed really helpful when I was buying the machine, but went downhill with service after that!

[Otter]

What I find very interesting is that I started CPAP therapy on 1/10/2011; however, neither my DME nor my MD have ever requested to see my data (full or otherwise).

You must be doing very well, then.

[OldLincoln]

I went through the base machine vs full featured on my first machine. After being here for a couple years I had all components written down and info and pics pf them from the web sites. I laid it all out for my doc who wrote the script with all the specific equipment I gave him. Early2rise has it right about talking to then BEFORE they fill it. If they fill it they will tell you it's filled and you have to take what they give you. Not true but that's what my first one told me (before I found this site).