Shady billing, accepted practice, or accident

[cdru]

I've had OSA for the past 6 or 7 years and have been on a fixed pressure CPAP machine that entire time. My machine started to have some leaks and parts were no longer available, so it was time to upgrade to a new machine. I went with a new DME provider and I picked up my new machine today and got the invoice for what will be sent to insurance:
ICON AUTO CPAP W/ HEATER $120/month rental
FPHC150 HEATER FOR CPAP HUMIDIFER $235 purchase
2 AIR FILTERS FOR ICON CPAP $8.30 purchase
THERMOSMART BREATHNG TUBE FOR ICON CPAP $75 purchase

I saw the rental and questioned that, but they said that insurance hadn't authorized purchase explicitly but that could be changed after the fact, and that the purchase price was $1200. I also questioned the $235 for the humidifier since the humidifier is built in. I was told that was required for the E0562 insurance billing code was included on the invoice.

It didn't sink in until I had already left that they were charging me significantly additional for the air filters and tubing that comes with the machine. A quick search also reveals that Fisher Paykel HC150 is a stand alone humidifier which wouldn't be necessary with the ICON Auto machine.

My question is, does this sound shady, an accepted practice, or just an accident? I've already had to jump through hoops with this company that has left me a bit jaded and therefor biased. Mistakes can happen, but it just sounds like they are taking a bit too many liberties with what they can bill insurance and try to get away with it. I have not questioned them on it yet, but I have a feeling that if I decide to purchase it from them, that the individual items are not deducted from the $1200 as "consumables" during the rental, and the $235 was just them billing for as much as they can with the hopes of getting away with it.

[Julie]

I won't speculate about whether it's shady, or anything else, but I would urge you to get a machine (e.g. the Resmed S9 Autoset or the PR S1 from Respironics, or the one I use) that have full tracking capability so you can see what's what every day if you choose. And getting an Auto machine gives you the option of using plain Cpap, but a Cpap alone won't do Auto. And you can get them and others outright from e.g. Cpap.com a lot cheaper than what you're arranging now. I'd look into it if I were you.

[RogerSC]

Yes, I remember noticing that my DME was billing my insurance company $80 for Swift FX nasal pillow replacements ($22 at cpap.com, less on eBay). The insurance company was reimbursing them about $20. I thought maybe the DME could take the $60 as a tax loss, to avoid paying taxes...don't know why else they'd bother to bill the insurance company for four times what they knew they'd get back.

[ems]

Doesn't sound right to me. I suggest you call your insurance company and explain all this to them. I would ask to speak to a supervisor.

I would also return the machine you got ASAP for a data capable machine. Don't let your DME tell you that you can't do that. While you are on the phone with your insurance company, ask them for another name of a DME in your area.

Let us know what happens.

[cdru]

I returned the machine on my way home from work. When she was writing down what all was being returned, I mentioned that she wouldn't find the HC150 humidifier with what was in the bag. I explained that it appears I was going to be billed for something I never got. She said no, that was a correct item since the machine has a built in heater. I asked if I opted to buy it for $1200 if I was still required to pay for the $235 heater that's built in, as well as the $75 tubing and $8.30 filters, she said yes. When I said that I can get the exact same machine with the same components for $600 at CPAP.com or other online suppliers, her only reply was that they don't have to do paperwork.

So I guess the answer to my question ended up being d. unmitigated gall to simply rip off a customer because they can. I understand a B&M shop has more expenses and overhead than an online store. But charging me 200+% more than what I can get an item elsewhere is just fleecing customers because they can (or the customer doesn't know better).

I simply returned everything I got earlier in the day, including the replacement mask cushions and headgear that I should have replaced long go. Those two items actually were priced fairly competitively, but it was the principal of doing business with them that I didn't like. I've already started the process to get my prescription sent to cpap.com.

[hyperlexis]

The key thing is that the humidifier is built in == fascinating legal issue. Could it be considered fraud? How can you bill separately for something that is integral?

And are you being defrauded by the insurance company, or the DME? Or no one...

May make an interesting class action suit. Maybe you could be my client to represent the class.

[hyperlexis]

I won't speculate about whether it's shady, or anything else, but I would urge you to get a machine (e.g. the Resmed S9 Autoset or the PR S1 from Respironics, or the one I use) that have full tracking capability so you can see what's what every day if you choose. And getting an Auto machine gives you the option of using plain Cpap, but a Cpap alone won't do Auto. And you can get them and others outright from e.g. Cpap.com a lot cheaper than what you're arranging now. I'd look into it if I were you.

The F&P is a good auto machine that has data tracking.

[LSAT]

I won't speculate about whether it's shady, or anything else, but I would urge you to get a machine (e.g. the Resmed S9 Autoset or the PR S1 from Respironics, or the one I use) that have full tracking capability so you can see what's what every day if you choose. And getting an Auto machine gives you the option of using plain Cpap, but a Cpap alone won't do Auto. And you can get them and others outright from e.g. Cpap.com a lot cheaper than what you're arranging now. I'd look into it if I were you.

The F & P Icon is an Auto machine with data capabilities. cdru has an auto.

[Janknitz]

You should have contacted your insurer before ever walking in to a DME to understand what and how they cover new CPAP machines. Most important to understand is whether they require rental or they permit purchase and under what conditions, whether they pay by HCPC's codes (most do) and how much you should expect to pay out of pocket. You also want to know if they might cover an online purchase.

Then you can walk into a DME from a place of knowledge, request what you want, and know exactly how much you're going to pay out of pocket.

DME bills are works of complete fiction. They often part out something that is sold together (i.e charge separately for the cushion, the mask, and the headgear). They charge outrageous prices knowing that they will GET whatever the insurer deems to be a reasonable charge (from which you may have to pay a co-pay or percentage of the INSURER's allowable amount, not the DME's price). It's the game they must all play, but it sucks for us consumers who never really know what things cost and don't often know enough to understand what our obligations are.

Start over again, but this time start with your insurer FIRST. See my blog post "What you need to know BEFORE you meet your DME."

[cdru]

You should have contacted your insurer before ever walking in to a DME to understand what and how they cover new CPAP machines. Most important to understand is whether they require rental or they permit purchase and under what conditions, whether they pay by HCPC's codes (most do) and how much you should expect to pay out of pocket. You also want to know if they might cover an online purchase.

While I haven't checked on the HCPC's codes, I have good insurance when it comes to DME where I pay a straight 20% with no limits other than medically necessary. Rental or purchase they said they don't care, it's up to my financial determination what's best for me.

[chunkyfrog]

The big question: in network vs out of network--what's covered, how much, and who is in each group.

[cdru]

The big question: in network vs out of network--what's covered, how much, and who is in each group.

For DME, there is no in or out of network. It's all treated the same for coverage with the only exception that an out of network provider I may have to pay the full price up front and then seek reimbursement, where in network usually I'd only be billed for what my portion after insurance was.

[mgaggie]

With the F & P icon machines, there are three types

Novo - usage hours only, strsight Cpap
Premo - data capable, straight Cpap
Auto - top of the line full data, adjusting pressure

[cdru]

Someone correct me if I'm wrong, but the Icon data is still a non SleepyHead friendly format and the software for interpreting the results is available limited and costs $80. Right?

[mgaggie]

Someone correct me if I'm wrong, but the Icon data is still a non SleepyHead friendly format and the software for interpreting the results is available limited and costs $80. Right?

Wrong, the latest version of sleepyhead worked on my icon novo