DME fraud?

[cryppie]

Hello,

I was sent to a local DME today to get a new cpap machine. I was quoted $22xx for an AirSense 10 Autoset, $4xx for a humidifier, and $50 for tubing - billed to insurance of course. I mentioned the cpap has the humidifier and tubing included and they told me they must still charge for it due to insurance coding. I told them I'll take it without the humidifier and they told me they can't do that since it comes with a humidifier - that I'll need to get a different model if I don't want a humidifier.. Does this sound right?

[Julie]

Very possible as many humidifiers are built in.

[robz]

I would say yes, without a doubt....when I was diagnosed and sent to DME to get machine, I thought it would be something my insurance would cover....So they got my equipment, checked my insurance and said I was covered....Now, at this point, I thought my insurance was covering the purchase of the machine....I got the machine on the 9th month of year...which PS, I had met my deductible for that year at this point.....roll over to Jan of the next year, I started getting a bill from the DME provider....I couldn't figure it out....I called and that's when they told me insurance pays half of the bill until you meet your deductible and then its totally covered.....I was confused....but then realized insurance was paying 75 bucks a month and I was paying 75 bucks a month, until the machine was paid off, which came to around 1700 bucks....I was pissed, that this was not explained properly....I felt it was to expensive, since you can order online, with prescription for much cheaper.....So I took it back and purchased one online, which came with humidifier and tube for like 1200 bucks.....It was just the principle for me, that I feel Like Insurance companies are being over charged for these machines, maybe not in all cases, but in my case and yours for sure...Between the great members on this site and youtube, you can get all the necessary info to setup and use your machine if you decide to purchase yourself......

[prodigyplace]

Hello,

I was sent to a local DME today to get a new cpap machine. I was quoted $22xx for an AirSense 10 Autoset, $4xx for a humidifier, and $50 for tubing - billed to insurance of course. I mentioned the cpap has the humidifier and tubing included and they told me they must still charge for it due to insurance coding. I told them I'll take it without the humidifier and they told me they can't do that since it comes with a humidifier - that I'll need to get a different model if I don't want a humidifier.. Does this sound right?

I noticed the same thing when I got my CPAP back in February. I believe DME fraud is a large part of high medical insurance rates & costs in the US.
Is your DME Lin(don't)care? My insurance as billed for CPAP and Humidifier on a 10 month rent-to-own basis. I will find out soon how true that is. For the P10 mask, they kept 2 of the 3 pillows saying insurance did not pay for them. I has to push to get the approved heated hose too. I ended up exchanging for a FFM in the first 30 days.

I also initially made the mistake of signing up for automatic supplies. My first month's supplies included a humidifier tank, new mask portion, and 2 CPAP air filters. Since I pay 20% of the supply cost, I then cancelled the automatic supplies. This is another area of DME fraud, IMHO.
Insurance says I am locked in to this DME since they requested the insurance pre-authorization. This is part of the lock-in fraud & lack of competition, IMHO. I was able to get a second prescription from my doctor so I could order mask, etc. from cpap.com.

[WRX03]

What is silly there is a cover that makes the humidifier in-op. There is a little magnet in it that toggles a switch in the CPAP. I guess they could give you that cover and not charge for the humidifier.

[chunkyfrog]

Medicare and insurance regulations have not kept up with technology.
Namaste.

[Okie bipap]

You will find the DME will bill the insurance very high prices for your machine and various other supplies, but the insurance companies do not pay that price. They pay a negotiated price which is usually much less than that. Your copay is based on what the insurance company actually pays, not what the DME bills them.

[chunkyfrog]

Note that some masks have odd numbers of parts. (testing the waters?)
On my first Swift FX, my DME charged separately for frame, headgear,pillows,,
AND "short hose"
The short hose was indeed fraudulent, (it WAS part of the "frame")
but BCBSNE sided with the DME.
This was the tipping point, where I went totally out of pocket,
buying all my supplies online. (cpap.com)
Apparently, there had been some "under table action" between BCBS and the DME,
as I received reminder letters that I was overdue for supplies,
---having not yet reached my deductible.

[Wulfman...]

Hello,

I was sent to a local DME today to get a new cpap machine. I was quoted $22xx for an AirSense 10 Autoset, $4xx for a humidifier, and $50 for tubing - billed to insurance of course. I mentioned the cpap has the humidifier and tubing included and they told me they must still charge for it due to insurance coding. I told them I'll take it without the humidifier and they told me they can't do that since it comes with a humidifier - that I'll need to get a different model if I don't want a humidifier.. Does this sound right?

I don't think it's DME fraud. It's more like the manufacturers have come up with a (sneaky) way of making the otherwise optional heated humidifier mandatory in the delivered equipment. But, the dollar amounts you mentioned have been pretty consistent with the insurance-billed amounts for the last decade or two. That's about what they were when I started in 2005.
But, I opted to buy my own equipment (out-of-pocket) from CPAP.COM and billed my insurance provider......then they reimbursed me for the in-network percentage as they considered me to be in-network. We both saved a bunch of money.


Den

.

[Janknitz]

It's typical for DME's to part out the various components, including BUILT-IN humidifiers, and also they part out masks--frame, cushion, headgear, hose in their billing even if they come all packaged together by the manufacturer. It appears to be an accepted practice because surely Medicare realizes that most of the newer machines have built-in humidifiers. But if something has a billing code, the DME WILL bill for it, and insurance companies will reimburse.

It's not exactly fraud. But it sure seems like it.

[SewTired]

Hello,

I was sent to a local DME today to get a new cpap machine. I was quoted $22xx for an AirSense 10 Autoset, $4xx for a humidifier, and $50 for tubing - billed to insurance of course. I mentioned the cpap has the humidifier and tubing included and they told me they must still charge for it due to insurance coding. I told them I'll take it without the humidifier and they told me they can't do that since it comes with a humidifier - that I'll need to get a different model if I don't want a humidifier.. Does this sound right?

It is not fraud, it is absolutely true. If you do not want to pay for the humidifier, then you need to select a model that does not integrate the humidifier into the unit. So, an S9 or a Respironics (if you want top of the line). All the insurance companies use the same codes as Medicare and Medicare currently has no code for integrated units. Also, Medicare (or insurance) do not pay for that panel the shuts down the humidifier on Resmed Airsense models.

FWIW, most of us who WANT a Resmed and WANT the humidifier do not want a separate code created for integrated units unless they are ALL integrated. Why? Because I guarantee you, we will have to fight harder to get the machine we want. Right now, the machines all go under one code and the humidifiers under another.

[chunkyfrog]

Good point, ST.
Be careful what you wish for--you might get it.

[Cpapian]

Hello,

I was sent to a local DME today to get a new cpap machine. I was quoted $22xx for an AirSense 10 Autoset, $4xx for a humidifier, and $50 for tubing - billed to insurance of course. I mentioned the cpap has the humidifier and tubing included and they told me they must still charge for it due to insurance coding. I told them I'll take it without the humidifier and they told me they can't do that since it comes with a humidifier - that I'll need to get a different model if I don't want a humidifier.. Does this sound right?

Can you go to a different DME? Who says you can't negotiate. This is a business transaction and they are not your guardian angels. Call around ..... simply say "I want NEW xxx machine/model, including x, x, and x. What is your price?" If it's over $1,000, ask them if is their best price. When you find someone in your ballpark, if you wanted you can go back to the original DME and tell them if they want your business, they should match the price you bargained, or you will buy elsewhere.

Or just buy through Amazon.

Don't go without a humidifier, you may regret that later on. And get the latest model. The one you chose is great, get that one, but at a reasonable price. I think we are all intimidated when we buy our first machine, and that is how DMEs take advantage of us.

Also, learn how to verify your machine is new. DMEs will try to sell used machines as new. The information is available on this forum.

Best of luck to you. Come back when you get your machine and well help you through the early days.

[chunkyfrog]

NOTE: If your insurance deductible exceeds the price listed online for the desired machine,
your insurance is not intended to be used for DME.
Whoever negotiated your benefits package deserves a beating.

[Chevie]

$22xx for an AirSense 10 Autoset

If you can come up with $22, I will gladly donate my two exes.

Gladly.