Insurance games played by DME provider

[dream321]

I use the Phillips Dreamwear nasal mask. In the past, the DME billed my insurance $50 per nasal cushion, the amount allowed was $29, and my out-of-pocket cost was just over $7 dollars.

Now, they billed my insurance $100 for the same nasal cushion, the allowed amount was $58, and my out of pocket cost was just over $14.

Does anybody know how they can do this? Can they just charge whatever they want and the insurance company will pay about half of it? At this rate it will cost me less to pay cash and buy it on the Internet

[LSAT]

They can't do that!...Sounds like they simply billed for 2 masks...did you ask them? Did you ask your Ins co?

[dream321]

It’s for one nasal cushion. I didn’t talk to my insurance company yet, since the phone monkeys there are rarely helpful unless I tell them exactly what to do. And knowing my DME, they’ll just say my insurance company allows it.

[LSAT]

That's the only way you will get the answer...otherwise you are just screwed

[Pugsy]

Who is your insurance with?

[chunkyfrog]

A previous DME insisted on billing my insurance for a full face mask-
-when I only requested a full face CUSHION.
I called my insurance (BCBSNE), who did not give even the tiniest fecal particle.
I did not order the cushion, and quietly changed to a different DME.
No explanation--they had to KNOW they were doing wrong.
This particular crook is now kaput--I guess karma finally happened.

[babydinosnoreless]

A previous DME insisted on billing my insurance for a full face mask-
-when I only requested a full face CUSHION.
I called my insurance (BCBSNE), who did not give even the tiniest fecal particle.
I did not order the cushion, and quietly changed to a different DME.
No explanation--they had to KNOW they were doing wrong.
This particular crook is now kaput--I guess karma finally happened.

In my case I tried calling the insurance company who didn't seem to care. I tried switching DME's (they were worse) so now I hold my nose and order when necessary and buy off of amazon/ebay when I can. I also try to pay it forward for all the help I received here and offer up extra pieces parts when I have them.

[Pugsy]

I doubt very seriously if insurance has had a 100% increase in the allowed amount for anything.
More likely is the DME billed for 2 cushions...and if you only got one cushion you call up the DME and complain that insurance paid for 2 cushions and you only got one.

No insurance company in the world has gone from allowing $29 for one cushion to allowing $58 for one cushion....that's a 2 cushion bill.

If you have Medicare....for sure they didn't increase the allowable amount....they rarely increase allowable fees for anything.

[chunkyfrog]

Don't forget the fantasy pricing on the statement--far in excess of allowables:
Pie in the sky to catch the uninsured desperate victim.
Like MSRP on anything, it is often not the "real" price.
Without insurance, all the smart kids buy online--cpap.com is my #1.

[dream321]

I doubt very seriously if insurance has had a 100% increase in the allowed amount for anything.
More likely is the DME billed for 2 cushions...and if you only got one cushion you call up the DME and complain that insurance paid for 2 cushions and you only got one.

No insurance company in the world has gone from allowing $29 for one cushion to allowing $58 for one cushion....that's a 2 cushion bill.

If you have Medicare....for sure they didn't increase the allowable amount....they rarely increase allowable fees for anything.

It’s $200 that was billed for 2 cushions. Ambetter is my insurance company.

[Janknitz]

Dream321, do I understand correctly that you were billed for TWO cushions but only received one?

First step is to contact the DME and report the billing error. See if they agree to correct the billing.

If they don't do anything, then report the fraud to your insurer. You were billed for 2, received only one.

If you are on Medicare, you can report the fraud to them as well. https://www.medicare.gov/forms-help-res ... care-fraud

Keep good records: Date, time, whom you spoke to, what they said. Consider sending "confirming memos". E.g. If DME says "oops, we'll fix that on our next billing cycle" write a confirming memo to the person you spoke to: Dear Ms. So and So, on [date] I spoke to you about billing me for two cushions when I only received one, and you said that this error would be fixed on the next billing cycle. I am writing to confirm our conversation and if I misunderstood anything please let me know within 3 business days of the receipt of this letter, otherwise I will expect the correction on the next billing cycle." Now you have documentation.

I know it's only $14 for you, but if this type of fraud is permitted to go on, it will continue.

[dream321]

Dream321, do I understand correctly that you were billed for TWO cushions but only received one?

No. I received 2. My insurance was billed $100 for each. Total $200.

[Janknitz]

Dream321, do I understand correctly that you were billed for TWO cushions but only received one?

No. I received 2. My insurance was billed $100 for each. Total $200.

OK, got it. So the DME can BILL whatever the heck it wants for the cushions. $1000 each if it wants to. All the insurance will pay is 80% of whatever they think the cushions should be covered for, in this case I'm guessing $35 each and you owe 20% of that which is $7 apiece.

The DME is engaging in fantasy billing, doesn't matter what they bill, the insurance decides what a fair price is (set by contract or Medicare) and then the insurance company pays it's portion of the fair price and you owe the additional percentage of what the insurance determines is the price. In most cases the DME cannot bill you for the difference between the insurance allowed price and the fantasy billing. That is a practice known as "balance billing" and it's illegal in most states. If you're on Medicare and use a non-participating DME provider, you can be on the hook for up to 15% over the Medicare allowable price. https://www.medicareinteractive.org/get ... -providers


DME's do fantasy billing for two reasons: 1) Some poor suckers walk off the street without insurance and pay the fantasy price because they don't know any better. 2) Every year the DME must submit its retail billing to Medicare so that Medicare can set the reimbursement rate for the coming year. DME's think if they jack up the retail price, Medicare will set the reimbursement rate higher. Medicare knows better.

[chunkyfrog]

Also, fantasy prices can be used in "creative accounting"---
to show a loss (for tax purposes) when there actually was a profit.
Too bad Elliot Ness is no longer around to get them for cheating on their taxes.