Feel I've been ripped off

[seamonkey21]

Hello everyone,
Once again, my luck with doctors and insurance has turned out to be non-existant.

After months of using a CPAP and taking 200mg of Provigil, with some success, I have taken a turn where I feel just as bad as before using a CPAP.

I went into ask about different chinstraps. And the fellow at the DME provider, while flipping through my info, let slip the word 'C-Flex' - to which I replied 'C-Flex? Where is that written? My CPAP machine isn't a C-Flex unit'.

His story was that insurance had declined to pay for such an expensive unit.

I never did recieve any information about my sleep studies other than that i needed to go see the DME company to get a CPAP machine and have them set it up.

What information am I entitled to get from the doctor and the DME? I know they will try to give me the run-around - this DME feels like a used-car lot. They're fired as soon as I can get to the bottom of this.

Has anyone else encountered something similar with insurance? I feel like I have been prescribed a Pinto when I needed at least a Taurus to feel better....

my CPAP is a RemRest - http://www.oxymaster.net/shp.php?prid=901000&lgid=en - similar to this one - with a passover humidifier. I get the feeling i've been sold about the crappiest stuff possible, after looking around....gah.

[Babette]

I do know exactly how you feel. I've already fired my DME, but I haven't accomplished all the things I need to do to hire a new one.

I DID get copies of my PSG's, my primary doc gave me those. You might call your Sleep doc or primary for those copies, and ask for for a copy of your cpap prescription while you're at it.

GOOD LUCK!!! and keep us posted. We'll help you all we can!!!
Barbara

[Guest]

I don't know the answers to your questions but I certainly can sympathize! I felt like I had so little information when I was diagnosed and given a machine, it really seems to be a question of self-education. I'm still learning and have lots to learn.

I was given a mask without being told that there were different types, and the mask I was given turned out to be the wrong size. I struggled for two months with air leaks and a sore face before it was recognized that the mask didn't fit.

I guess it's the luck of the draw, some providers are helpful and give you alot of information in the beginning and others don't. You have to ask lots of questions, this site is great for getting information.

Frances (oops, just realized I haven't signed in, I guess I'll come up as "guest")

[dieselgal]

It really is ashame that the DME's have no regard for whether they are setting you up with something that will actually work for you. They could care less most of the time because they get the same amount of money no matter which unit you get. The only way to get what you want or NEED is to make sure your Dr. puts in writing that you MUST have a certain machine and then you still have to fight all the way.
They really take advantage of the fact that most of us know nothing about CPAP when we start out so its like taking candy from a baby. The truth is that just like everything else the almighty dollar becomes more important than your health.

[snoregirl]

If your prescription said Cflex, there is only one manufacturer that it could be Respironics. So your doctor ordered that machine specifically if the prescription said c-flex. As to what level of machine he specified if any, that is another story.

A Remrest (whatever that is) is not a Respironics with Cflex. Get a copy of that script from the doctor and read it yourself. The basic choices in Respironics are the plus (no useful data collection capability), the Pro M series or Pro2 (older version but fine) that is straight CPAP but collects useful data, or the Auto either M series or older "tank" model. Read the descriptions at our host site Cpap.com.

You should have a heated humidifier, not passover. Again see what the doctor ordered yourself. You may already own the passover as it is usually a purchase while the machine many times is a rental and will be purchased after you show compliance. If you do own the humidifier, keep it. The mask is also probably already yours.

Call your insurance company yourself and see what they will cover.

If your doctor ordered a Respironics machine with heated humidifier then get the DME to give what the Dr ordered. Especially if the insurance says (to you) that they will pay.

Or give back the machine and hand carry your prescription and copies of your sleep studies (get these from the doctor too) to the DME of your choice after getting a list of approved ones from your insurance co.

Also, check your deductable and copay. Make sure your are not paying out of your own pocket more than the cost of the machine of your choice online cash (no insurance). Aprox $700 for the top of the line machine and humidifier. If you are, then your insurance is really worthless and you can decide if you want to bother when you could order up cash, get what you want and have it here quickly.

[seamonkey21]

sound advice - many thanks. am waiting to hear back (left a message) from the sleep center regarding copies of the scripts and sleep studies.

hoping for the best, but expecting the worst.


Michael

[quote="snoregirl"]If your prescription said Cflex, there is only one manufacturer that it could be Respironics. So your doctor ordered that machine specifically if the prescription said c-flex. As to what level of machine he specified if any, that is another story.

A Remrest (whatever that is) is not a Respironics with Cflex. Get a copy of that script from the doctor and read it yourself. The basic choices in Respironics are the plus (no useful data collection capability), the Pro M series or Pro2 (older version but fine) that is straight CPAP but collects useful data, or the Auto either M series or older "tank" model. Read the descriptions at our host site Cpap.com.

You should have a heated humidifier, not passover. Again see what the doctor ordered yourself. You may already own the passover as it is usually a purchase while the machine many times is a rental and will be purchased after you show compliance. If you do own the humidifier, keep it. The mask is also probably already yours.

Call your insurance company yourself and see what they will cover.

If your doctor ordered a Respironics machine with heated humidifier then get the DME to give what the Dr ordered. Especially if the insurance says (to you) that they will pay.

Or give back the machine and hand carry your prescription and copies of your sleep studies (get these from the doctor too) to the DME of your choice after getting a list of approved ones from your insurance co.

Also, check your deductable and copay. Make sure your are not paying out of your own pocket more than the cost of the machine of your choice online cash (no insurance). Aprox $700 for the top of the line machine and humidifier. If you are, then your insurance is really worthless and you can decide if you want to bother when you could order up cash, get what you want and have it here quickly.

[Slinky]

If you are in the US you have a legal right to copies of your medical records. The full data, including graphs, from both your sleep study and your titration study (or a split night study if that is what you had) are a part of your medical records. You can just request them from the sleep lab or clinic (they may want to get permission from the sleep doctor) and they should be given to you w/no problems. They should run about 5-6 pages each.

Also ask for a copy of your order/script for your xPAP equipment from the ordering doctor. Again you have a legal right to it if you are in the US.

Call your insurance company. Ask THEM what your CPAP benefits are.

In MOST CASES the insurance companies do NOT pay for specific machines. They reimburse based on the HCPCS code. That code is the SAME for every CPAP machine, including autoPAPs. Thus most insurance companies are reimbursing the same amount for a bare bones CPAP as they are for an autoPAP. This can cut into the DME suppliers precious profit margin so naturally, rather than give you what the doctor ordered, a mid-range CPAP w/C-Flex, they've tried fleecing you w/a bare bones only straight CPAP.

IF your ordering doctor is NOT affiliated w/the DME supplier I would be quick to inform him that whilst your script was for a CPAP w/C-Flex capabilities this DME has deliberately given you a bare bones straight CPAP w/o C-Flex. Tell him also of the lack of progress you are encountering and ask if he would check your data (tongue in cheek) to see if your pressures or something need to be adjusted. Play your cards right if this doctor isn't affiliated w/this local DME and you just might get a fully data capable CPAP w/C-Flex at no extra cost.

You may have been sent to this local DME because they are the only local DME contracted w/your insurance but you won't know until you call your insurance company and ask.

It sure does sound like this DME supplier is one cheap sheister outfit. Just outta curiosity, turn your CPAP over and see what the serial number is. If the Respironics are like the Resmeds the first 6 numbers of the serial number are the year and month the machine was produced.

[Slinky]

Ha! The Rem in RemRest fooled me! As RG said, its not even a Respironics CPAP and C-Flex is a proprietary "name". You want to check too to see if your equipment order stated a "heated" humidifier. If so, you may well be able to complain to your insurance company about this DME supplier on all counts and possibly be able to return that passover humidifier for a heated humidifier.

Once you have a copy of your script in hand you may well have a case for filing a complaint against this DME supplier w/your state's equivalent of the business/medical licensing bureau. All states have them, they just go by different names from state to state.

Ha! The thought just occurred to me. Put a request IN WRITING and send it Certified Mail, Return Receipt Requested to this local DME supplier for a copy of your equipment script/order. THEY also have to legally honor that request. If they refuse to give you a copy of that original order from the sleep lab you have THEM by the short hairs. (All of this assuming you are in the US, of course). They are as legally bound to provide you w/copies of your medical records upon request as the doctor is.

[Guest]

biggest problem I see going with one of these "no-name" cpap machines from a local yocal DME is no one but your current DME may support it. Most of them are not going to give you the clinical manual for the machine, so if you need to make a change to settings you are pretty much screwed unless you want to PAY to get it changed. DME is not going to make any change unless the doctor gives them an order authorizing the change. Last time I went to the doctor for a visit (only because I felt bad for calling them asking for a new hypertension medication refill script) it cost me $85 bucks. I don't have coverage for preventative or routine visits, I only have major medical coverage. If I had to go back for every little change I needed on my machine that is what I'd expect to have to pay for that change. They are not going to call the DME for free. Then it may take weeks to get a change made. Gas isn't cheap, if you have to drive to your doctors office or to the DME it all costs money.

Buy an off-brand machine then you cannot come to a forum like this and find information about your Edsel cpap machine because not that many may own it. If they bought theirs from a local yocal, they may not have the manual you need either.

But that is totally different when it comes to a more popular machine like a Respironics, a Resmed or Puritian Bennett machine or even a F&P machine. Polaris is becoming more popular, if the clinical manual is available for it, it may even become more popular.

My opinion is: having the ability to program your own machine makes it more popular not less popular. the more popular a machine you get the easier it is to find support for it. I bet more than half the people that own a Respironics machine already know how to program it here.

as for your machine? Never heard of it, have no idea how to program it, know absolutely nothing about it. You need help with it? Bummer dude! (I think you catch my drift).

DME's are business, they are only there to make money. Insurance only pays the XXX dollars for a machine. That XXX dollar amount doesn't change if you buy a Hyundai or a Mercedes. They are only going to pay that DME XXX dollars for a "machine", they all have the same "bill code", the only way they get more money is if your disorder requires a special machine like a Bilevel, then they have a different code for that where they get paid more money, but their cost is also higher for that machine.

Now here is an example only (actual figures may not be accurate), but it is what happens: Let's say

-the DME knows they are only going to get $700 reimbursement from your insurance. It doesn't matter if they charge them $800, $1200 or $1750 for that machine, they are only going to get back $700.

Is the amount they charge your insurance company relevant? Could be, some people have zero copay or deductible, some have 20%, some have 50%. So if I the DME charge them $1200 and you have a 50% deductible they may collect $600. But if your insurance communicates like they should to you, you should learn your part is only $350 not $600, or 50% of what insurance actually pays.

SO they are out to make PROFIT. So if their COST on that machine they supply is $500 they are only going to make $200 profit when it is all said and done. Now IF their cost is only $300 for giving you a cheaper non-brand, plain jane machine (vs $500 cost), hey they now can make $400 PROFIT from your sale instead of only $200. Hey if you are not going to complain about the machine you got, this is a gold mine to the DME.

Now if you are the avg. patient that doesn't know any better, they can blow smoke up your rear end and say "your insurance won't pay for that". But you know what, they WILL, that more expensive machine has the very SAME bill code as that off-brand machine they gave you. If they gave you a Plus it would have the same bill code, if they gave you the Pro that gives sleep data, it has the same bill code, if they gave you the brand new A-Flex machine, it will have the SAME bill code.

Bottom line is: the better machine they supply you, the LESS profit they are going to make on the transaction. Same goes for a mask, same for a hose etc. To maintain that higher profit level, some are going to lie, cheat and steal to maintain those higher profits, they will tell you anything they can.

It IS a rip-off just as you say it is, it is a legal license to steal. You have to keep in mind that there are patients, sleep techs and DME employees that visit these boards, so disclosing their "secret" practices doesn't make you any more popular and may even get your message deleted by the latter if they can, but just know it is not the forumadmin.

Now CPAP.com, CPAPUSA, CPAP-SUPPLY etc. etc. are "online DME's". I don't put them in the same category as the others, because the difference is they are not hiding anything from me, they have their prices fully disclosed so I as a consumer know exactly what I am getting before I make my decision to buy.

Now if those DME's that charge your insurance $1200 for that machine if you have insurance, why can't they then only charge you $700 for that same machine if you don't have insurance? But they don't, if you walk in with a script for that machine, very FEW DME's will be honest with you and sell you that machine for $700 the same price they would get if you had insurance. IF you don't have insurance and you are paying cash, that means the DME doesn't have to jump through all the hoops of the transaction with paperwork, submit the bill to insurance then wait >120 days to see their money. You would think they would jump at that opportunity, no paperwork, no waiting, get the same amount right away.

Go ask a DME like Apria if they will sell you that same $1200 machine for $700 since you are paying cash, they will tell you no, can't do that. That is the price we charge insurance and we cannot budge from that price and Medicare reimbursement says we cannot charge less. Even though the price they actually get paid from insurance is only $700. Even if you know it, they say well that is the negotiated price we have with insurance, they say we have to charge them $1200 for it. Well then if you negotiate with them for a better price, why can't you negotiate with me, I'm paying cash? No paperwork, no waiting for your money.

But no, they will say insurance companies MAKE them do that. They say Medicare makes them do that. It is all BS if you are paying the bill without medicare or insurance. The system is severely BROKEN. The system is a racket, a rip-off, a legal license to steal, all backed up by doctors, FDA and even our government.

Now there are are a select few online vendors, they are DME's also, but I don't put them in the same class as the other rip-off artists. They may have 2 divisions, one that "plays by the rules" of those price protectionist practices (because they have to like Apria for medicare reasons), but they also have a separate division where they don't.

I can go to their other division and buy that same $1200 machine, not for $1200, not for $700 but maybe $580 and get the top-of-the-line machine, not some stripped down DME profit making machine. They sell it to me for a reasonable profit, they sell it to me at a price I know BEFORE I commit, I know exactly what I'm getting, I get exactly what I want, I get the manuals with it, so if I need a minor change, I don't have to spend $85 to get it changed. Online vendors like this are tits in my book.

Sadly though, I see them becoming under increased pressure, those same suppliers that supply them with cpap equipment to sell to me without all the hassles of insurance related transactions. I see them as getting pressure from the supplier because the supplier is under pressure from the racketeers that they are under-cutting their prices. First its jacking up prices by 40% or not allowing them to sell that product at all, next it may be removing software availability. What will be next?

This is all no big deal if you have good insurance, but even if you do, that is changing every day or at least every year when your insurance coverage renews, with higher premiums, higher deductibles etc.

But the proof is in the pudding. I have no fear of our host deleting this message and know they won't, but it may not be up very long because some DME members here may just find it as attacking, rude, nasty and/or valgur if they still have a Delete Spam button. But I'm pretty persistant, I'll just say it again until the system finally gets changed.

[Slinky]

Nah, SnoreDog. You didn't say anything in this post that SAG or anyone else would take offense to enough to delete.

[Brookbank]

I look at the bill rejected from my insurance company now that I know (kind of) what they are charging for and I am disgusted.

When I first received my machine I would have basically paid anything to get sleep equal to that experienced in the second half of my study (two hours of testing score of 95 - no question)

Anyway the DME billed soft costs - tubing, humidifer containers, carrying case, filters, etc (total about $500) - a mask - $330 for a full face ultra mirage - and then rental on the machine ($195) and on the humidifier ($65) - to get out of the door. Then the rentals continue at the $195 plus $65 per month. They waited three months to bill and the insurance company has placed the claim on hold pending additional information. Problem is that it will go against my deductible so I will ultimately be liable.

After learning a bit, my machine including the "softcosts" is less than $500 to purchase. The mask - which I never quite was able to get to work on a regular basis was much lower thatn the $330 (I have since purchased two out of pocket from my own funds which work great most nights).

Have not felt this bad since I bought a ford escort in 1981.

BUt better days are ahead and sleeping well!!

Good luck with our DME - there should be an education process before we are sold this equipment.

[Bookbear]

Seamonkey, under Federal law (HIPAA) you are entitled to a copy of your prescription and any and all medical records. The doctor/clinic/hospital has 30 days to provide you with them, and that includes your sleep study and any and all records of tests, blood work, etc. kept by your sleep doc, including his/her notes about your case. They are NOT the doctor's "property". They may charge a "reasonable" fee for making copies.

Insist that you be given those records. Do not settle for partial or incomplete records, missing pages, etc.

This link provides you with information and links to the relevent government documents. You doc/clinic may try to stonewall, but if you begin handing them the printouts of the documents, they will cave. They face some stiff penalties for not providing the documents and they know it.

http://www.privacyrights.org/fs/fs8b-MedFAQ.htm#2

Check with your insurance company to see if you can use another DME. Make them, and your own doc, aware that the current DME did NOT fill your doctor's prescription as written, if indeed the doc wrote c-flex on the Rx.

Best of luck to you. I hope you get this sorted out. Don't hesitate to ask questions here, there are many people with good solid information to share.

[Bamalady]

Good luck with our DME - there should be an education process before we are sold this equipment.

I agree.....BUT I think nobody wants us to be educated.

[seamonkey]

everyone,
many thanks for the well-organized advice - it will be very helpful for me.

i usually sound more coherent and less...well...crazy. but, as many of you can relate - i am very, very, very tired.

Michael

[Babette]

Oh Michael, Honey, we ALL understand the trials of being sleepy & cranky and trying to wade through the run-around. I at least am less sleepy & cranky in my 7th week, and ready to try again to go ten rounds with my DME and Doctor!

Hugs,
Barbara