Stupid Insurance Tricks

[darthlucy]

So I got my equipment on 6/22, and went to my insurance web site to see just how much the DME had raked them for. They billed $1500 for the S8 Elite (of which insurance paid $818) and $350 for the humidifier (of which insurance paid $241). There were three additional billed amounts that were not paid at all. I called the insurance company to get more info, and found that the DME billed $199 for my Activa mask, $64 for the headgear (as if that's a separate item!), and $59 for the hose (as if that didn't already come with the CPAP!). The really beautiful thing is that the insurance company told me that my policy doesn't pay for "supplies," which these items are considered to be!

My first fight was that I had specifically called and asked what was covered, before I got everything, so I would know not to let the DME hose me (pun intended!). The kind lady I spoke to on 6/15 told me everything was covered, no deductible, no copay. I told the guy this today, and he checked back on the call logs and found I was telling the truth. Yea for me! He said he'll resubmit the mask based on the fact that I was given incorrect information.

Ok, one battle down....for now...until/unless they continue to deny the claim. At which point I guess I'll have a fight with the DME. And at which point I'll return my $263 Activa and $59 hose and re-purchase them myself elsewhere.

So I asked to clarify that my policy will not cover any masks in the future? That's correct, he says. I then asked him how they expect patients to actually use this machine; how do you expect me to get the air from the machine to my face without a mask? Or did you just intend on buying this rather expensive door stop for me? They expect that patients will pay for masks themselves. Ridiculous.

Good thing we have cpap.com and ebay, I guess!

Anyone else have a stupid policy like this?

[snoregirl]

Well as depressing and annoying as it is that your insurance won't pay for supplies, consider that many of us don't even use our insurance for that stuff because by the time enough is bought to cover the deductable there isn't any more benefit, so the insurance, while it "covers" is worthless.

So try to be happy that you paid nothing for the actual machine and buy what you need at Cpap.com.

I know it is hard to look at it that way, but most insurance stinks, and that is unfortunately the way it is.

[john44077]

Back in March when i got my first cpap machine, a Fisher and Prikel basic cpap. That the insurance company paid for the humidifer unit. THen June 1 when the DME took the machine back from me when i lost insurance. That they wanted the humidifer back. I said wait a sec. I said to the DME biller that there crazy in the first place since on that unit, the humidfier is built into the bottem. DId they want me to just return the top of the unit and that i hope i dont break anything. I said since the bottem/humid part was paid 100% by the insurance, it was mine. Amazing how i have not heard from them about my 3 month rental charges of $33 x 3 months.

[darthlucy]

[quote="snoregirl"]Well as depressing and annoying as it is that your insurance won't pay for supplies, consider that many of us don't even use our insurance for that stuff because by the time enough is bought to cover the deductable there isn't any more benefit, so the insurance, while it "covers" is worthless.

So try to be happy that you paid nothing for the actual machine and buy what you need at Cpap.com.

I know it is hard to look at it that way, but most insurance stinks, and that is unfortunately the way it is.

[rested gal]

Anyone else have a stupid policy like this?

A couple of years ago I gave one of my autopaps to a struggling single mom with kids. Her insurance covered diagnostic tests...covered her having a sleep study that showed she had severe OSA...but had NO coverage for "Durable Medical Equipment." In other words, didn't even cover letting her get a machine, much less a mask or anything at all.

So, yeah. There are some really unhelpful policies out there.

And millions of people who don't have any insurance at all.

I don't mean that your policy's lack of coverage for certain things is any less of a problem for you. Has to be frustrating after you've paid premiums for so long. I'm glad you got a machine out of it, at least.

[CarrieS]

Geez Im glad I have good insurance we pay a pretty penny a month but at least hubbys emplyer covers our deductible. So far I havent had any issues with bills but then again I havent heard anythign so I hope our insurance is as good as I think it is.

[Jirel]

I was very surprised that my insurance covered EVERYTHING (except the doctor's visit) with no copays. Then I was shocked when the DME told me that the CPAP was bought outright by the insurance company. Yeah, I OWN my cpap! I can't get a new filter until I've used it for 6 weeks, but I'll live with that.

Of course, that doesn't stop me from paying $100 a month on perscriptions and around $400 a year in doctor co-pays (if nothing unusual happens) but hey, at least I have insurance. I shudder to think what is going to happen when I go on medicare.

[Susanm]

Medicaid has some pretty stupid aspects to it also ... I lost my coverage about 3 days after I found out I had OSA. Medicaid rents a machine for 10 months, and then it is considered paid for and it belongs to the patient. So I got one month rental. The DME (Advanced Services) is charging $119.43/month for the basic machine. I think our host here sells that machine for about $650, so the DME is making a nice profit on that. Now here's where the really stupid part comes in ... Medicaid paid for the heated humidifier (which I didn't ask for and don't use) outright @$390.00. So I own a really nifty paperweight. I got my mask from the sleep center, and that was paid for in full as well, and it was also rather pricey. With what Medicaid wasted at the DME, I could have bought a nice little low end setup here at cpap.com.

Now we all know why premiums are so high ...

Susan M

[Treesap]

I paid $114 for my part of the machine. The insurance paid for the rest. Today I called them to see what insurance would pay for hoses and filters. The insurance pays 80% for those. I can only get a filter every month, and I can get a hose every 3 months. The 20% for the hose is $10.78!! That means they charge my insurance $53.91 for the darn thing! That is a huge ripoff! I think I will just buy the items myself and use them as tax deductions.

I know the insurance company deducts a certain amount before they pay; I wonder how much it is.

[Guest]

Fortunately my wife still works and has health insurance. Whatever her insurance doesn't cover Medicare does. It cost's me absolutely ZILCH. I hate to even think about her retiring.

[darthlucy]

Anyone else have a stupid policy like this?

A couple of years ago I gave one of my autopaps to a struggling single mom with kids. Her insurance covered diagnostic tests...covered her having a sleep study that showed she had severe OSA...but had NO coverage for "Durable Medical Equipment." In other words, didn't even cover letting her get a machine, much less a mask or anything at all.

So, yeah. There are some really unhelpful policies out there.

And millions of people who don't have any insurance at all.

I don't mean that your policy's lack of coverage for certain things is any less of a problem for you. Has to be frustrating after you've paid premiums for so long. I'm glad you got a machine out of it, at least.

You're absolutely right, RG. I really am grateful for the coverage I have, and I'm not complaining about having to pay a portion. For me, the annoying thing is the ridiculous billed/paid amounts, and the illogical decision on the part of the insurance company to buy the machine outright right off the bat, and not to buy a mask. If I didn't have the resources to buy my own mask, they would have purchased me a $1000 doorstop.

[tillymarigold]

My insurance company's stupid policy is that patients with UARS are considered to not need treatment. Period.

I have to pay everything out of pocket until I someday have another sleep study (also out of pocket) that shows an AHI above 5. Not sure if I'm hoping that day will come or not.

[darthlucy]

[quote="tillymarigold"]My insurance company's stupid policy is that patients with UARS are considered to not need treatment. Period.

I have to pay everything out of pocket until I someday have another sleep study (also out of pocket) that shows an AHI above 5. Not sure if I'm hoping that day will come or not.

[tillymarigold]

My insurance company's stupid policy is that patients with UARS are considered to not need treatment. Period.

I have to pay everything out of pocket until I someday have another sleep study (also out of pocket) that shows an AHI above 5. Not sure if I'm hoping that day will come or not.

Ok, so maybe this is wrong, unethical, dangerous, fraudulent, impossible, or all of the above, but I couldn't help but wonder if it's possible to fake a sleep study. Like pretend you're sleeping and hold your breath every once in a while to get the results you want?

Sorry to make light of your situation, it really stinks!

Oh, don't think I haven't thought of it. But no, at the PSG they can tell if you're actually asleep or not due to muscle tone and brain waves. My PSG did record two apneas (which would have pushed me over into OSA instead of UARS, I was just below the line) but they weren't counted in my results: they were the time at the start and the end when the tech asks you to hold your breath to check everything's working.