Call Me: "Rockin Mama - Take II" (Update: RESOLVED!)

[ThomasMcKean]

They offered me an Escape today.

I told them NO, I wanted an Elite.

They told me NO, I can't have an Elite.

They were (at least) up front with me about why, the cost and insurance.... They also told me "You don't need to have that information." (That is direct quote!)

So I asked them what if I got a prescription for that particular device? (Which I don't think should even be necessary?) They said if I showed up with that then they MIGHT be willing to get it for me, if (IF!) I was willing to pay the extra cost in cash up front.

The advocate in me is telling me that may not exactly be legal...?

So...What are my options here? Do they have a right to say I don't need the Elite? Do they have a right to make me pay the extra cost? Do they have a right to refuse me and make me go elsewhere?

What exactly are my rights as a client in this particular situation? I know stem to stern what the rights are in situations I have worked with as far as others who have hired me go, but I am new to CPAP. What can I do, what can THEY do? What can I do when they don't do what they should do but won't do? *Blink*

HALP! *Blink*

[ChipsXJ]

i am no authority on insurance....but seems to me that I remember reading here somewhere that the DME bills the insurance a set rate for equipment............then the cheaper model they can give you the greater profit for them.

Others will chime in soon.

I would find another DME.

Good luck.

[SharkBait]

I'm in the same boat as I bought my own equipment...

I guess they reserve the right to refuse to sell certain equipment. Hopefully you have a choice in DME's. Sounds like they were at least honest about it. I can respect someone saying, "Hey, I'm running a business and the profit margin on that piece of equipment simply isn't worth my messing with it". I won't like that answer, but at least they were shooting straight with you. I own a business and there's certainly a price point at which I can't afford to license my product because it costs more than that price to support it.

Good luck.

[ThomasMcKean]

I'm in the same boat as I bought my own equipment...

I guess they reserve the right to refuse to sell certain equipment. Hopefully you have a choice in DME's. Sounds like they were at least honest about it. I can respect someone saying, "Hey, I'm running a business and the profit margin on that piece of equipment simply isn't worth my messing with it". I won't like that answer, but at least they were shooting straight with you. I own a business and there's certainly a price point at which I can't afford to license my product because it costs more than that price to support it.

Good luck.

That makes sense.... But only in the small term. I mean wouldn't they want my future business? If this CPAP thing is for life, then I will be coming back to them again and again and again (and again, even) for supplies and such. Or so I am led to believe. Wouldn't that give them business and profit?

[Catnapper]

I don't know this to be a fact, but I think that there is a contract between the DME and the insurance company on what is paid by insurance and maybe what the maximum the DME can get out of the patient.

I would try another DME if that is possible. If not, I would ask the insurance for clarification.

[ThomasMcKean]

I don't know this to be a fact, but I think that there is a contract between the DME and the insurance company on what is paid by insurance and maybe what the maximum the DME can get out of the patient.

I would try another DME if that is possible. If not, I would ask the insurance for clarification.

HELLO!!! DUH!!! Ask the insurance company! Yew know if I was not so tired from not sleeping since Monday night, I would have thought of that. THANK YEW! I will do that RIGHT NOW and post here in a bit. Maybe it will help Rockin Mama as well.

[nobody]

They don't want to give you that one because it costs them more. The insurance pays the same amount no matter what machine you get. If your insurance allows you to use another DME, you could try suggesting you might take your business elsewhere if you don't get the machine you want. Some insurance only works with one DME provider, though. Alternatively, if you have a doctor willing to help you out, you could get a very specific prescription for what you want and I don't see how they could refuse. Just make sure they don't pull a fast one on ya by telling you it's one thing but giving you another.

[Babette]

1) Get your script written to your specifications.
2) Fax it to https://www.cpap.com
3) Buy the machine you want
4) Send invoice and claim to your insurance.

PWONG! Yer done. Less headache, more good sleep time.
Babs

[Wulfman]

FIRST......Make sure you have your prescription (physical piece of paper) and hang onto it......it's good for "life".
You've got two alternatives.....find another DME that won't lie to you.....or buy your equipment online (like from CPAP.COM).

Personally, I chose the latter.....four years ago......and haven't regretted it.
(my insurance provider also reimbursed me for 80% of the cost of the equipment)


Den

[ThomasMcKean]

FIRST......Make sure you have your prescription (physical piece of paper) and hang onto it......it's good for "life".
You've got two alternatives.....find another DME that won't lie to you.....or buy your equipment online (like from CPAP.COM).

Personally, I chose the latter.....four years ago......and haven't regretted it.
(my insurance provider also reimbursed me for 80% of the cost of the equipment)

Talking to very cute sounding girl "Mandy" with the insurance company as I type. I will report here soon....

[ThomasMcKean]

UPDATE: Very cute sounding girl Mandy may well be a very cute BLONDE because she is not understanding me. She seems to think DME is denying my insurance for ANY CPAP.

Stay tuned...

[Slinky]

Start at Square 1. Call your insurance, ask what local DME CPAP suppliers they are contracted with. You might have to wander a little further afield than you would like - but it could well be worth it to get a fully data capable CPAP.

As an aside: how much extra do they want for the Elite over the Escape they want to provide? Get this supplier to provide you w/the entire nitty gritty on paper, billing amounts, your copays, etc. for a complete set up and individual items so you can do a fair comparison. Both for the Escape II AND for the Elite II.

Unfortunately, you can't run a true comparison at cpap.com because cpap.com doesn't have the Escape II listed, only the S8 Escape. It wouldn't hurt, however, to call cpap.com and ask if they have an "unadvertised sale price" on their Resmed S8 Elite II w/EPR complete bundle and just the Elite itself as well. Their advertised price for just the Elite II is $695, w/Humidaire 3i $795 or w/H3i AND software and cable reader $995.

Heck, you might even want to price shop the Resmed S8 II AutoSet online.

Do you know the reimbursement method thru your insurance? Do they pay 100%, 80%, what? Do you have secondary insurance that will pick up any copay? It might be worth your while to consider paying out of pocket for just the Elite II and getting the rest of your supplies from this local DME - maybe. You have to look at this from all angles. A PITA - but to get what you want - which is NOT unreasonable ....

Ask your insurance if they would consider you "in network" and reimburse you if you purchase your equipment out of pocket and submit a bill including all proper coding.

[jules]

I believe Thomas is dealing with Medicare.

[Wulfman]

FIRST......Make sure you have your prescription (physical piece of paper) and hang onto it......it's good for "life".
You've got two alternatives.....find another DME that won't lie to you.....or buy your equipment online (like from CPAP.COM).

Personally, I chose the latter.....four years ago......and haven't regretted it.
(my insurance provider also reimbursed me for 80% of the cost of the equipment)

Talking to very cute sounding girl "Mandy" with the insurance company as I type. I will report here soon....

What I did, after I got my equipment from CPAP.COM (charged to my credit card), was to use the invoice from them and made up an invoice TO my insurance provider (the party being billed)......FROM "me" (the party doing the billing). Since I'm considered "in-network" by them, they reimbursed me at that rate. You would probably need to check it out with them first, but many insurance providers will do it that way. They usually won't pay CPAP.COM directly, because they would be "out-of-network" and CPAP.COM is a "Cash sales" business, so you'd have to charge the purchase to your credit card first.
If they're resistant to it, tell them that you can save them money by doing it this way.

Den

[SharkBait]

I'm in the same boat as I bought my own equipment...

I guess they reserve the right to refuse to sell certain equipment. Hopefully you have a choice in DME's. Sounds like they were at least honest about it. I can respect someone saying, "Hey, I'm running a business and the profit margin on that piece of equipment simply isn't worth my messing with it". I won't like that answer, but at least they were shooting straight with you. I own a business and there's certainly a price point at which I can't afford to license my product because it costs more than that price to support it.

Good luck.

That makes sense.... But only in the small term. I mean wouldn't they want my future business? If this CPAP thing is for life, then I will be coming back to them again and again and again (and again, even) for supplies and such. Or so I am led to believe. Wouldn't that give them business and profit?

Absolutely. As with 99% of medical supplies/equipment the mark-up on this stuff is huge. I don't know if it's as huge for the retailer as it is others in the chain. I read that some DME's pay about the same for CPAP's as what we pay CPAP.com. This might be B.S., but I certainly hear the same thing from a friend of mine that owns a golf shop about clubs he sees selling on line...

I wasn't saying that line of thinking was rational thinking. It's up to them, but yeah, I could certainly see it being in their interest to give you the machine you want even if it's at cost. As Gillette made famous -- "Give away the razor and sell the blades!!!".