My Nightmare with the DME

[socalmonkey]

If I can ever get through this nightmare with my new DME, I am going to be getting a new data capable machine. I have great new insurance, and they'll pay for 100% as long as the DME is in-network. So the new in-network DME told me the other day, that my claim was denied because the sleep study was missing a couple things. Upon talking to the insurance company, they said no claim has been presented or denied. The DME now admits it was there billing headquarters that said the Sleep Study was missing things and it would be denied. But I was told that it "was denied by my insurance"... when in fact nothing was ever "denied".

To make a long story shorter... after days of going around and around with the sleep study people... and finally getting them to send the complete study (which turns out there is no such thing)... so they faxed the technician notes. Well now the DME tells me today, they contacted my insurance, to show them the sleep study, to make sure they will accept it and are waiting for a call back. I have the study... there is nothing really missing from it. Why they didn't just submit it for pre-approval in the first place is beyond me.

So this sleep study (my 2nd one) was done on Memorial Day weekend... so that shows you how long I have been pressing to get this done. First, it was getting the script from the doctor, then all this needless delay. So I am hoping to get all this cleared up this week so I can get a new data capable machine. But what a bunch of junk to go through in dealing with doctors, insurance and now the new in-network DME (not that my old DME was any better - because they were horrible - you know the ones that name starts with "A").

So here is hoping for the best to get this mess resolved! It really is a pathetic system, and a wonder that any of us, ever get our medical needs met.

Thanks for listening to my rant.

[Wulfman]

Check with your insurance to see if they have other in-network DMEs that you can use or ask them if they will reimburse YOU for an out-of-pocket purchase (buy it online from CPAP.COM and bill your insurance provider)......because it will be a lot cheaper for them to reimburse you (assuming you're in a position to purchase out-of-pocket, temporarily) .
Also, tell them that this DME is lying to you and suggest that they be taken off the in-network list.

You don't have to put up with that sort of thing.


Den

[BleepingBeauty]

Sorry to hear your tale of woe, but I can relate. I got the same runaround from my DME when my doc wrote a scrip for a data-capable machine last year. DME told me flat out that my insurance wouldn't cover it (I had an M-Series Plus at the time). Insurance said it never received a request, so it wasn't approved or denied by them. Also said the doc needed to request authorization. The doc told me my scrip was my authorization. So the Doc never submitted the request, DME never submitted the scrip, and insurance knew nothing about it. And, of course, I never got a data-capable machine.

I have no choice in DME (this is the only one contracted with my insurance), and they hassle me every six months, when I'm due for a new mask. If I could afford to never have to deal with them again, it would be a happy day. (If my insurance would reimburse me for purchases online, I'd abandon my DME in a NY minute.)

It's amazing to me that these DMEs, whose purpose is supposedly to help the patient achieve effective therapy, make it so incredibly difficult for us to get what we need from them. There has to be a better way...

P.S. Did you make an error when you said this has been going on since Labor Day? I hope you meant Memorial Day, although it wouldn't surprise me if you really did mean Labor Day, with the way this process goes.

Good luck.

[socalmonkey]

Check with your insurance to see if they have other in-network DMEs that you can use or ask them if they will reimburse YOU for an out-of-pocket purchase (buy it online from CPAP.COM and bill your insurance provider)......because it will be a lot cheaper for them to reimburse you (assuming you're in a position to purchase out-of-pocket, temporarily) .
Also, tell them that this DME is lying to you and suggest that they be taken off the in-network list.

You don't have to put up with that sort of thing.


Den

Thanks those are all good ideas. The other DME in-network is the "A" one... and I refuse to go to them. Insurance will not reimburse me and my plan pays nothing for "out of network".

I will get this done... it just takes persistence. But it's like they try to discourage you from buying from them. What a racket!

[Muse-Inc]

You have my sympathy.

I wasted 4.5 hrs today trying to find a local DME that handles CPAP masks (I get all from my stuff from my sleep doc but he does not carry the Hybrid anymore only Liberty but he'll write a script for me). So call insurance for list of in-network DMEs (was told our host is not in-network). Call the DMEs she's given me, none handle apnea supplies & most sound like nincompoops. Call insurance back and ask now what? She points me to the website list of DMEs who are in-network. I've now called 25 DMEs without success...this is Atlanta and none handle CPAP supplies, what's wrong with this picture? Locate website for RespCare & cust serv phone number, describe my situtation, ask for all its dealers, we find it on website (I was on sister site without the list); nice chat with those folks. Call insurance company, get lost in the phone tree, keep pressing "0" eventually gets me a human. Insurance person starts calling the DMEs whose name looks like they should be listed as in-network -- this takes forever but we finally get a hit. On the insurance website this DME is listed only as their corporate address...nowhere near me, 'so sorry' says insurance gal. She calls DME and we get Billing...billing? Anyway, yes they handle CPAP so insurance gal hangs up and I get transferred to CPAP guy. He says he thinks the branch office has the Hybrid in stock...it's now after 5 pm and they are gone, so I get the details of what he needs...he needs the page of my sleep study that shows I had apneas and how many, etcetera...why? He says that insurance demands it, I say insurance has already noted the new mask as part of my scheduled replacement-maintenance. That's a huge report, hope my doc or his office folks know which page that is. So tomorrow CPAP guy is supposed to call me back and let me know if they have it in stock. If so, gotta call doc with FAX # and what the DME needs...then, afte they get hte FAXes, I can go get the mask. Makes me wanna just go with the Liberty but that mask looks a heck more complicated than the Hybrid and ya gotta order 2 to have all sizing options *sigh* and that means fighting with insurance.

This should be easier.

[socalmonkey]

P.S. Did you make an error when you said this has been going on since Labor Day? I hope you meant Memorial Day, although it wouldn't surprise me if you really did mean Labor Day, with the way this process goes.

Oops! You're right, I meant Memorial Day weekend. (I corrected that) Thanks.

[socalmonkey]

The nightmare continues: more back and forth with DME and sleep study people. DME lies to me again and says insurance denied it again and won't approve it! Called insurance company at lunch... same story, they have not denied anything, because nothing was submitted. So I submit all the information to insurance for a "notification" approval.

Then later today, in the mail, is a list from the DME of equipment they can provide. The first machine I originally asked for is on the list (when they told me it they didn't carry it). But the A-Flex machine (I now want) was not on the list. They only carry the Plus C-Flex machine. More phone calls. They confirm (if I can believe anything they say) - they do not carry the A-Flex model and claim they can't provide it.

So back to the insurance company. More calls to DME's. No luck. Most phone numbers disconnected or nobody answers or they don't even know if the carry CPAP (actually had one tell me that). The main DME provider for the insurance company... is the "A" word company. The one I was trying to avoid (from a past bad experience). I gave in and called them. They can provide me with the exact A-Flex machine, mask model and humidifier model I want. BUT... (like many here have run into) they must have the specific machine on the prescription! No way around it... they said it's the only way to get the machine I want.

Back to the doctor. More calls. I even went in person and dropped off a letter with the exact specification. Now, waiting for a response. I have a long relationship with the PCP, so it should not be a problem. But then again, I never dreamed this could all be such a nightmare!

[DoriC]

Socal, I can't tell you how sorry I am for all you're going through. It is so hard to believe because way back when my husband was due for his first replacement mask and we wanted the same UltraMirageFF, the DME told us they don't carry that mask anymore and we'd have to take the "upgraded" Quattro which we had already tried and never worked for him. They said they couldn't do a special order for us. I called Medicare and they said DME had to provide the mask of our choice . Without my even asking, the lady said she would take care of it. That same afternoon, I got a call from the DME saying that they would have a new UM for us the next day. Stay strong, Dori

[Muse-Inc]

Your story is just an onging series of things gone wrong! I wish you a good outcome.

In my case, the DME's CPAP guy called me back and said they don't have any Hybrids in stock (the one he remembered is the one they show folks) but he's gonna check and see if they expect some <they don't have computers that track inventory? >. I told him I decided to just wait on a mask until sleep doc analyzes data from APAP loaner and oximeter and then decide what the next step is; I did ask him to check when they are getting the Hybrid back in stock & we chatted about chin straps. Turns out he's a fellow hosehead...of the Respironics variety; he wasn't sure of the difference in ResMed's current 2 autotitrating flow generators <why am I not surprised?>.

Meanwhile, returning to CPAP last night was not fun, besides being anxious over events *sigh* I couldn't get comfortable... ya know the drill: too warm, toss off covers, too cool, cover up and stick foot out, foot gets too cold, change sides, scratch itches, re-adjust pillow for the umpteenth time, turnover, now foot itches, sit up and take care of foot itch, linens are too warm, lie back down and now pillowcase has wrinkle I can feel that's gonna leave a mark, and on and on. Finally feel asleep sometime after 3:30 AM, slept late, had events, pressure felt too high again, and I woke with aches in lower ribcage area that had disappeared using the APAP...must be a body guarding thing. When I woke up, my mouth was slightly open & dry dry dry...first time I've noticed open mouth...maybe just a chinstrap will work instead of mask change.

So now I wait for sleep doc to call after he's done analyzing the printouts. Then, we can talk device & software & card reader & recording oximeter as medical necessities (we can at least talk ), talk chasing leaks, talk about how often he wants to see data (maybe I can email them to his office).

[socalmonkey]

... I woke with aches in lower ribcage area that had disappeared using the APAP...must be a body guarding thing.

That is interesting. My lower ribcage aches too. I never thought the treatment could be the cause. But it makes sense. It will be interesting to see if mine clears up with APAP.

Sorry to hear all your trouble too. It's unbelievable that this is so hard. The system is flawed. It needs to be reformed.

[stephiemarie78]

I recently had the same problem. My dr sent a script over for a RemStar Auto and was told flat out they could not give me this machine.

Basically what it breaks down to the national contract your DME company has with your insurance provider. You insurance may pay 100% but they set that price with the company. So different DME will have different prices contracts. So say all CPAPS are coded with a certain number, Bipap/Vpaps another number, Bipap St another number. Depending on were your cpap falls they get xx amount paid to them from your insurance company no matter what type of cpap it is. So if they aren't going to make much money in reimbursement for that cpap they will tell you its not covered.

I didn't give up and pressed on till I found out what other cpaps that were an auto and full data that they would give me. I ended up with the ResMed VPAP Auto 25!

[lktnky]

Meanwhile, returning to CPAP last night was not fun, besides being anxious over events *sigh* I couldn't get comfortable... ya know the drill: too warm, toss off covers, too cool, cover up and stick foot out, foot gets too cold, change sides, scratch itches, re-adjust pillow for the umpteenth time, turnover, now foot itches, sit up and take care of foot itch, linens are too warm, lie back down and now pillowcase has wrinkle I can feel that's gonna leave a mark, and on and on. Finally feel asleep sometime after 3:30 AM, slept late, had events, pressure felt too high again, and I woke with aches in lower ribcage area that had disappeared using the APAP...must be a body guarding thing. When I woke up, my mouth was slightly open & dry dry dry...first time I've noticed open mouth...maybe just a chinstrap will work instead of mask change.

Thanks, Muse-Inc., for a great description of my bedtime ritual. I needed that laugh!

[jdm2857]

Muse --

Sure you don't write for Jerry Seinfeld?

[Muse-Inc]

...great description of my bedtime ritual. I needed that laugh!

Gee, glad I could be the source of some amusement...we don't chuckle enough far as I'm concerned.

Sleep doc's office called to tell me my insurance says 6 mos for replacement, I say not replacement more complex mask for therapy as I can't use pillows anymore 'cause of mouth leaks...staffer agrees this change is a 'medical necessity' and will have doc write it on Rx and she'll FAX it to the DME and I give her CPAP guy's name; I ask her to xfer me to scheduling. I ask for next available appt or cancellation & why, then apologize profusely for being a first-class *itch last Thurs when I realized I was gonna have probs with initial pressure set to 4, she thanks me as if no one ever does that <maybe they don't, I do 'cause I know I'm difficult to deal with when acutely stressed...apologies go a long way to helping the other person realize they did no wrong in the interaction, all my problem>. She tells me she's got an appt tomorrow (Fri). I'm so excited! An hr later, I call CPAP guy and he's already got the FAX plus the diagnostic sheet from my PSG..wow..is my sleep doc's staff efficient or what! The DME has the mask on order, he'll check to see if wait is like a wk or a month...the sooner, the better for me as I'm breaking that mouth seal and losing CPAP air, the hiss wakes me up repeatedly and even tho I close mouth and lips and fall asleep immediately, it's still fragmenting my sleep -- taping is NOT an option. He's gonna check on their replacement policy if I can't handle the Hybrid & hafta try the Liberty. Doc's office wrote medical necessity to get a new hyrid-style mask in the script so that should cover either one.

MY DME nightmare so far has been finding one that is 'in-network' with my insurance (hundreds of DMEs here , 99.9% don't handle apnea supplies <why so few here?>, they handle infusion/mobility/prosthetics, etc ). My DME experience might change depending on how getting the mask goes . They are at least local, well, within 30 miles and for Atlanta, that's local.

Meanwhile, I'm excited! Maybe he'll let me have the ResMed APAP cause the CPAP's steady pressure isn't so good for me...aches in lower ribcage are fierce now and radiating around to the back like when I first started CPAP and I'm breathing shallowly again after just 2 nights! No more breathing almost naturally now that I'm back on CPAP...I miss that, it made xPAP therapy much easier. Will be making my case for an Rx for software and card reader to track leaks and optimize my xPAP therapy...gotta go write up notes. If I'm successful, notes will be for sale (will stretch my unemployment)

[ricochetv1]

I wish everyone could have the experience I've had with my doc, insurance, and DME.
First, my insurance has no limits for DME supplies. They have no specific timetable of when I can get what. As long as I don't show a pattern of equipment abuse, they don't care.
My doc was more than happy to specify my shopping list on the scrip, the DME called me the next day, and gave me no crap about it. They'd already authorized it through insurance and I'm having it delivered the evening of the 21st.
They have respiratory therapists on-staff, and they were glad to see that I'm getting good equipment, support mask changes whenever I need them, etc.

I was a bit scared about dealing with the DME from the comments I've seen on this board. When I had my experience I almost yelled, "Thank G-d!" out at work.

So, provided they continue to be a good company to deal with, I highly suggest finding out if Ivedco is in-network for your insurance. It looks like they're just a local Dallas company, though, which is a shame, unless they're willing and able to ship stuff around. Maybe they're the exception that proves the rule? I don't know. Haven't had any experience with DMEs beyond this.