Insurance / DME

[CiresWrossed]

So this weekend I received a letter from my DME which provided my original CPAP machine requesting that I pay them $2,200 for my CPAP machine. Apparently, they received notification from my Insurance company that pre-approval was not required. So they gave me the machine and I used it religiously for 5 months. However, my insurance company BCBS denied the claim they made saying it could not be made without pre-approval. Apparently BCBS admits they were incorrect to suggest pre-approval was not required in the first place. And since the submission for the machine was after I started using it.. they would not accept the documentation al. la. sleep study that it was a medical necessity. So the DME appealed and BCBS denied the appeal. Apparently now I must appeal this personally and until it is resolved I am on the hook for the $2,200 for that machine. To make this even more crazy about 5 months after I was given that machine I decided to establish a backup machine; so I bought a PR which is newer, better and much quieter -- and it's my primary and only machine I have used in the last 10 months. I packed up the old machine in case my PR broke.

So I'll know more of the details soon. But right now I can say...

1. If I must pay $2,200 for a machine that costs 1/4th of that online. That is crazy; what is their overhead.
2. I should have been more suspicious when they gave me the machine. I assumed they had the pre-approval completed. I should have asked for documentation. What if that machine would cost $20,000... I guess my bill would be $200,000.
3. Looking at the paperwork it appears BCBS actually did pay the DME a fraction of the amount the DME requested. About $400 of the $2,200 they originally billed. For some reason the DME hasn't subtracted that from the $2,200 they are saying that I owe.
4. I guess I will need to speak with the Maryland sleep commission.

I'll update this thread later next week once I know more about what happened.

Be careful out there, CW

[roster]

3. Looking at the paperwork it appears BCBS actually did pay the DME a fraction of the amount the DME requested. About $400 of the $2,200 they originally billed.

$400 is probably the amount the insurance company allows for that machine. They would never pay $2200. Call the DME and tell them the insurance company has already paid for the machine. Demand that they cancel the invoice and send you a copy of the credit or cancellation notice.

This billing could be the result of DME incompetence or it could be the DME wanting to see what they can get out of you. Don't take any s*** off of them and don't give them one penny.

[SleepingUgly]

Are you saying you got the machine 15 months ago (5 months you used it, then you got the PR 10 months ago, that's 15 months), and NOW the DME is saying you weren't approved to have it? What took them so long to say so? (Was there a 13 month rental period?)

You say BCBS is admitting they made a mistake in saying pre-approval wasn't needed. Does the DME have documentation that BCBS said you do not need pre-approval?

If BCBS paid one red cent, that suggests they agreed to pay for it. It's almost like post-hoc pre-approval.

No one thinks to ask for verification that pre-approval is necessary--that's the DME's job, who contracts with your insurance, so don't beat yourself up about that. Someone screwed up, it's not you, but now you need to hassle with it. Get on the phone with BCBS and try to get to the bottom of this. They may even have documentation that they told your DME that you didn't need pre-approval. The peon who answers the phone won't know not to tell you--just don't tell them why you are asking, if you can avoid it. Find out what they paid, and why they paid it if you weren't authorized to have it. Then get a supervisor on the line.

I wouldn't pay anything. Given that you don't even use the machine, in the worst case scenario you could return it to the DME.

[Patrick A]

Isn't this the same post?
viewtopic/t54588/Insurance--DME.html

[Emilia]

I have BCBS and they have an excellent online presence. You can access your account and see all claims, payments, etc. right there.... I'd do that first before talking to anyone!

[SleepingUgly]

Isn't this the same post?
viewtopic/t54588/Insurance--DME.html

Yes, we need to keep this content all in one place or our wires really will be crossed!

[Patrick A]

I have never had a problem with BCBS FEHB. I don't know about the types of BCBS. Also since I was put on Obamacare they pay even better now. Maybe because they are not getting stuck full bore anymore.

[elena88]

geez louise what a cluster you know what..

so sorry you have this screw up to unravel.

I also have bcbs, however everything is out of pocket until we meet our Godzilla deductable..

I was given a rental for an at home titration for a week.. THEY never told me how much that was going to cost.

then they gave me a system one auto Aflex and billed my insurance company... double what it would cost on line, and bcbs beat them down
to the negotiated rate which was a little more than the online price.. so they send ME that bill. I paid it IN FULL..

next, I trade in my machine for an s nine.. CLEAN SWAP, FAIR TRADE.. I dont owe them squat.. I was in the thirty day return time..

I gave them the system one, they handed me the s nine.. out the door I go.. I have already paid in full for AN APAP.. so I shouldnt be billed
for anything because we just swapped them.

A couple months later I get an EOB (explanation of benefits) from bcbs showing that they have been billed SEVERAL THOUSAND DOLLARS
FOR the s nine.. IM freaking out! I call bcbs, and I say.. what the hell is this about? They say, they did not negotiate the rate down on
this machine because it wasnt medically necessary.. "WTH????" i WAS so mad, I said, if they were going to bill me again, I wanted a credit for
the first one, and the negotiated rate for the second one.. NO, no special rate.. WHAT??? so I told them, I would return the machine to the DME,
and screw it.. I would live without.. ( this was the excuse I was looking for to bolt!) I know, my bad........
I later discover that blueshield would not negotiate the rate down, because it was my second machine.. I didnt NEED two of them in their opinion..
IM now livid.. I DONT have two damn machines, I have one, and I paid for it already!
I called the dme, and said.. WHY DID YOU BILL MY INSURANCE FOR THE SECOND MACHINE??? If you expect me to pay triple retail, IM returning it
right now.. and they said, I COULNDT RETURN THE MACHINE without a release from my doctor.. and I said fine, I will drive it over and dump it
on your counter, and you can worry about the paper work later.. Im not paying you three thousand bucks for this, and wheres my credit for the first one?
I then discover they were double billing, hoping bcbs would pay for it, but they didnt know I wasnt even close to meeting my deductable..
I HATE MY DME! I mean X DME.. BUT i think I have to use them to rent a bipap in two weeks.. ewwwwwwwwwww.
ONly because they work out of the hospital with my sleep doctor..
so, I would tell everyone.... if there is some snarky way that a dme can mess with you they will .. so ... spend that time youre waiting to fall asleep at night thinking of ways to preempt their shenanigans.. think of slimy, sneaky things, and then youll be in the right mind set to deal with a dme.
by the way, if your dme is not like mine, hallelujah ! youre lucky1

[Kevin G.]

elena88

You do not have to deal with the DME because it is associated with the hospital. It would be illegal for the doctor or the hospital to require that. Get a copy of your prescription and and go to another DME. Check with your insurance carriers regarding other DMEs.

If they are saying you cannot return the machine without the release from your doctor they are lying. They do not own you. Returning the machine while dramatic may not be in your best interests since they could claim the returned machine is used and has lost its value thus billing you for the difference. Or they could charge you rental rates.

Since you have a potentially messy situation I recommmend that you consult with an attorney to know where you stand before getting dramatic. Also ask the attorney whether the double billing is a case of insurance fraud.

I would get on the phone to the state agency that regulates DME's and talk to them about the statement that they cannot accept a returned machine without the docutors permission.

If they operate out of the hospital I would talk to the Hospital administrator and put the squeeze on the DME. Let your doctor know about your difficulties with the DME.

[SleepingUgly]

Can you sit on this until you get the bipap?

If not:

(1) If the DME is out of your doctor's hospital, see if you can get your doctor on your side and helping you. That is ONE advantage to using a DME that a doctor has an affiliation or close ties with, so if you have a good relationship with your doctor, use it to your advantage.

If #1 fails:

(2) Go to your DME's website and look up who their accrediting body is. Is it Joint Commission or someone else? The words "Joint Commission" scare the *@#% out of DMEs, and I assume another accrediting agency would have the same effect. Call the Joint Commission (or whoever) anonymously and tell them the scenario and ask them if that kind of treatment is of interest to them (especially the double billing). If they say yes, write a letter to the DME documenting what has transpired and threaten that if they don't do X (whatever reasonable request you have), you will file a report with the Joint Commission.

Do not do #2 unless you've got no other options (and you may want to deal with the bipap issue first) because once you've threatened this, you must see it through. And remember: never threaten this unless you already know JC is going to be interested in it--so call them first, anonymously.

[elena88]

thanks Kevin and sleeping ugly...

I did not know I could use another dme because the doctors exam room is right next door to the dme room.. thank you!
I too thought double billing was insurance fraud as well...

I did get to the bottom of it after seven more phone calls...

my machine was a clean swap! NOW, they are saying.. OH we just billed your an insurance company again as a favor to YOU..
so it would increase your deductable amount.. HOW can they do that? isnt that like making a pretend bill???

So my s nine is mine, I dont owe them a dime, but if I have to buy a bipap in a few weeks, I will have two new machines...

I guess I will use the s nine as a backup or give it to my husband to try... but maybe I wont need the bipap, maybe?


thanks for all your help. Im going to look into using another dme for that rental, I guess it will be ackward, but my doctor is really great,
and whatever makes me happy, makes her happy. I will just need a script for a bipap to rent one or buy one, the apap/cpap script wont work
I guess.

[SleepyRT]

Just a heads up for everyone that is dealing with a DME company they are unhappy with:

1. I'm the RT for a sleep DME company in Texas and there are a few things I give every patient the very first time I meet them. A copy of their prescription, their psg interp, the titration interp, and the Client Bill of Rights. Not only does this educate the patient but it lets them know that if for ANY reason they are uncomfortable with me or any of the staff, they have the right to move on. In the end its about your health so if your DME keeps dropping the ball contact another. Your physician's office will most likely have a few you can speak with.

2. If you are setup with a machine you are unhappy with (say you received an F&P and you would rather have the S9) please understand that in most situations there will be some type of charge. Most of the time the company is not just being a jerk and charging you for the heck of it. An S9 is a fairly expensive machine and really cuts into the profit margin. Actually when we set a patient up with that machine in particular we break even. I hope that doesn't sound harsh but people are sometimes uncomfortable with the fact that healthcare is still a business.

3. Be very leary of anyone that tells you they are going to even swap your WORKING cpap machine for a much more expensive model 5 (or 15??? not sure) months after you rec'd the original. The only time we do an even exchange for a machine after any type of time is if A.) the machine is broken or B.) the physician has called and ask the patient to be transferred from a straight CPAP prescription to an AutoPap prescription. You shouldn't be charged in that situation (and it shouldn't be billed) because we know up front the insurance company (most) will not cover another machine for 5 years unless the upgrade is to bi-pap.

Now something I tend to do is evaluate the patients interest. If I have a patient that is interested in the education we offer and provide, is educating themselves at home, has questions, and really seems interested in their new diagnosis I will start them with the S9. ONLY becasue it will offer someone with that kind of interest a little more data and when they call or come in for a download we can go over all their questions one by one. People who are more reluctant are still very high on our list but normally I have to call them to find out how they are doing, so a machine that runs quietly, maintains a pressure, and offers some type of EPR or ramp is normally good for them. You can get all of that (except EPR) in most standard machines they make today.

I know its a lot but one of the key parts of successful PAP therapy is your DME provider. At least thats what I believe and I try to impress on everyone else here . I know my vote is a little swayed Our complaince rate is about 80% right now and we want it higher. Last time I posted I picked up the term "Cpap Buddy" and I tell all of my patients thats how they should see us. Again, if you are dealing with a horrible DME, just move on. Of all the stresses a first year cpap user has, their DME should not be one of them.

[SleepingUgly]

SleepyRT, where in TX are you? I need a good DME for a relative.

[elena88]

SleepyRT"Just a heads up for everyone that is dealing with a DME company they are unhappy with:

1. I'm the RT for a sleep DME company in Texas and there are a few things I give every patient the very first time I meet them. A copy of their prescription, their psg interp, the titration interp, and the Client Bill of Rights. Not only does this educate the patient but it lets them know that if for ANY reason they are uncomfortable with me or any of the staff, they have the right to move on. In the end its about your health so if your DME keeps dropping the ball contact another. Your physician's office will most likely have a few you can speak with.

Wow, you give them all that AND bill of rights? That is a recipe for success and trust with your patients!
I decided I have had enough of my dme so I found another one who was closer, and has great prices, and will let me try on all sorts of masks,
and even LOAN me a vpap for a week, let me download the info, take it to the doc, and see what she says.. no charge for the loan!
I was NEVER allowed to try on any masks when I left with my first cpap machine, I was given one set of nose pillows, and that was it

2. If you are setup with a machine you are unhappy with (say you received an F&P and you would rather have the S9) please understand that in most situations there will be some type of charge. Most of the time the company is not just being a jerk and charging you for the heck of it. An S9 is a fairly expensive machine and really cuts into the profit margin. Actually when we set a patient up with that machine in particular we break even. I hope that doesn't sound harsh but people are sometimes uncomfortable with the fact that healthcare is still a business.

I understand the s nine is more expensive, but the doctor wanted me to have it, and the dme was making excuses whey I DIDNT need it right in
front of her, she finally said GIVE IT TO HER!

3. Be very leary of anyone that tells you they are going to even swap your WORKING cpap machine for a much more expensive model 5 (or 15??? not sure) months after you rec'd the original. The only time we do an even exchange for a machine after any type of time is if A.) the machine is broken or B.) the physician has called and ask the patient to be transferred from a straight CPAP prescription to an AutoPap prescription. You shouldn't be charged in that situation (and it shouldn't be billed) because we know up front the insurance company (most) will not cover another machine for 5 years unless the upgrade is to bi-pap.

I was given a resmed auto to titrate for a week, that was a rental. I liked the auto. I went back, and they were going to give me a cpap, and I said I want an auto, so they gave me a respironics system one auto with Aflex. I had it less than a month, it was making a tone I couldnt stand, driving
me insane, and the pressure pulses stopped me from sleeping.. and that function YOU cant shut off.. so this machine was not working for ME, its
great for most everyone else who isnt a shallow breather with R.A.D. and hyper sensitive hearing.. I did some reading, and decided I wanted the
S 9 auto.. and the DME SO did not want to trade for that.. but come on, I was suffering with the one I had.. I practically had to pry the new machine
out of his hands.. he gave in after the doctor got on his case.. That seems back asswards. I had hoped he wanted to actually HELP make my therapy
successful.

I realize eveyone has to make a living, I was on that end of retail for a while, but there is a difference between being greedy and fair.
My dme will not allow you to talk to anyone in the billing dept for forty eight hours, so if you have a question to return a mask, they hope its too late
by the time they get back you.

Now something I tend to do is evaluate the patients interest. If I have a patient that is interested in the education we offer and provide, is educating themselves at home, has questions, and really seems interested in their new diagnosis I will start them with the S9. ONLY becasue it will offer someone with that kind of interest a little more data and when they call or come in for a download we can go over all their questions one by one. People who are more reluctant are still very high on our list but normally I have to call them to find out how they are doing, so a machine that runs quietly, maintains a pressure, and offers some type of EPR or ramp is normally good for them. You can get all of that (except EPR) in most standard machines they make today.

I know its a lot but one of the key parts of successful PAP therapy is your DME provider. At least thats what I believe and I try to impress on everyone else here . I know my vote is a little swayed Our complaince rate is about 80% right now and we want it higher. Last time I posted I picked up the term "Cpap Buddy" and I tell all of my patients thats how they should see us. Again, if you are dealing with a horrible DME, just move on. Of all the stresses a first year cpap user has, their DME should not be one of them

Wow, to have a dme be an advocate, a teacher, someone who is there who actually cares and helps.. That would be a stress reliever! good on you mate

[brazospearl]

SleepyRT, HUGE congratulations on the good work you do with your clients! You and your organization are proof that treating people properly increases compliance. If all RTs & DMEs worked like you there would be many more well-rested cpapers. Thank you for the good work you do.

Where are you, specifically? We might be able to do business.