Insurance company stopped covering CPAP rental!

[joeattardi]

Hi all,

Hope everyone is doing well. I've been away from the board for quite some time.

I've been getting calls from my DME about an unpaid balance, one that was quite high. I logged in to BCBS to look at my recent claims, and was shocked to see that the last three were not paid. They list the following reason:

"Your Health Care Plan covers the rental of durable medical equipment up to the purchase price. Because the rental charges exceed the purchase price, or the purchase price has been paid on a previous claim, no further payment can be made."

I was never told this when starting CPAP therapy, and haven't found anything in my original paperwork stating this. What do I do? I can't keep paying the $90/month that the DME is charging me. I'll be calling them tomorrow but don't expect much help.

I hate the healthcare industry

[Emilia]

How many months did the rental go for? Usually BCBS follows the same rules as Medicare with 13 months rental and then it is yours. If, as you say the claim reads, the purchase price was reached, you should own the machine at this point. What was the original price for the machine, monthly rental premium, and do you see on their claim page an accounting for each and every rental payment?

It could be the DME is attempting to upcharge you.... which is illegal. You need to get a full accounting of the agreement, payments, balance, when the purchase price was reached, and settle this. I'd refuse any further payments to the DME until you are satisfied by all documentation.

[Janknitz]

Call your insurance company FIRST so you understand what the policy was. Many insurers do "capped rentals"--that means that once the rental period is over YOU OWN THE MACHINE. Kind of like "rent to own". If that's the policy of the insurance company, then the DME has to follow it. They can't keep charging you a rental fee forever, but they will try. That's why you must be armed with your insurance company's policy first, so that the DME can't play you for a fool.

My guess is that the DME is mistaken and it is a capped rental. If that's true and they persist in trying to collect unpaid rental fees from you, file a fraud charge through your insurance company and whatever state agency in your state oversees DME's.

[Slinky]

I'm guessing that this local DME provider is not contracted w/your insurance company so there is no contract setting the full amount to be paid.

Or they have a bozo or more in their billing department who don't know their fanny from a hole in the ground and figger they can buffalo the patients thru anything they want to charge.

[DaveLP]

I had a similar situation, also. I was with BCBS and changed to Cigna after 4 months. The original deal was 13 months and the machine was paid for. I began receiving bills and contacted Cigna to resolve it. They negotiated a payoff with the provider and I paid a percentage of that. Home Free!

There seems to be a disconnect in your situation. After two years with a CPAP because insurance and the provider wouldn't buy off on an APAP, I bought my own APAP. I should have done that in the first place, but at least I have a backup packed away just in case the new one fails.

Knowing what I know now, I would have negotiated strongly with the Dr, DME provider, and the insurance company to let me buy myown APAP and submit the bill for whatever they would contribute toward the machine of my choice.

[Roger2]

"Your Health Care Plan covers the rental of durable medical equipment up to the purchase price. Because the rental charges exceed the purchase price, or the purchase price has been paid on a previous claim, no further payment can be made."

Assuming by bcbs you are referring to Blue Cross Blue Shield they are usually very helpful in informing you that you are or are not dealing with a contracted provider. You need to establish that before doing anything else. If your provider is contracted with your insurance company then you are in good stead and can forget about paying them anything more. If they are not then bcbs should have advised you of that at the outset of your contract with them.

If the provider is not contracted with your insurance there is not much you can do. I would suggest you first call your insurance companies customer service provider to see what the providers status with them is. If they are a contracted provider then the insurance company should be helping you with this problem. If the provider is contracted with bcbs then you can probably get some help from your State Insurance Department and or your State Attorney Generals office.

Roger

[Ladelnutts]

I have BCBS as well and was told by them that they only pay to rent a machine for 10 months every 3 years. At the end of the rental period you can either return the unit or pay for it out of pocket. They do not have an agreement with DMEs that after the 10 month rental period that the unit is yours. The unit still is the property of the DME and it is the responsibility of the insured to negotiate the payoff of the machine or the terms of rental if you want to keep it.

The good side is that the DME really doesn't want to take the machine back. By this time it has been used for almost a year. Your best bet is just to keep saying that you will return it until. This gives you some leverage in the bargaining. I called a DME to rent a CPAP when mine broke and they said it would be $300 a month. Let's just say for giggles your insurance is only paying $150 a month. At the end of 10 months they have paid $1,500 for a machine that cost the DME roughly $500. The online price for the cpap I have is $740. I guarantee the DME didn't pay that much and even if they did they are doubling their money.

Good Luck!

[Emilia]

Let's remember that BCBS has hundreds of different plans, both HMO and PPO in every state of the union.... the OP will need to contact his insurance and determine what their policy with him says.

[Roger2]

Let's remember that BCBS has hundreds of different plans, both HMO and PPO in every state of the union.... the OP will need to contact his insurance and determine what their policy with him says.

That is quite true but bcbs also underwrites a Medicare advantage plan with a choice of an HMO or PPO option, which is governed by the criteria set by Medicare through a third party administration agency. All of the States have to comply with the same criteria and after a year of rental the insured owns the equipment unless he or she rejects it before the year. Neither the provider nor bcbs have anything to say about it.

The other plans such as those bcbs offered by many employers are different. Although my wife has Medicare she is still working and has bcbs through her employer which is primary over Medicare and her plan is a lot different than mine.

Roger

[Janknitz]

Joe, I want to make sure you did contact your insurance company. NEVER, NEVER, NEVER, EVER, EVER, EVER take a DME's word for what is covered or not! Do your homework.