is this a scam?

[DebMA]

i've been on cpap therapy since last november. since it's been almost a year, today i called my insurance co to verify that i had met my deductible prior to ordering some new supplies. i have had the same mask, tubes, headgear, etc for 11 months, and i decided to treat myself to some new pillow (even though i don't really need them - mine have had a freakishly long life so far!) if i had met the deductible already. i had a really nice conversation with a polite, helpful representative. during the course of the conversation, she mentioned that it was "strange" that my DME had not billed since july; that their policy is that after ten months of "rental", the cpap becomes mine, and that during the "rental" period, the DME is required to submit compliance data with each bill to the insurance co. the rep said that she would have expected a bill from august, which would have completed the ten month rental period.

guess what?

my DME has NO compliance data from me since january. they have only requested my data card once! (as an aside: the pulm who did my sleep study and prescribed my cpap machine retired the month after i began treatment, and did not give any notice; the practice did not replace him and they did not have any suggestions for a new dr for me...so all of the treatment he planned - three and six month follow up appointments, review of my therapy etc, never took place either. my gp is checking for another practice that meets my needs, but right now i technically don't have anyone overseeing my treatment.)

i had to cut my conversation with the insurance company short today; is it worth it to follow up? is it possible that the DME is falsifying data to the insurance co? or did i misunderstand/was the rep misinformed regarding the frequency of compliance data reporting (maybe it's only once during the ten months)?

thanks!

[Lizistired]

My DME asked for my card at about the six month mark. He said they just ask for it whenever. I would contact your sleep center and get copies of your reports, condensed graphs and prescription if you don't have them already. My prescription expires at one year. I wouldn't worry about the follow ups if you haven't needed to see him. Your GP can write you a new prescription. It sounds like the therapy must be working for you.

[GumbyCT]

is it possible that the DME is falsifying data to the insurance co?

Certainly, anything is possible in this sleep business.

IF you aren't having any problems you are prob better off not having any follow-ups. You can get all the help you need right here.

[jules]

11 years ago I was in the hospital for pulmonary failure. During a couple days they didn't take my blood pressure. Finally after a 36 or so hour lapse since the last reading they had the gall to wake me up at midnight to take it. I complained the next morning about it to the RN in charge. She said there were readings - I said they weren't real (all these nice 120/70's it seems). Some aide got fired I hope for it - I know she got bawled out big time - oh she also rifled my stuff between the time I talked to the RN and the bawling out in the hall took place. I complained about the rifling too when I talked to the patient advocate later that day.

Each insurance has their own criteria on what they expect and I can see falsification taking place. It saves "time" but it isn't right.

[JohnBFisher]

Of course, a scam on the part of the DME does NOT invalidate the need for the xPAP therapy. If you are not gaining the benefit from it that you think you should derive, then (1) go back to your doctor, and (2) work with your insurance company to find another DME in your area. Be certain to interview them before you sign up with them.

But xPAP therapy can and does save lives. The therapy is not a scam.

[Lizistired]

I have doubts about the insurance company requiring compliance data with every billing. Seems a stretch. Every month? Granted compliance is the bottom line for the DME, I just don't see it being required every month. Maybe at the 30 day mark which is when we normally have the first follow-up and the Dr's office would provide it.

[LSAT]

When I started I needed to supply compliance numbers at 30 days only....nothing since.

[RandyJ]

My DME asked for my sd card at 2 months and then downloaded my card again at 4 months when they switched out my machine for a different one. They haven't asked for the card since, it's been almost 3 months. They bill my insurance company every month for the rental.

[ozze_dollar]

Nobody cares about me because I had to pay for my machine.No one follows me up.
No prescriptions needed.
Pay for all my supplies.

[chunkyfrog]

Not a scam. At all.
Education about apnea lags for patients, professionals, and the general public.
Small wonder there is such an abundance of misinformation bouncing around out there.
The scam theory is probably the easiest to disprove.

[The Texan]

At the start, my DME required compliance data every 30 days for 6 months, then never asked again. The Dr asked for the data at the 90 day mark and never again. Once they are paid, you become past history and they are now looking to others for their income......I have not had anyone in 2½ years, ask for any information or ask how I am doing.

[Tip10]

All depends upon your insurance company.
Call them and ask them what they require.

Neither my insurance, nor my DME has ever asked for nor received any compliance data from me -- they've never looked at the card, they've never seen the machine since they gave it to me. NADA -- nothing.
But then again my insurance doesn't do that silly rent to own BS.
My DME provided me the machine based upon doctor's orders -- once I'd had the machine for 30 days they billed insurance for full amount.
My insurance, of course, disallowed about half of what insurance billed and paid the allowable amount, minus my very small deductible, in full -- DME then billed me for the deductible amount and I paid it. Done Deal. Machine is completely mine. No capped rental BS, no compliance BS, no hassles.

When DME called me to set up the appointment to pick up the machine I asked what the machine would be -- they flat out said that since doc wrote the script for straight CPAP the machine would be the S9 Elite -- basically said it was the "best" straight CPAP machine they dealt with. If I absolutely wanted something different then I'd need to call my doc and discuss it with them.

Oh, and when I went in to pick up the machine the RT at the DME walked me through every option available on it -- including the clinician screens (although she recommended that those be left alone or that I call them to make changes there if necessary -- note NEVER said I couldn't -- just recommended that I call them about it).

IMHO, this is the way it OUGHT to work, unfortunately, from what I've read on here this is definitely the extremely rare exception.

[sl33py]

What do you mean by compliance data? I've also seen others mention that they have been compliant.. Is this some requirement that some insurance carriers require a minimum usage in order to cover? My treatment center never mentioned this... only to use it, which I do every night. Don't you have to use it every night (and wouldn't you want to try) in order to see the benefit?

[archangle]

What do you mean by compliance data? I've also seen others mention that they have been compliant.. Is this some requirement that some insurance carriers require a minimum usage in order to cover? My treatment center never mentioned this... only to use it, which I do every night. Don't you have to use it every night (and wouldn't you want to try) in order to see the benefit?

Medicare and many other insurance companies require you to use the machine 4 hours a night 70% of the time or they won't pay for the machine. This is called "compliance." The specific requirement may vary. Most CPAP machines record how much you use the machine every night in some way.

Many DMEs are incompetent and don't explain this to you, or get the details wrong.