OK -- Now I'm mad.....

[SleeplessinBradenton]

Spoke with some woman in the DME's billing dept. today -- again! -- because I was supposed to have been eligible for a new mask thru my insurance March 30. I was told when I called about 2 weeks ago that there was some eligibility letter that they send out (to inform you that you are now eligible for certain new equipment, I guess -- ?? I don't know how this ins. stuff works yet!) and they were late getting the letters out. She assured me that I would receive it any day.

I am anxious to try another type of mask because I have been having a heck of a time trying to adjust to the mask I have (ComfortGel). I have a prescription for a new mask from the dr. and I wanted to catch DME before they go ahead and automatically send out a replacement of the mask I already have. I also have a Swift that someone gave me that luckily I can use right now as an alternate, but I'd sure love to find a mask that I can live (sleep) with that fits right (half-way decently anyway), doesn't tear up my face, doesn't leak all night, etc. etc. I never had an initial mask fitting from the sleep lab or from the sleep doctor. "Trial and error" is the best I can do over the next few months to try to find a mask that is tolerable.

Anyway, today I got a classic run-around, after again getting the "the letters are late going out" story. Then, after being on hold for quite some time, she came back on the phone and said that BC/BS assigned me a new contract number and they need that first. I explained that everything is the same and I have heard nothing about this from ins. co. Then she said they haven't been paid yet for the cost of the humidifier. I had to explain to her that this had been re-submitted to insurance with letter of medical necessity from the dr. (DME's billing office is actually the one that handled this!). I received a letter last week that medical necessity was indeed determined for the humidifier, and assured her that ins. should be processing it now. Then she goes on to say, "Also, you owe us a $109.11 balance. We can't let any more equipment go out until this is paid." (Apparently this balance is my co-pay from CPAP rental, mask, hose, etc. etc.) for Dec. and Jan.) I have never received a bill from DME for this balance.

The question is -- can they do this? Also, if this is the case, I guess I can probably forget about getting another mask to try when June rolls around, because by then BC/BS will probably have decided to just buy the silly CPAP for me instead of paying for monthly rental. Then I'll owe DME BIG BUCKS because the cost of it will go under my deductible for the year.

BTW -- I asked ins. co. previously about buying equipment myself to save them money, but such purchases would be considered "Out of Network" provider. What is the best way to handle that situation?

Thanks, and sorry for the long read.......

[NightHawkeye]

BTW -- I asked ins. co. previously about buying equipment myself to save them money, but such purchases would be considered "Out of Network" provider. What is the best way to handle that situation?

I'm sure I don't know the best way, but I can tell you what I did when I was told the very same thing. This was back in December of last year and I had already met my high deductible for the year and wasn't at all sure I would meet the deductible for this year. I decided that my cost could very well be significantly less by buying directly from CPAP.com rather than renting from a DME, even if insurance only paid the out-of-network 60% rate. I went ahead and ordered it from CPAP.com and later heard folks hear talk about being reimbursed as in-network if you submit the bill directly to your insurance.

Sure enough, even though they'd told me verbally otherwise, they reimbursed me as in-network 100%. I didn't do anything at all to help them reach that conclusion. I can tell you for sure that it was a whole lot less hassle going through CPAP.com than going through a local DME would have been. The only drawback is not having the ability to try out masks, but I think I've done as well with my masks as many/most folks here have.

Good luck, SleeplessinBradenton. Hope this helps. It's just my experience, of course, but I'm not the only one this has happened to. FWIW, my insurance wasn't keen on my buying direct, and initially told me that wasn't even an option. Perhaps if I'd persevered further I'd have gotten a more accurate answer.

Regards,
Bill

[snork1]

"I was told when I called about 2 weeks ago that there was some eligibility letter that they send out (to inform you that you are now eligible for certain new equipment, "

They inform you when elligible?!?!?!?
Wow! Late or not, that is certainly better than anything I can hope for. I have to track and guess when my next elligibility is for any equipment.
And I can't seem to get a straight answer from the DME OR my insurance company as to how often I can get new machines or masks or replacement parts.

[twillson]

Anyway, today I got a classic run-around, after again getting the "the letters are late going out" story. Then, after being on hold for quite some time, she came back on the phone and said that BC/BS assigned me a new contract number and they need that first. I explained that everything is the same and I have heard nothing about this from ins. co. Then she said they haven't been paid yet for the cost of the humidifier. I had to explain to her that this had been re-submitted to insurance with letter of medical necessity from the dr. (DME's billing office is actually the one that handled this!). I received a letter last week that medical necessity was indeed determined for the humidifier, and assured her that ins. should be processing it now. Then she goes on to say, "Also, you owe us a $109.11 balance. We can't let any more equipment go out until this is paid." (Apparently this balance is my co-pay from CPAP rental, mask, hose, etc. etc.) for Dec. and Jan.) I have never received a bill from DME for this balance.

Wow! When I read stuff like this I can really appreciate my own DME situation. I got 2 interfaces and an extra cushion within the first two months trying to get a handle on leaks, sizing, etc. No problem with my heated humidifier, either given a medical necessity form for all of the above. I have been charged the appropriate co-pays, but since BS/BC negotiates down the prices, this hasn't been too bad. Also I am getting everything done (including my initial sleep studies) within the same year so I will reach my max co-pay soon.

I think you can expect to pay your portion of treatment costs (deductables and co-pays) but you shouldn't have any grief from your DME beyond that if your doctor supports your claims for "medical necessity". I live in a small town in Kansas and I have a choice of DMEs. I would suggest that you seriously consider making a switch to a different DME, or even try one of the online options before you go back to this one.

[SleeplessinBradenton]

Yeah, I realize, of course, that I have to pay any co-pays that may be due to the DME, but yesterday's conversation with them just made me feel they were holding equipment "ransom" until I do pay. But as I said, they haven't even sent me a bill for the balance due!

I spoke with the ins. co. today regarding this, and they just said that the DME can do whatever they want. Nice! I also inquired to them (ins.) again about purchasing equipment online, and she still wasn't sure costs would be reimbursed, but thought it may be possible if the online provider is a licensed, registered medical equipment provider.

Thanks for the kind responses to my gripe. I have many more -- too lengthy to go into now, and MUCH goofier than this one! This experience so far has been a nightmare for me (no pun intended).

[NightHawkeye]

I spoke with the ins. co. today regarding this, and they just said that the DME can do whatever they want. Nice! I also inquired to them (ins.) again about purchasing equipment online, and she still wasn't sure costs would be reimbursed, but thought it may be possible if the online provider is a licensed, registered medical equipment provider.

Interesting doublespeak from your insurance company. On the one hand, the equipment provider can do whatever they want, but on the other hand the equipment provider needs to be a "licensed, registered medical equipment provider". Whoever you talked with is making this stuff up as they go along. Not too different from the initial response I got from my own insurance company, really.

Do you really want to purchase on-line or would you prefer to go through a local DME?

Regards,
Bill

[sleepylady]

Hi Sleepless,

Sounds like you have a doozy for a DME. If they want to play games, then call your insurance and ask what other DME in your area they participate with. I would then take all of my business elsewhere. Your DME should have been able to tell you off the bat how often you can get replacement masks, filters, and hoses. My DME doesn't send out letters, but she let me know it's every six months for masks. Anyway, when I knew it was close to the date, I called my DME and said this is the date when I'm eligible for a new mask would you please order one for me. Your DME shouldn't be giving you the runaround about bills and such. I guess for the most part I'm pretty lucky. It took a lot to get the APAP I wanted and was prescribed, but in the end they did come through.

You might want to look at how expensive the equipment you have from the DME is going to cost you vs. going online. If you are more comfortable using the DME, then stay with them. My insurance also views online providers as Out of Network so I stuck with my DME. Also, I was well into the 10 month rental so didn't have much of a choice. I will say, next time I'm going to go the online route as it'll be cheaper. My co-pay is 50% so it's a tad ridiculous if you figure in the costs the DME charges.

One question, why didn't you try on masks at your DME's office? You should ask if that's a possibility and if you're allowed to "test drive" the masks. My DME let me try on a big selection of masks. From there she said I had up to two weeks to make sure the mask fit. If I had problems with it she'd exchange it as long as it was before the two weeks. Ok, I made her go through five switches so she complained a little but hey I had a hard time finding a good mask for me.

Best of luck and let us know how it goes.

Melinda