DME

Guest · Post by **Guest** » Tue Sep 26, 2006 3:05 pm

snoregirl wrote: And have you called your insurance co yourself to check if the info you are getting from the DME on upgrade cost (machine not covered) is correct?

bairdbeth wrote:I have not called my insurance as I can never get anyone who can tell me a straight answer.

Your DME is reimbursed the same amount of money from the insurance company whether it's a Pro or a Plus. This 'upcharge' they claim you must pay because "it is not a contracted model" is malarky. It's worth your while to contact your insurance company so you can tell the DME you spoke with so-and-so and they said the Pro is covered. Your DME is counting on the fact that you (and all their customers) are ignorant about how things work with reimbursement rates and they are counting on the fact that you won't take the time to check it out with the insurance company. $100.00 is a lot of money and IMHO it's worth taking the time to talk to your insurance company. Just my 2 cents worth.

snoregirl · Post by **snoregirl** » Tue Sep 26, 2006 6:10 pm

Well, I am the kind who would likely fight for the $100, BUT

It is possible that the Insurance will only cover the base model. Possible the DME is being straight with you. Without reading the fine print, or being able to get someone on the phone from the insurance company to give you a straight answer it is hard to tell. I know from personal experience that that can be very difficult.

Giving the DME the benefit of the doubt (wow did I just say that?) the $100 is reasonable since it corresponds to the cash price differential

AND

Insurance is paying 100% if I remember correctly which in my opinion is pretty good.

While I might be tempted to fight, I might also just take the Pro M for a total out of pocket of $100 and get on with it if they can produce it fast.

bairdbeth · Post by **bairdbeth** » Tue Sep 26, 2006 6:26 pm

I called my insurance. They do not list machines they cover, nor will they give you an amount. All she said was we cover 100% of eligible contracted cost. She did say that it would be a basic machine, not many "frills".When the DME called back they offered the Pro 2 (for an upgrade fee as well), but I decided I wanted a smaller machine ( M Series Pro) as I have several trips planned in the next 9 months. It comes with all the things I wanted and they have it in stock in their other office across town (they would have to order the Pro2). I am to call their RT on Thursday afternoon or early Friday to arrange the home set-up. The DME also gave me the timeline for when my insurance will cover new mask and supplies. She said that the insurance would tell me to replace the mask every 6 months (which is what insurance told me and have listed on their website), but they will actually cover a new one every 3 months (at 100%) I think I made the right choice on machine, I now can't wait to get started. I know it can be a rough start, but I so want to feel better that I am ready for the fight!

Severeena · Post by **Severeena** » Wed Sep 27, 2006 3:02 pm

bairdbeth, I have American Home Patient for my cpap supplies. The problem is if they cannot make a profit they will not sell it. I have to go to another DME for someof my supplies. This is very typical of American Home Patient.

Sharon

Severeena · Post by **Severeena** » Wed Sep 27, 2006 3:04 pm

bairdbeth, I have American Home Patient for my cpap supplies. The problem is if they cannot make a profit they will not sell it. I have to go to another DME for someof my supplies. This is very typical of American Home Patient.

Sharon

Guest · Post by **Guest** » Wed Sep 27, 2006 4:22 pm

Severeena wrote:bairdbeth, I have American Home Patient for my cpap supplies. The problem is if they cannot make a profit they will not sell it. I have to go to another DME for someof my supplies. This is very typical of American Home Patient

Sharon

Heh. Well yeah I would hope so. I think it's pretty safe to say that selling something for less than you paid (as a habit) is going to be pretty poor business practice. lol

snoregirl · Post by **snoregirl** » Wed Sep 27, 2006 7:55 pm

Just make sure your machine is new. I seem to remember somewhere back a ways someone saying American Home Patient tried to give them a used machine. I could be wrong but good to check the hours on it when the bring it and set it up.

If your insurance will cover 100% for a new mask every 3 months then I would take it. Get some different ones as you go.

My insurance will cover a "mask" every 3 months but headgear every 6 mo. Hard to try a new one at 3 months if you can't strap it on!!

As for the DME telling you that your insurance will cover masks sooner... it would make sense that they would tell you this as they make quite a profit on each mask. The more they sell your insurance company the better for them.

But for you since your coverage is 100% why not experiment with what you can. You never know in this world when the insurance coverage will change for the worse.

See when they will give you hoses and filter too. Hoses keep fine as do filters in your closet.

What I wouldn't give for 100% coverage!!

bairdbeth · Post by **bairdbeth** » Wed Sep 27, 2006 8:11 pm

I have American Home Care Supplies. I think it is different than American Home Patient? I already asked if it was a new machine as I won't except a used one. I was assured it was new. They were open to ordering me whatever CPAP I wanted. I hope this hints at good things to come.I will remain optimistic and upbeat about my DME, just as I am about becoming a hosehead. If a positive outlook means I have a better chance of getting help and co-operation from my DME and starting and staying CPAP compliant, then just call me "Pollyanna". That is not to say I will not look to online sources if my insurance won't pay 100% I plan a new mask every 3 months until insurance says otherwise. I would love to have options to switch out. Thanks for the advice and the support!. I call the DME's RT tomorrow to see if machine is in and to set up a time for her to come to my house to set it up!

birdshell · Post by **birdshell** » Wed Sep 27, 2006 10:52 pm

You go, bairdbeth!

For one thing, understanding the situation of the DME providers is all to the good. I truly believe that they are trying to work within a system that is frustrating, as they deal with multiple insurance companies. Each company has multiple levels of coverage, and sometimes even their minimum wage employees are of little help.

Of course, that does not mean that taking an adversarial approach is in ANY way a good plan. One should always choose one's battles wisely, considering the consequences.

Then again, from some of the horror stories shared here on the forum, there definitely ARE times when the 'Steel Magnolia' needs to emerge!

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FYI: I believe there was a thread/posting that if a machine has less than (40?) a certain number of hours, it can be sold as new. I tried searching for it, but couldn't find it. However, it sounds as if your DME provider will take good care of you.

Severeena · Post by **Severeena** » Thu Sep 28, 2006 1:05 pm

Yes it is. bairdbeth
[/quote]

snoregirl · Post by **snoregirl** » Fri Sep 29, 2006 6:12 pm

judging from your other post, I guess the doctor/DME gave you the machine THEY wanted you to have after all

bairdbeth · Post by **bairdbeth** » Fri Sep 29, 2006 6:33 pm

The RT said the Smartcard would give me the data that I want, but someone posted that is not right. I will use this machine for the weekend and call them on Monday. The paper I signed had Plus, but there was another page that neither of us saw and it says Pro. At least I can start. It is a rental, It was not bought out right. Rentals can always be returned!

snoregirl · Post by **snoregirl** » Fri Sep 29, 2006 7:23 pm

Let us know how it goes. Always an interesting story to those of us who have been through dealing with DMEs

Good luck!!!

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