Insurance issues

Greetings all!

I'm a long time lurker who has learned a ton from you guys. I was hoping someone could give me some advice before I go ballistic.

Background:

I am 35/m 6ft 200lbs. I went to my primary care doctor for a checkup and told him many common symptoms of OSA. He referred me to the sleep doctor who scheduled a sleep study. I was diagnosed with moderate OSA and scheduled a followup titration study. At the titration they gave me a laminated insurance sheet showing the different local DME providers and gave me about 3 minutes to pick one. Next to the providers were insurance plans they worked with. I picked the closest one to me that showed it worked with Blue Cross (I am in Michigan and have Anthem BCBS) which was airway oxygen (http://www.airwayoxygeninc.com/). I went to my followup appointment after the titration and was prescribed CPAP and told them the DME would call me to schedule a time to pick up the equipment. I picked up my Resmed S9 auto set and Swift FX mask. The DME told me that my insurance does purchase rather then rental.

The therapy has been going exceptionally well. With this forums help I downloaded the detailed data from the card and have great results. Even better, I have been feeling much more rested and have a lot more energy throughout the day.

Insurance:

My Anthem BCBS insurance has been fine so far. They paid 100% for both my sleep study and titration, as well as for the office visits (minus a couple $25 deductibles). Everything has been fine until I check my mail and have a notice from Anthem saying they denied my CPAP equipment as I went to an "out of network provider". They show two claims (one for $1200 and another for $275) which were denied. This is not a bill, but I'm sure I will be getting one from the DME soon enough. The claims were from my DME appointment which was 7 months ago.

I'm at work and can't call anyone for a while, but just wanted some input. I went to an "in-network" primary care doctor, who referred me to an "in-network" sleep specialist, and then went to what I thought was was a covered DME based on the information they gave me. Plus it was 9pm at night and I wasn't exactly in a position to call Anthem to verify DME's. Looking online at Anthem's website I don't see anything showing what their "in-network" DME's are.

Help??

TLDR; My insurance paid for my sleep studies and doctor visits, but I got a notice 7 months after the fact that they are denying my claim for my CPAP equipment saying I used an out of network provider.

I have the same insurance. Prior to buying my equipment, I called BCBS and asked them which local DMEs they cover, and they FAXed me a list of about 10 establishments. I ended up buying my equipent from CPAP.com, not wanting to hassle with the DME compliance/rental/limited equipment issues and never looked back. The folks at CPAP.com warned me that BCBS likely wouldn't reimburse me, but they sent the form anyway. Just for grins, I submitted the paperwork and BCBS flatly refused to reimburse me for the equipment because I didn't purchase it from an in-network DME.

I'm surprised the DME didn't mention their non-affiliation when you gave them your Ins data. (OK, not really surprised. A sale is a sale, no matter who gets stuck with the bill!)

I doubt there is much you can do. I just hope you now have a NEW DME who works with BCBS...and that you told them WHY when you fired them.

I hate to say it, but you may not have much standing here.
Rule # 1: The only place you should go for info about your insurance policy is your insurance company.
I'm sure the sleep doc meant well by trying to help you find a DME (provider), but you really should check with both the DME directly and the insurance company to make sure that what a third party told you was true. A call to the DME would have let you ask the question "are you an in-network provider for XYZ ins. company?"
A call to your ins company should get you a list of DMEs in oyur area or at the least a yes or no on the specific DME you're wondering about.

You might have grounds for a small claims lawsuit if the DME didn't tell you they weren't affiliated with BCBS. If the DME acted as if they were approved by BCBS, then it's reasonable that you should have expected that they were. There's a legal term in contract law for "acting as if a relationship exists." You can Google the legal term "estoppel." And reasonable expectation is frequently what a judge will use to decide the merits of your case.

However if you have BCBS, it's likely you have a pretty good job. So what's your time worth to pursue the matter? Then again, having a business such as your DME served with a summons often makes them more amenable to seeing your side of the argument. They don't need the negative publicity, they don't need to have one of their employees' time tied up in non-productive work that, at best, will result in no award to you.

Dislaimer: I'm not a lawyer, what I say is just what I know from experience. It wasn't meant as legal advice.

Thanks for the responses. Not really what I was wanting to hear, but what I kind of expected. I'm going to have to make a lot of angry phone calls this afternoon.

Good luck with that. No need to be angry. Just be clear that their conduct implied that they were approved by BCBS, which caused you financial damage. If they are conciliatory, then that's fine. If if not, best to handle this in writing via certified mail.

That way:

1. You have proof of what was said.
2. You provided the DME with an opportunity to make things right.

In my state, you have to do the above before filing a small claims action. Usually, the arrival of a certified letter will get their attention, because they know that you are setting up a paper trail that can be used in court later.

I would try packing up the machine, going back to the DME office, plop the box on the desk and tell them, "You did not tell me you were not an in-network supplier for BCBS. Here is your machine back, I will not be paying for it." If you already paid them a copay amount and they won't refund it, just kiss it off and start over. That is, if that approach will save you money in the end. Otherwise you may just have to chock it up as a horribly expensive learning experience.

I'm sorry that happened to you.

These things happen all the time because you're rushed into a DME and decision without time to think things through and be a careful consumer. On the one hand, sleep doctors and clinics don't want to give you any time to back down--which is a good thing on one hand because otherwise you might, but on the other hand, the DME's see you coming from a mile away with a big sucker sign on your head because of the "crisis" you're in. That's why I wrote "What you need to know before you meet your DME" (see my signature line) and the first step is always to call your insurance company to understand what they will cover and with whom. You had apnea for a long time, and there was no reason to run out at 9 p.m. to get a machine, but you didn't know that.

I agree that a calm but firm letter stating that they led you to believe your insurance WOULD cover this is in order, and, yes, definitely send it by certified mail to the manager of your DME. You should also CC your doctor or the clinic that referred you there--this is poor treatment of their clients, and they should stop referring people there.

Were you renting or did you consider it to be a purchase? If it's a rental, I agree that returning it immediately is in order. You may not get any money back for co-pays and they will try to bill you for the rental, but at least you won't incur any further expenses with these crooks. If it was a purchase, that's a more difficult scenario.

Ok, there's been lots of sympathy for wrestleben (and I include mine now) and lots of correct finger pointing at the DME who should have said something when shown the insurance card.

But no-one has YELLED about this yet:

wrestleben wrote:I was diagnosed with moderate OSA and scheduled a followup titration study. At the titration they gave me a laminated insurance sheet showing the different local DME providers and gave me about 3 minutes to pick one. Next to the providers were insurance plans they worked with. (emphasis added)

So I'll YELL about it and I'LL YELL about it LOUDLY: This whole insurance mess was CAUSED BY the in-network sleep lab putting UNNECESSARY and UNFAIR PRESSURE on wrestleben to pick a DME RIGHT AWAY with NO opportunity to contact his insurance company (it was 9:00 pm) and NO way to contact one or more of the DMEs before making the decision that was being presented to him as "IT MUST BE DONE NOW!!!!!". And the whole mess could have been prevented had the sleep lab simply given wreslteben a copy of the list and suggested that he start making phone calls to select the DME in the next couple of days after he had a chance to take in all the financial (as well as medical) implications of his choice.

Ok---yes, wrestleben coulda and shoulda made those phone calls before hand. But let's be realistic: How many people start making the phone calls as soon as they get the phone call that says, "You have OSA and we need to schedule a titration study"? I don't think it's an uncommon reaction to hearing "OSA" and saying to yourself, "Let's wait and see what happens at the titration study. Maybe they'll tell me something I need to look for in trying to find my equipment. And I'll call the insurance company when I know I have to get the CPAP." After all, this diagnosis tends to stun some of us. I know I didn't make those calls right away.

I'm sensitive to this issue because my (soon-to-be-former) sleep doctor's office tried to push me into signing a contract with the DME ("located right next door so it's convenient") that turned out to be one of many that were unwilling to provide me with a full efficacy data machine. Fortunately even though I was STUNNED by what the doctor was telling me, I retained enough of common sense to say I was NOT comfortable signing ANY paperwork concerning DMEs until I had a chance to talk to my insurance company and talk to some DMEs myself. I had put off making the calls to the insurance and trying to locate a DME after receiving the "You have OSA" call because the way it worked at my (soon-to-be-former) sleep doctor's office is that my ONE and ONLY follow-up with the doc himself took place between the initial diagnostic study and the titration study. I was naive enough at the time that I thought I might get some useful information out of the guy about what makes a quality CPAP machine and perhaps a list of DMEs for me to take home and start calling.

Personally? I think ALL sleep labs and ALL doctor's offices should be PROHIBITED from presenting a newly diagnosed patient (with ANY ILLNESS) a (short) list of DMEs and saying "Choose the DME now off this list! We'll give you about five minutes to look at the list and make your choice!"

Well, remember your state of mind before the brain fog cleared? In my case, I was walking around work half the day unaware that my fly was open. I was glad to be able to find the sleep center. I was answering the question, "Do you want fries with that?" with "Huh?"

Critical thinking improves only after the fog burns off. All the more reason to pressure the DME into making it right.