insuranne misbehavior; dme picks up the tab

In preparing to open a Medical Flex account at work (in part for all those miscellaneous CPAP related expenses) my hubby and I have been going back through my medical bills for the period of Aug 1, 2010 (when I was first diagnosed with OSA) to now.

Two things have become clear:

1) I have genuinely rotten health plan as far as paying for PAP equipment is concerned.

2) I'm blessed with a good DME.

I've written before at length about the difficulty that both I and my DME has had in getting a consistent answer to the basic questions of: How often will the insurance pay their 50% for a set of replacement pillows? and How often will the insurance pay their 50% for a replacement mask?

The name of my health plan is Independent Health, and in what follows, I've abbreviated it as IH.

In the 14 months I have been on CPAP/BiPAP therapy, I have been told by both IH representatives (by telephone) and my equipment provider (both by phone and in person) that I am allowed to replace the nasal pillows at each of the following intervals: Once every 6 months; once every 3 months; once every month; and AS NEEDED. I have also been told that if I replace the pillows before six months, then I cannot replace the headgear when it turns six months old, but I've also been told that every six months I can replace the headgear (and, indeed the entire mask, which includes the headgear, the small hose, and the pillows) regardless of when the Direct Nasal Interface was last replaced. After receiving three different and contradictory answers in a little over a week from IH reps by phone last spring, I even asked the manager of my equipment provider to contact IH and see if she could get a written copy of the replacement schedule for both the Direct Nasal Interface (by itself) and the entire mask. The manager was eventually able to get an IH representative to dictate the information to her, but she was unable to obtain a written copy from IH. She gave me a copy of her written notes. On her notes, it indicated that I could indeed purchase a Direct Nasal Interface once a month with IH coverage for 50% of the negotiated price and that I could also buy an entire replacement mask every six months---regardless of the number of times I replaced the Direct Nasal Interface in the interim.

Because we want to open that Medical Flex account, I have gone back through my receipts from my equipment provider and compared what was filed with IH and what the IH web site shows was paid to my equipment provider. It has now become clear that neither the equipment provider nor myself has been able to determine when I am eligible for replacement supplies partially paid for by IH. It is equally unclear what the actual coverage will be: IH has paid anywhere from $0.00 to $20.00 for replacement nasal pillows, including paying $10 on 8/19/2011 and $17.50 on 9/19/2011. Each and every time I've purchased a pair of pillows from CPAPXpress, they've charged me $16.20 and filed a $16.20 claim with IH.

IH seems particularly capricious in paying for the disposable fine filters, which the manufacturer clearly specifies should be replaced once a month: IH paid $0.00 for filters on 11/20/2010, 1/17/2011, 1/22/2011, and 3/22/2011, and 5/31/2011, but seems to have paid its $2.50 on 7/19/2011, and 9/19/2011.

And it gets worse!

At the start of my therapy, CPAPXpress set me up with an S9 Autoset. The original bill listed the purchase price of the machine as $800 (to be paid as a 10 month rental) plus $250 for the heated humidifier. I was responsible for 50% and IH was responsible for 50%; so my copays were to be $400 total for the machine and $125 for the humidifier. And the $400 copay was to be paid in 10 monthly installments of $40 each; likewise IH was supposed to make one $40 payment each month.

In December 2010, I was switched to BiPAP by my sleep doctor. A letter of medical necessity was filed with IH. And CPAPXpress gladly swapped my S9 AutoSet for a System One BiPAP Auto. The bill shows the purchase price of the BiPAP to be $1660 + $250 for the heated humidifier. My 50% share of the bill was $830 for the machine and $125 for the humidifier. CPAPXpress applied the $205 (two monthly installments at $40 plus my $165 copay for the S9 heated humidifier) to my copays for the System One BiPAP, with the result being a remaining balance of $750, which was split into 10 monthly payments of $75. A claim for $830 for the machine, $125 for the humidifier, and appropriate adjustments to take into account what IH had already paid towards the S9 were filed with IH, along with a new payment schedule.

But the IH claims paid web page clearly indicates that IH continued to pay $40 per month as per the original contract for the S9 and not one cent more. Hence IH reimbursed my DME a total of $400 for the System One BiPAP instead of $830. As in, the payment history makes it look as though they simply denied the claim for the BiPAP. But I was never informed of any denial of coverage either in writing or by phone call.

Fortunately for me, CPAPXpress never attempted to make me cough up the extra $35 per month that IH was unwilling to pay for the new medically necessary machine. And they told me at the end of my 10 payment, the machine has been paid in full. It's nice to have a DME that has your back ...

And, since my employer does offer a choice of insurance/health plans, it looks like hubby and I have more legwork to do before the end of year "open transfer" period ends: It looks like one (or both) of the other two plans offer much better coverage of CPAP equipment. But there may be other hidden costs in switching and we want to get it right ....

Did you send copies of your post to your state insurance licensing board?
Something is definitely not on the 'up and up'.
The regulators need to see what a peculiar bunch you have to deal with.
Somebody got some 'splainin' to do.

chunkyfrog wrote:Did you send copies of your post to your state insurance licensing board?
Something is definitely not on the 'up and up'.
The regulators need to see what a peculiar bunch you have to deal with.
Somebody got some 'splainin' to do.

Not yet, but I plan to this week. I want to take the time to write it up in proper English that a NYS bureaucrat stands a chance of understanding. And I will keep folks updated. I also plan on having a long conversation with the DME as well.

This is not what I need right now. But we gotta play the hand we're dealt. And right now, mine's not a very good one.

And, yes, it's not helping the insomnia, which has come back in spades. *sigh*

i second what the frog said
a couple of things come to mind :
1) get a copy of your policy. as a subscriber you are entitled to it . it should state the reimbursement rates.ask for all addendums too. it may say something to the effect that they go by medicare schedule or manufacturer recommendations. if it is vaguer (if thats a word ) than that the insurance commission has something to deal with. it really can't be arbitrary.
2)if the plans you are looking at are ones that are currently offered you should be able to get copies of them too. that will give you a heads up on planning.

if you are fogged up like me this can be some daunting reading,but its the only way to see the apples and oranges.
i can attest to how screwwed up new york state can be.

i wish you good fortune

Have fun. I never did succeed in getting straight answers to my questions from my insurer when I had one. It's one of the things that gives me a bit of sympathy towards the DMEs (but only a bit). Can you get an actual explanation of benefits statement for each claim the DME filed? I'd also want to make sure that your DME did actually bill the revised monthly payments and get refused before calling in the state. I've seen some really sloppy billing over the years where providers just failed to bill. Or perhaps gave up in total frustration with the insurer as I sometimes did.

It may be too late if you are about to change plans, but with every insurance, every year, you should request a copy of your "Evidence of Coverage". That's the actual contract your insurer has to provide care, but unless you specifically request a copy you never see it, especially when insurance comes through your employer.

The EOC is the bible. The insurer is contractually bound to provide what's covered in the EOC. That doesn't mean that insurers don't feign ignorance or forget what they are contractually bound to provide. If they deny coverage for something either specifically covered in the EOC or not excluded in the EOC, you can usually win an appeal. The EOC should have info about DME coverage, and if they don't state a particular replacement schedule you have a good argument for replacement as needed.

The other half of this equation is that you must 1) demand an explanation for every denial or partial payment and 2) appeal! Otherwise they continue to screw with you and with less savvy people who just give up altogether.

If your insurance comes from an employer, make sure the HR department knows about this lousy treatment from the insurer.