Looking for some advice . . .

*** NAMES HAVE BEEN ALTERED TO PROTECT THE CRIMINAL ***

First of all, I appreciate any help. I have been lurking for some time preying on the collective wisdom of the group, but I have an issue I have not found directly addressed in this forum. If we have anyone out there that speaks "Legalese", please, I need your opinion. I'll document what happened so you'll have some idea of what my issue is.

I was diagnosed in February - March 2006 with Obstructive Sleep Apnea. I was prescribed a CPAP machine by my physician in March 2006. The prescription for the machine was filled by a medical supply company in Rockwall, Texas I'll call "Dewey, Cheetham and Howe". I used the machine for two weeks, but had complications due to my Asthma. I consulted with my doctor, and he changed my prescription to a BiPAP. On April 26th, 2006 I returned the CPAP machine to "Dewey, Cheetham and Howe" in exchange for a BiPAP machine. I paid an additional co-pay to cover the added cost of the BiPAP over the CPAP. Unknown to me, from April of 2006 to March of 2007 a dispute has been ongoing between Blue Cross Blue Shield and "Dewey, Cheetham and Howe" over my claim. The claim was finally formally declined by BCBS in the beginning of March 2007. I received an invoice from "Dewey, Cheetham and Howe" on March 7th stating I owed them the balance on the BiPAP ($2600), or I had to return the machine, which I did. Currently, I have neither the CPAP machine nor the BiPAP in my possession. STAT Medical acknowledges that I have returned both machines. When I requested that they return my CPAP machine that I was originally approved for and that they were PAID IN FULL for by BCBS, they are delaying. They are avoiding my calls, and when I do call from a different phone and get through, the person I need to speak with is in "meetings" and "Unavailable". "Dewey, Cheetham and Howe" now states they want to file a claim against BCBS for a rental fee of the BiPAP for the time I had the unit. I have no doubt that once the claim is filed, BCBS will deny it; they have said so much, which means the cost of the rental agreement will fall to me. My issue is, I never at any point signed a rental agreement with "Dewey, Cheetham and Howe", was never told of the possibility of a rental charge, even while they engaged in a prolonged dispute with BCBS. If anyone had told me that in the event my claim was denied, I would be responsible for a rental fee, I would have declined the machine until the claim was settled between BCBS and "Dewey, Cheetham and Howe", to eliminate any liability on my part. I was never given this option. Over the past 3 days I have contacted:

The Texas Attorney General's Office - They told me they have no idea whom I should contact

Texas Department of Insurance - They said they could not help because my issue is with the equipment provider, not the insurance company.

Dallas County District Attorney's Office - Referred me to the Texas Department of Insurance

I also contacted 2 different attorneys; both said my case had merit, but there was not enough money involved to bother with a lawsuit

Until the dispute is settled, I have had to pay for a BiPAP out of pocket so that I may continue my treatment while the fight continues with both BCBS and "Dewey, Cheetham and Howe".

Any ideas on whom I should go to next? Any advocacy groups out there?

Have you tried a local news station that might approach the DME on camera?

or a letter to the local newspaper. Also maybe the Better Business Buraeu. You could also try the state health board that regulates the licensing of these facilities. I would guess that denying you treatment (not giving the original CPAP back) could constitute a major liability issue. Finally, you could try to get your doc involved too.

Thanks for your input! Unfortunately, getting my doc involved is not an option - he is now my former doctor. When I received my file after the claim for the BiPAP was denied, I read what was quite possibly the WORST letter of medical necessity ever written. If I was to hand the letter to anyone, and my wife agrees, the way the doctor wrote the letter it sounds like I just wanted to "try out" a BiPAP. Like I do this for fun. No mention of failing on the CPAP, no mention of issues with my asthma.

This is a very unfortunate situation and provides a stress we cpapers don't really need.

Do you know why your insurance denied the claim?

I had a non-sleep claim denied by my insurance because the provider didn't send information the insurance requested. I think it was a year later I received a bill from the provider. I called my insurance to find out what was going on. They told me since the provider hadn't done what they were supposed to do, the provider would have to write off the charge according to their contract.

When you said "a dispute has been going on between Blue Cross Blue Shield and "Dewey, Cheetham and Howe"", who told you that? The insurance company or the DME? My provider led me to believe insurance had "denied" my claim which wasn't really the whole story. Given what happened to me, I wonder if the DME dropped the ball on the billing and didn't give you the whole story. If you didn't hear the whole story from the insurance company, I would definitely find out.

On the other hand, if the insurance denied your claim because of the poor letter of medical necessity, maybe you can appeal to the insurance and have the decision reversed.

In my state I would contact the state licensing board.

HOWEVER, are you ABSOLUTELY SURE that you did NOT sign ANY papers w/this DME supplier? As long as insurance was involved I absolutely cannot conceive that you were not required to sign ANYTHING, that you were just able to walk in, show them your insurance card, pick up your equipment and walk out. I have a copy of EVERY piece of paper I have EVER had to sign w/my *&^~ DME supplier and I'm here to tell you, there IS a phrase to the effect that I agree to be responsible for any charges not paid by my insurance.

On the other hand: the entire problem w/BCBS refusing to pay JUST MIGHT BE BECAUSE this DME did NOT get your signature.

We had a somewhat similar situation many years ago. We had sold our house and put a mobile home on our property whilst building our new home. We got burned out of our trailer. The bank we had the loan for the trailer w/got REAL snarky and threatening whilst we were waiting for our insurance settlement. Which surprised us no end since my family and we had done business w/this bank for YEARS. Turned out they were running scared BECAUSE THEY had FAILED to put a lien on the title to the mobile home!

Have you been able to determine FROM BCBS "why" they are refusing the claim? Do you have copies of anything and everything BCBS did pay?

You might also give consideration to contacting your state legislator, the one for your district. I assume like Michigan they have access to legal staff and they often dig in and apply pressure to help a constituent.

I have already been in contact with another doctor (This afternoon in fact) and he told I need to speak with the State Board of Medical Examiners (Which I plan on).

My claim was denied by BCBS because it was "Not a medical necessity". This came straight from BCBS when I called them to find out what the issue was. As far as signing anything, that is the funny thing. When I first received the CPAP, I remember going through some paperwork with them at their storefront. However, when I received the BiPAP, the only thing I signed was a credit card receipt. It was that simple. I walked in and handed them the CPAP, they handed me the BiPAP. I paid the difference in the copays and walked out. Interesting thing is BCBS said the BiPAP is a separate claim. BCBS paid the DME in full for the CPAP. Which begs a further question, did the DME commit insurance fraud? When I contacted BCBS about this mess, they were suprised that I had returned the CPAP - they had no record of a refund from the DME.

This is bizarre.

You said the claim was finally formally declined in March of 2007. Do you know what was going on all of that time? Did BCBS ask for additional documentation the DME didn't provide? If so, that could fall under what happened to me. My provider didn't provide the information in a timely fashion, so they had to write off the charge. It was their own fault.

I don't understand how the dispute went on for so long - what did BCBS or the DME expect to change during all of that time?

Phurious,

The Texas Department of State Health Services is responsible for licensing medical devise manufacturers and distributors in Texas. Here is a link to the main webpage for the part of the department that deals with medical devices.

http://www.dshs.state.tx.us/dmd/


The website has a variety of information, including about complaints and contact information in the licensing unit. I am not exceeding hopeful that this agency has the authority to investigate or respond to the type of dispute you are going through. However, you could contact them and ask. Perhaps they could head you in the right direction.

I like some of the suggestions others have provided. Dallas will have one or more TV stations that do those consumer advocacy news investigations. Also, the suggestion about contacting your state representative or senator is a good one.

Go to:

http://www.capitol.state.tx.us/

to look up your representative or senator and get their email and telephone contact information.


Good luck!

And be sure to send a copy of all your correspondence to the DME -- that might spur them into doing the right thing for you.

The first thing I suggest is start a documentation trail. Send a certified letter with return receipt requested. Let them politely know that there has been a mistake and the action they need to take to correct the problem.

Keep your emotions out of all correspondence. As Sgt. Friday would say, "Just the facts."

Do not threaten to sue. Just let them know there has been an error that you would like corrected in the next 10, 14 or 21 days.

-747
Not an attorney, nor play one on TV.

So here is the bizarre. I got Blue Cross Blue Shield involved seeing they had paid for the CPAP. They conferenced a call between BCBS, myself, and Dewey Cheatham and Howe. On the call, the "Head" of the medical supply house agreed that this was out of hand and wrong, and said they would return the CPAP machine to me. She went on further to say they were going to wave any rental fees because this had gone too far. Now, keep in mind all of this was recorded by BCBS, you are told as much when the call begins. Today I went to pick up the CPAP from the medical supply house, and they refuse to release it until I sign a form acknowledging that I owe them $1548 in rental fees.

Does anyone here have a real, legal opinion on this matter? If you do I would love to talk about it. I am considering calling the police and having the store owner arrest for theft.

Can BCBS provide you with documentation that the DME (medical supply house) was in fact paid.....maybe a copy of the check that the DME cashed/deposited (accepted as payment for your equipment). If they can, then take that documentation to the DME and demand your equipment back. If they still refuse, contact the county attorney and pursue charges against them. Also, contact the Better Business Bureau, state regulating boards, etc.

Den

You might also look into taking them to Small Claims court.

Linda3032 wrote:You might also look into taking them to Small Claims court.

True. And in which case, you'd also need most of the same documentation. Also, if BCBS can give you a copy of the recorded conversations, that might be very useful.

Den