(Hi there) And did my med supplier commit fraud with my Ins?

Hello everyone, this is my first post. Just wanted to say hi.

A quick rundown of my situation:
I had my 2 sleep labs about 2 weeks ago (first to diagnose, then with CPAP). I was diagnosed with severe SA, and now need to use CPAP. Also without going into too many details, I already have so many unrelated fairly major health problems that I am going near insane. I have diabetes, high blood pressure, very high (but now treated) cholesterol, depression, and Lupus (SLE) - which causes pretty bad chronic pain most of the time. I've also had insomnia for as long as I can remember, and have been taking 20mg of Ambien (2x the normal dose, but yes it is prescribed, mainly to help help cope with the normal insomnia and pain) for about 5 years. And so, now sleep apnea to add to my fun list of problems...arg

I'm sorry for posting so much info and this will probably be too long for most people to read, but if anyone could help answer any of the following questions, I would be really really grateful. Also, I've been looking through the old posts on here, and there is so much valuable info - so thanks everyone for that as well. Ok, here it goes.....

1) My sleep Dr. prescribed the CPAP equipment about 1.5 weeks ago and sent it to what I guess is his normal place that he uses for supplies. It's about 30 min away, not ideal, but not horrible. It took 3-4 days just to get in the place to get an appt. and get setup, and they never returned calls unless I called back 5x. So when I finally got in here and met with someone, they said it was already pre-authorized for about $1,700 total; my portion was 30%, so about $400-ish (I have Blue Cross PPO insurance). And they had me pay this amount, the $400 that day by credit card. Since I've never had this equipment before, I didn't know the prices, and just thought that was that - since they said they had a pre-negotiated rate with Blue Cross. Here's the problem...

They gave me a Respironics Plus M series (with heated humidifier). And I chose out of 3 masks, the "Opus" nasal pillow one. When I got home, I looked around online to see price wise how it compared and was shocked. The machine can be bought by cash for less than $500 almost everywhere. Even with a SmartCard (which mine DOESN'T have, but sounds pretty useful), it is like under $600. So here's my issue, I looked at the itemized receipt that they're billing my insurance with and it showed this:

1 CPAP machine = $1,000
1 heated humidifier = $500
1 nasal mask = $160
1 mask headgear = $100
1 6' tubing = $50
1 disposable filter = $17
1 micro filter (thingy whatever it's called) = $5
and probably a couple other things.

So, they're charging my insurance (and me, by the 30% copay) $1500 *just* for the CPAP machine & humidifier. That sounds very absurd, I can understand small price differences, but that is huge compared to other places. On the company's own website, they actually list a package deal of the M series w/heated humidifier (exactly what I got) for a total of $750 (still high, but far from $1500).

So I called them and asked. She put me on hold for a few minutes, and then came back and said that the website prices are only if you pay cash without insurance. It was useless to ask them, so I'm done with bothering to talk with them (plus, they never return my calls).

I'm wondering if this is actually insurance fraud? The extreme price - which is different than the cash price by a huge margin seems very fishy. Also, it looks like when you buy a nasal mask - doesn't the headgear come with it? They charged it 2 separate fees as stated above (again, much higher than the average price anywhere I can find).

And the biggest red flag that I want to look into is, isn't the tubing (and I think at least 1 disposable and 1 fine particle filter) included inside the package for the machine? Everywhere online says that it includes this in the box. It really appears to be almost fraudulent double charging to the insurance (and me)....does anyone know?

Again, sorry for all of the questions and length. But I'm really stressed out here, and am not sure where to turn. Thanks for any help, hope everyone is sleeping well!

My understanding is that DME's use Medicare allowable cost's as a guideline and those numbers ouund about right for Medicare.
DME's have brick and mortar cost's that are no applicable to internet sellers. In return for these additional cost's you are "supposed" to get help in fitting, maintenance and repair of your equiptment.

Many of the people here will tell you that DME's are incompetent thieves. I sometimes wonder how many of these same people are affiliated with our host.

Thanks for the info.
Is the tube/hose that the product says is included inside of the box -- normally put separately on the bill for $50 though? (same with the filters). Also the mask + headgear separate charges, which although may optionally be sold separately -- seems extremely high. That really doesn't seem right.

As a quick sidenote to this:
I talked to my Dr. on Friday and had him switch me to another place, which is only about 5 minutes away. I have no idea why he didn't send me here first. And I spoke with the new place (very nice BTW, and they actually called me back) and explained the situation to them. They said that with my 30% copay thing, there's no way that they should have charged me at that time, until the full bill was processed by Blue Cross - he said that otherwise, there's no way to know how much of that Blue Cross would cover, and thus how much I would need to pay. But...that 1st place did charge my credit card that day, and the claim hasn't been processed yet by BC.

Normally I get a notice from Medicare terlling me waht I will be billed for. Don't. Of course I am set up fifferently than most folks. My wife still works and because of that Medicare says that Cigna has to be my primary.
The progression is that Cigna pays all they will pay, then Medicare usually picks up all the rest. Sometimes I might have to pay 10 or 15 bucks and that's only when surgery is involved.
On hoses, I have been using the same 2 hoses for a couple of years. I use a hose for the night and then hang it up to completely dry while I am using the second hose.
Filters get changed and cleaned on a regular basis. I think that Cigna muse pay 100% on filters because I have never seen a bill on those. Cigna will spring for a new mask every 6 months. Be sure and have your doctor to write a prescription fo "mask of choice", that way you don't have to go back to him every time you want a new mask.
If I owned CPAP.cpm I would have all of my employees working this board on a regular basis, bad mouthing DME's, etc. That's VERY good business plan and I don't blame them one iota for doing it.

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CPAPopedia Keywords Contained In This Post (Click For Definition): medicare

I had Aetna insurance when I was first diagnosed. I too had my insurance charged separately for every little component. My insurance did not buy the machine outright, but leased it for me for a year - then at the end of the year, it would have been mine.

I quit my job and lost the Aetna insurance and had to give the machine back (that's when I discovered it was a rental.) I contacted the DME who said I was fortunate that the insurance had paid part, and I could purchase the machine I currently had for ONLY $1,000. It was a Remstar plus - which could be purchased from our host site for $299.00 - including the hose and filters.

Lucky for me, I started looking for a better price on line discovered this site. I decided to buy a better machine with a card reader and software bundle, and still didn't end up paying $1,000.

I am NOT affiliated in any way with the site, and I DO think DME's are a ripoff. I had terrible service from mine, they only offered me one mask that I had to put on myself - no one fit me for it, or answered any questions for me.

I had been scheduled for one of their classes and to pick up the machine. When I got there, they said there was a mistake and I was not allowed to take that class, that it was for Kaiser patients only. They wanted me to come back in a few weeks to another class. I had taken time off work to go to this class, and had no intention of taking more vacation time for this. I pitched a fit as only a sleep-deprived woman can. A man came from the back, handed me the machine and a mask, gave me no instructions, and I left.

I'm actually grateful they were so awful. It led me to this site, which has answered all my questions and introduced me to some very nice new people.

Is there any way you can contact your insurance company, ask to return the machine to that DME, and go through this site to get the machine you want?

If I owned CPAP.cpm I would have all of my employees working this board on a regular basis, bad mouthing DME's, etc. That's VERY good business plan and I don't blame them one iota for doing it.

Oceanpearl, do you really think those of us who had terrible experiences - multiple times and multiple different DMEs are all working for this site?

I cannot speak for others, but I will go on record repeating I am NOT affiliated with this site, I TOTALLY think my DME did a terrible job, overcharges, and did not provide instructions.

[quote="SleepingBeauty"]
Is there any way you can contact your insurance company, ask to return the machine to that DME, and go through this site to get the machine you want?/quote]

I really don't know. I haven't even been able to speak with them, as the person I have to talk to is always "in a meeting, and will call me back very soon", yet, no call.

But even if I did, I would really like to know if this is indeed fraudulent business practices. If anyone here has bought a Respironics M Series machine, did the hose/tubing (and filter) come inside the box itself?

Or did you have to buy it separately. Because if it comes inside of the box, I would almost be positive that that would indeed be insurance fraud. I'm not one to jump the gun, or am "sue happy" or anything like that. I just don't want this company to continue operating and ripping off customers and overcharging insurance agencies so my rates go up even more....

I am going to make some assumptions, and if I am wrong someone please correct me, about the price differences between on-line and a walk in supplier.

The walk in supplier has upkeep directly related to their service. Usually they have a nurse, RT, or someone that is supposedly knowledgeable to help you in your decisions. They have secretaries, people that go into the homes, etc. that the on-line suppliers do not have. All the extras drive up their costs over what an online supplier has.

It is also up to us to keep an eye out for those DME's that border on the shady side of things (I have dealt with one of those and with the help of this board fired them and switched DME's).

The insurance companies allow them certain charges. Whether the equipment came in the "original" box is a mute point. The DME's apparently are allowed to legally charge for those items.

I can get a new hose on eBay for a fraction of what one will cost me at my DME's. How do I know that the hose from on-line supplier (eBay or other) has passed rigorous testing and meets the orginal manufacturer's guidelines? With all of the scare with items coming from overseas that are lead-based, etc. do you want to take a chance with your health?

I buy items on-line and am not completely knocking on-line sales totally. I feel for those that do not have insurance it is comforting to know that they have access to more affordable equipment!! For those of us with insurance it is up to us of how to proceed. For me, I will stick with my DME at the present time for sake of quality control and if an item is defective I can holler and complain to them about it!!

Weigh the pro's and con's and compare apples to apples (other DME's allowable charges) versus apples and oranges (DME's to on-line cost comparison).

Thanks again

sleepycarol - you bring up some good points. The fitting and such (would) be a plus if your local retail DME has lots of items in stock to try and is nice enough to spend time. I think I just got a bad taste in my mouth from that first place I went because it all seems so screwy, they're quite rude and rushed, and are so very hard to get a hold of. I'm not a needy-person, but with this major new thing, I of course have questions and need some advice and help - which I definitely didn't get.

My dilemma now I guess is:
I have Respironics M Series Plus w/humidifier that I'm fairly sure that I'm stuck with. Having never been on CPAP before (or any medical equipment like this), I had no idea what the actual differences are between "renting" and "owning"...

The place said that Blue Cross would let me do either - rent or own. I asked the difference and she couldn't give me a straight answer, mostly just said that I was lucky because Medicare and some insurers make you rent it for 12 or so (I think it was) months and then you pay off the balance. Just the sound of "renting" a machine that I was breathing out of honestly in my mind made me think it was like used or bad or something, and again could get no answer. So I said I'd buy it, and put it on my credit card (If nothing else, I just figured that would be easier to pay off slowly since I'm used to my credit card, and wouldn't have to deal with yet another bill and company).....Now - was this a really bad idea??

I still honestly don't even know what that choice really means. I'm afraid I made the wrong decision. I really am so confused about the entire thing.

They had a couple masks that she said were the "best" for me to try. Here's another big question I had (I didn't ask her because I'm too darn shy). I'm a big time germ-a-phobe. Plus I'm extremely susceptible to getting sick because of the immunosuppressants I'm taking for the Lupus. When I got in the room, she already had my machine setup and the masks to pick from sitting there. I know they legally almost positively have to have them sanitized or a new product for health reasons, I have no idea if they were. For anyone that goes to a physical DME store to get their masks -- what do they do with the ones that you try on and don't like? I just had this sick feeling that they were all like dirty test masks that they use 10x a day. If not, how do they recoupe this cost (maybe from the $1200 they overcharge customers from? )

I think I agree with you though that if you have a reliable local store that can help you test things out and find the right things, you'd might as well pay a bit more if you can just for the sake of being able to have a place to take it for repairs (uh oh) or whatever. But for hoses, and other goodies, maybe I'd be better off buying with cash from somewhere online.

Ok and 1 last question, I promise
Does anyone have and use the Smartcard option? I love gadgets, and plus it does seem like it might be helpful to be able to track your progress without having to go into a full-on sleep study. I would have thought that my doctor would have prescribed a model with one, or at least preferred that I get one if I could afford it (I wonder if Blue Cross would pay for it still). Now that I know it exists, I am kind of surprised and disappointed that my Dr. doesn't at least recommend getting one with a Smartcard and have the patient bring it in for him to look over the data (Does anyone's Dr. do this?) - seems like it would be much more reliable and useful than just asking me how I was doing...heck I'm hopefully sleeping, I have no clue.

It sounds as if your DME was like the first one I dealt with.

Read your prescription and your sleep study paperwork (which I hope you received). Make sure you understand which machine was ordered for you. If you have questions about the machine you were prescribed and the one you were given and do not understand if they are the one and same, ask on here!! These people have a wealth of knowledge and told me that what I received from the first DME was NOT the machine I was prescribed. They were very, very supportive when I had to take the machine back and told them I would not use it as it was NOT the prescribed machine. To make a long story short I just simply gave it back as it was a rental and I had the insurances blessing on returning it. (In your case not sure since it was purchased but if it is not the same as what you were prescribed still think there should be avenues you could proceed to get the correct one.)

From the first DME I was given the same machine as you -- an M series Plus CPAP. The DME told me it was "smart" because it had a ramp feature and c-flex. Not knowing any better I accepted that.

Actually what the doctor ordered for me was an APAP and not a CPAP. It is up to you to be your OWN advocate!!

Double check your prescription and if you have questions, ask away.

Thanks
No, actually I never did get a copy of the prescription or the results. I was going to get them next time I went to the sleep dr...in about a month or so, which is probably too long to wait if something is wrong.

I think I'm just going to stop by my sleep dr.'s office and have them copy everything for me right then and there. The DME place had the info and prescription obviously, but she/they did not give me a copy or even show it to me, they just said "this is the best of the best" - sounds like the all too familiar sales pitch.

I'm only on a setting of 7, which I understand is on the lower end. Does the C-flex feature make a visible difference? Or is it just another marketing term; so far I haven't really noticed any difference with the 1,2,or 3 setting of it.

But the Smartcard feature is something that I probably would have paid for extra, even if my insurance didn't cover it. It really sounds like something that makes sense, but again, have no idea

When you mentioned the prescription, does the doctor ever write on it about getting one with a Smartcard? Or is that supposed to be just an option offered by the DME?

Like I said, when I walked into the room, the machine I got was on the table ready to go - I wasn't offered any choices.

If I undestand it, and again I am not an expert, the M Plus series is fairly basic. It has the capability of seeing if you are compliant with useage but little else (this information came from another forum member). The first DME said it captures all data but at this point everything they told me was an out and out lie so don't put much faith in what they tell me. I was told you need a Pro if you want your data -- but like I said I am not an expert.
I would stop in at your sleep doctor or your regular doctor (at least mine had the script and sleep study so I could ask her questions) and find out more. I wouldn't wait too long and ask you doctor about upgrading if necessary!!

Apria billed CIGNA $440.00 for Remstar Plus M series (including hose, filters, etc). They billed $218.75 for the humidifier. They billed $60 for the Swift Nasal Pillows and $28 for the headgear.

Since insurance only pays a 'certain' amount, I wonder if they didn't bill them for a ridiculously high price so that your 30% would pay them in full for the device? I'm thinking that your insurance company came out okay but they 'screwed' you.

Try your state insurance commission?

Barbara

Tomorrow is Monday.

1] Take the Respironics Plus back to the DME and insist on a refund. Just tell them the machine is not sufficient for your needs.

2] Call your Credit Card company and notify them that you have returned the machine as insufficient for your needs. Be sure to tell them that they billed and charged you BEFORE they had any way of knowing what your actual copay was w/o billing your insurance first.

3] Call your insurance company and
a] find out what local DME suppliers they are contracted with;
b] what your DME benefits are, your copay and any deductables,
c] can you purchase from a reputable online DME supplier and be reimbursed by your insurance when you provide a paid invoice for the equipment.

4] Contact your sleep lab, inform them you have returned the Respironics Plus to the DME supplier because it is not sufficient for your needs. Ask them to provide you w/a copy of the summary report data from your sleep AND titration studies, including graphs (about 5-6 pages) as well as the dictated reports from each study (usually 1-2 pages) and the equipment order (script). Tell them that the machine you were given, the Plus, was not fully data capable, that it was not capable of supplying your doctor w/the information necessary to monitor your therapy and to give him the information needed to make any adjustments that might be needed, that you can't imagine that he wouldn't be interested enough in your response to therapy to want and need that data. Tell them you are not at all comfortable w/that data NOT being available to your doctor.

Yep, too many "sleep doctors" (??) could care less what CPAP you are provided w/as long as it can be set to and hold the presure he scripts from the results of your titration study. Many could even care less about your compliance!!

The charges from that DME are legitimate allowed charges according to Medicare which sets the standards, including mask, separate from headgear (Medicare will reimburse for a new mask every 3 months, but a new headgear only every 6 months) and including the filters as a separate billable item. It is standard, approved practice.

Items, including CPAPs, are billed by insurance codes, HCPCS codes. The near bottom of the line Respironics Plus w/C-Flex is reimbursed at the same billable/allowed rate as the fully data capable Respironics M Series Pro w/C-Flex as the Respironics Auto w/A-Flex. The Plus costs the DME supplier less than the Pro or the Auto so it gives them a larger profit margin to provide the Plus rather than the Pro or Auto.

Since online DME suppliers don't work w/the insurance companies they don't have as many hoops to jump thru and just bill mask and headgear as one unit, etc. They must meet some government standards but not necessarily Medicare regulations. billmyinsurance dot com and cpapforseniors dot com are the only two online DME suppliers I am aware of who work w/insurance and their prices are accordingly higher but still less than the local DME suppliers.