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socalmonkey, This is a tough way to begin a DME relationship. I suggest that you have an actual meeting with the manager, even if he/she has to come to town for it, and level the playing field. Tell them that the one thing you will not stand for is for them as your medical provider to lie to you. That is unethical and very unprofessional. Also you are entitled to see and have a copy of your records. You want to see the documentation of the refusal by your insurance company including the name and number of who refused.

I did not do this with my first DME but actually interviewed my current one before doing business with them and specifically told them to be honest with me and they have been.

Also, I don't know about your insurance but mine (United Health Care) has a few on contract, but only 2 "preferred". One being Apria and I knew I didn't want them. The other could have been called "The DME from hell" but they have a peaceful sounding name.

When looking for a new one, I reversed the process and looked up DMEs in the yellow pages then called and asked the insurance company if they were in-network. They cut through the list when you give them names. Afterward I looked them up on the network web site and found only the two preferred DMEs. The others were mislabeled as labs, or under a different category for nation wide in-network DMEs. So, I recommend checking with them one more time before being stuck.

Anyway, I wish you luck and determination in dealing with this situation.

GOOD NEWS! I got the "equipment specific" prescription from my doctor today no problems!

So early this morning I called my insurance company, and had them switch the DME on my "notification" request. Faxed all the info to the new DME, and things are looking up. I will follow up with them tomorrow. Now I should be able to get the specific equipment I need, since it's on my script. Although I doubt it will happen until next week. But my luck seems to be changing... and if it weren't for all the good advise on this site, I might still be in DME hell.

OldLincoln: I have the same insurance as you. The DME you mentioned, is the same one I didn't want to go through originally. But now I am going to them. Since they seem perfectly happy to supply exactly what's on the script. Time will tell.

Thanks everybody, for the support. Listening to my story is not new for many of you. I appreciate the hand holding, as I go through the same thing. I hope my next post will be that I got the equipment! Here's to sweet dreams!

Muse-Inc wrote:...The DME has the mask on order...

Talked to sleep doc this morning: he's pleased with the 5 night's data (the events and O2s data), lot better than PSG with a lower pressure needed; he had my CPAP pressure set lower. He dicatated a ltr to insurance for an APAP when chatting with me...did tell me they won't want to approve but maybe we can get it because on APAP I had fewer wakeups and improved daytime sleepiness and many patients report better therapy and comfort using an APAP which improves patient compliance. He strongly recommends approving an APAP for me. Too, he just had another patient this morning, a guys who's lost about 55#s, who is having to go to a hybrid mask because of mouth leaks that weren't there before the wt loss. I call back in 2 wks to see what insurance says *sigh*. 14 more days on CPAP and even then it might not be approved...I breathed so much better on APAP.

EDIT: He's not concerned with leaks at this point, the Hybrid will likely take care of it. He's also not concerned about the what seem to me to high & seemingly erratic pulse rate following events; he said if it continues to worry me, to have my cardiologist do an overnight Holter studey but he said it sounds like expected behavior that I'm probably just noticing as I likely haven't have many events until I started leaking CPAP air...that I likely had become accustomed to it before the PSG.

Called CPAP guy and the DME has not ordered mask contrary to what he said yesterday, did say they don't usually carry any hybrid-style masks and will have to determine their cost, discuss with supervisor, yada yada yada . He said he'd call me back after this afternoon's meeting. If I were stil working, I'd just order the mask from Johnny *sigh*. I'm not impressed with the DME.

GOOD NEWS CONTINUES... my insurance company approved everything today! 100% covered and approved! No questions or concerns about the sleep study like the old DME claimed. I am so happy. Everything seems to be going well with the new DME (my original one from 3 years ago). They confirmed my order and specific equipment today. It seems I might have been prejudging them (or would that be post judging them). It's going smoothly like it should have right from the beginning.

On Monday I should be either picking up the equipment or have an appointment for Tuesday. I'm going to press them hard for Monday (my day off). There's a chance I have to attend a class on the A-Flex machine. Has anybody ever heard of that? The class is only held on Tuesday. They make you attend the class before you can pickup the equipment? We shall see.

But I am confident this a done deal. One of the big keys, seems to be getting the exact equipment specified on the prescription. Just like many people here have said. I wouldn't think it matters, but apparently that is how the game is played. And going to a DME that seems to be primarily a CPAP supplier. They seem more knowledgeable and focused on one thing.

So perseverance is paying off. Thanks again for all the support!

I asked my PCP to write my prescription for the exact machine I wanted. She did so and I never heard a peep from the DME about not being able to get that machine. I got the machine I wanted so I was happy.

socalmonkey wrote:If I can ever get through this nightmare with my new DME,...

I had my own set of problems with my DME. I finally bought the equipment I wanted at cpapauction. It is one way to end the problems, and, not that expensive. Figure $500 to $700 for a good bibap

--G

socalmonkey wrote:GOOD NEWS CONTINUES... my insurance company approved everything today! 100% covered and approved! ...

You might want to double triple check on the 100% covered. Turns out my equipment was covered up to a limit. I found out about the limit 6 months after the charges were incurred. And, that's after I called (3 times) to the insurance company to check the charges were covered.

Read the verrrrrrrrrry fine print

--G

Insurance companies are as bad or worse than the DME's. "We can't guarantee coverage until a bill is received". Why? Why can't you look up the coverage a person has? What is so hard about that?

This thread should be a book representing the pitfalls of working with some DME's I started with mine 7 months ago, and I'm still trying to get a chinstrap from them. Occasionally they will bring one out in, encased in sealed plastic. I have been told, if you open the plastic, you buy it, if it fits you - or not.

Your DME sounds like it is just giving you the runaround - is there still a thing in this world as business loyalty to their patients? Dah, who keeps them in business. Guys like you.

DME's of the world, Awake.

Good luck in getting this resolved.

Jan

georgepds wrote:

socalmonkey wrote:GOOD NEWS CONTINUES... my insurance company approved everything today! 100% covered and approved! ...

You might want to double triple check on the 100% covered. Turns out my equipment was covered up to a limit. I found out about the limit 6 months after the charges were incurred. And, that's after I called (3 times) to the insurance company to check the charges were covered.

Read the verrrrrrrrrry fine print

--G

I have a great plan from United. It's an EPO and I absolutely have "no limits" for 100% of DME (In-Network only). I work for a large national company who takes very good care of it's employees.

socalmonkey wrote:

georgepds wrote:

socalmonkey wrote:GOOD NEWS CONTINUES... my insurance company approved everything today! 100% covered and approved! ...

You might want to double triple check on the 100% covered. Turns out my equipment was covered up to a limit. I found out about the limit 6 months after the charges were incurred. And, that's after I called (3 times) to the insurance company to check the charges were covered.

Read the verrrrrrrrrry fine print

--G

I have a great plan from United. It's an EPO and I absolutely have "no limits" for 100% of DME (In-Network only). I work for a large national company who takes very good care of it's employees.

Cigna Choice PPO here, unlimited for DME, but I have to pay 20%... Still not a bad deal.

Wow... and here I think I have it bad.

I deal directly with the DME and my insurance. My DME and insurance do NOT talk to each other. I go to the DME with a list of things I want, they assemble and I pay out-of-pocket. Then I submit claim to insurance. About 2 weeks later I get a cheque in the mail for 100% out-of-pocket.

The only problem with this kind of system is that you need to have the cash to make the out-of-pocket purchase... which when time comes for a new machine is going to be around $2,000.

Well I finally have it... an appointment that is... to pick-up the equipment tomorrow at the DME.

It's a good thing I kept calling them today, or I would still be waiting for an appointment. My first call this morning was met with "you have to talk to so an so". Several calls to her voice mail (all morning) went unreturned. I waited until early afternoon, then called again. By luck, got the same nice person I talked to Friday. She looked it up and said, "oh it looks like it was completed late Friday, so you need to make an appointment". Hello... that is what I was trying to do all morning. I pressed for today, but settled for the next available appointment. Now I have to take time off work to do this. Too bad it couldn't have happened today (my day off).

But if hadn't been this persistent, I would still be waiting. Since I started with the "A" company DME last Thursday, every contact with them has been initiated by me. They never have called me. So apparently this is how the game is played.

So my nightmare is almost over. Here's to dreams of data... coming soon!

socalmonkey wrote:So my nightmare is almost over. Here's to dreams of data... coming soon!

Congratulations for your persistence. <g> I got my titration moved up several weeks by calling and calling -- and my post-titration appointment by more than 6 weeks. I think I also expedited my machine by several weeks. You're right, though. Every contact with Big A is initiated by me.

All stubbornness. Remember the stubbornness. There will be humps as you adjust to this new way of life. But you have demonstrated that you have the persistence and stubbornness to make it!

The nightmare goes on and on and on....

So CPAP guy at the DME called me yesterday and informed me that I hafta pay up front and then get re-imbursed from insurance -- ain't gonna happen 'cause I'm still battling re-imbursement from last Dec when the on-call nurse sent me to an Urgent Care place (whom they now claim is not in-network) instead of the ER at my chosen hospital. Because I've got the ID of the call, they can't deny I made up the nurse's recommendation...at least they keep good records. I ask, How much? and he says, I'll get back to you and a bunch of BS re cost and profits etcetera.

He calls me back just now <obviously they just calculated how much to gouge my insurance for the mask>, tell me that my insurance does not have pymt rates for this mask <what? am I the only one in the State wanting a Hybrid?> so they'll use the Medicare rates which should be similar, and then informs me that I'll hafta write a check for $301+ before they'll order it!!! Johnny gets something like $120.

This whole DME racket is insane. Medical insurance is so driven by the profit-motive that Americans will never pay reasonable prices for medical care, drugs, & equipment -- get rid of the greedy insurance bums, I'm for a single-payer plan...gotta be better than the unholy alliance of avarice and power we've got now. Living on unemployment in a State that pays minimal rates (oh, I'm grateful for what they do pay from what they've collected from employers don't get me wrong but my buddy in WV gets $100+ more than I and both of us are in the top tier in our State), this is depressing .