DME question

there may be more hidden than this ----

my insurance contract with this DME chain 4 years ago was --- so I was told ----- DME gets paid 80 % of what they bill - then my part was - of that 80 %, when you divide that 80 % in 100 pieces, I pay 10 of those, insurance pays 90 of those. So I would be charged 8 % of what they billed and of course do they bill all insurance companies the same - I seriously doubt it -

also the contracts were even more complicated - my insurance is CIGNA card but on it at the time it said "First Choice" - all 3 had contracts with the DME chain - the State did (they paid the premiums and was self funded), CIGNA did, and First Choice did and the DME company and insurance ppl had to juggle all 3 sets of numbers and deal with them. At that stage it was more than I wanted to know about and consistency from month to month paying for the O2 I had been on wasn't there.

jules wrote:Yep, a DME dealing with insurance bills by the piece not the package.

When I got a swift from a major DME my insurance got billed for the headgear, the mask and a nasal pillow and refused to give me all 3 sizes without my money to pay for the other two sizes because they could sell them to other patients for replacements.

Sounds exactly like what Mattman said he does(or did) in another thread and justified it.

"Save the 'DME' !! "

it really boils down to if you want to use insurance, you deal with their rules and expect hassles

if you really want a new mask or machine, you pay out of pocket

GumbyCT wrote:

jules wrote:Yep, a DME dealing with insurance bills by the piece not the package.

When I got a swift from a major DME my insurance got billed for the headgear, the mask and a nasal pillow and refused to give me all 3 sizes without my money to pay for the other two sizes because they could sell them to other patients for replacements.

Sounds exactly like what Mattman said he does(or did) in another thread and justified it.

"Save the 'DME' !! "

Please don't misquote me. Thanks. I know you have it in for me but at least quote me accurately. I'm sure you can still find things I've said that you think are horrible without making new things up.

What he's incorrectly alluding to was one of the first threads I was ever involved in here back in like 2006 when people were discussing DME companies keeping things like extra pillows out of masks.

I commented that we sometimes (no always) did keep the extras that no one was using specifically so that we could give them away at no charge to other patients who needed them.
I also further went on to say that based on what I heard from people here we were also changing our ways to specifically ask people if they minded if we did so. FYI - all but maybe 1 or 2% had any problems with us doing so. In fact, most of them said they would have been thrown away as they didn't care about extra sizes that didn't fit them anyways.

Here's the thread by the way:
viewtopic.php?f=1&t=14864&p=125362&hili ... ws#p125362

cinco777 wrote: Let's see if I fully understand what you are claiming. My Insurance Company tells its DME (it only contracted with one) to Bill it (the Insurance Company) for my AutoCPAP machine at $875 and my machine's STANDARD feature, a Card Reading module, at $305, for a total of $1180, as these are the numbers on the invoice that I receive from my DME, along with my 20% copay amount of $236. However, you state that my Insurance Company has previously told its DME (in a hidden agreement/contract that we the insured never see) that it will only pay the DME a smaller "allowable" 'y' amount. For math purposes, let's say this "allowable" 'y' amount totals $260. So, as the insured, I may think (if I am naive) that I am getting a really great deal since I am only paying $236 for a machine that costs my Insurance Company $1180.

However, since the Insurance Company is only paying the contracted (hidden) "allowable" amount 'y' of $260, it is really a great deal for them as they only pay $24 to the DME for the machine and I pay $236, 10x as much. Since you are an ex-DME with insider expertise, please correct any "bad" assumptions, including math, that I have made in my example.. Thanks. I'm so so glad that my online vendor didn't have these bothersome "consipiratorial" restrictions.

Not sure where the conspiracy and hidden parts come in but in a roundabout way I think you've got it. I told you, Insurance Companies suck! lol Now try making a living out of not only understanding it all, but understanding ALL the different companies and the different ways they do stuff! It's just a bucket of laughs all the time I tells ya.

But in a nutshell yeah, you have:

Insurance company sets up billing codes and rules for how to bill an item. Say, a CPAP setup might be broken down as a CPAP Machine (E0601) a Mask (A0701), Headgear (A0702), Chinstrap (A0703), Humidifier, etc etc. (Codes aren't right, just illustrating)
This is what they require a provider to submit on a bill to them when those items are provided.

Insurance Company sets an amount they are billed for a CPAP - say $1,600.00 (This is the 'submitted amount')
This is what whatever provider you use is to put down on a bill (Same if it's an online provider or brick&mortar)

Insurance Company ALSO sets an amount they will actually pay - say $900.00 (This is the 'allowed amount')
This is usually a percentage of the submitted amount and is usually around 40-60%.

You should be able to get both those amounts from your Insurance Company or (usually easier) from your equipment provider. They wouldn't actually know it until they verify your insurance since they are all different and even within the same company each policy can be different (For example, Blue Cross Blue Shield of Florida has hundreds of different plans and the specifics on each can vary wildly).

Wulfman wrote:

mattman wrote:Again, it's how Medicare has set it up.

Medicare (And other insurance companies) decided that items should be billed seperately.
Again, it's how Medicare has set it up.

Medicare (And other insurance companies) decided that items should be billed seperately.

Which one is it? Medicare or the insurance companies?
Do the insurance companies go by what is established by Medicare/CMS? I suspect that's the way it is, but I'd like a clarification on this. It would help explain why things are so screwed up.


Den

Yeah, I use the terms more or less interchangeably. And yes, most Insurance companies wait for Medicare to setup guidelines and then just either follow them (most cases) or use them as a launching point and modify them (occasionally).

m

I didn't quote or misquote anyone - re-reading your link - I standby what I said.

You, my friend, are trying to put a positive spin on getting your hand caught in the cookie jar. Why is that DME no longer in business?

GumbyCT wrote:I didn't quote or misquote anyone - re-reading your link - I standby what I said.

You, my friend, are trying to put a positive spin on getting your hand caught in the cookie jar. Why is that DME no longer in business?

mattman wrote:......... I guess I should have clarified a bit better. I'm not talking about any of this happening all the time or even on a regular basis. I'm talking about snagging parts to keep a small handfull of extras around. A few here and there is all anyone I know does. And you are correct - we should ask.
........

So mattman, your position in the past was "just a little bit" of stealing was OK. What is your position now?

If a client were to be asked if they wanted to donate extra pillows or cushions (unused sizes) to others in financial need, that would be one thing. However at the DME I went to this was not the case. They were open that if I wanted more than one I had to pay for them (had to pay for the first - not included in the mask price even), and they were going to sell the other pillows from the box to others.

GumbyCT wrote:I didn't quote or misquote anyone - re-reading your link - I standby what I said.

You, my friend, are trying to put a positive spin on getting your hand caught in the cookie jar. Why is that DME no longer in business?

Who said they aren't? They absolutely are. Sorry

rooster wrote:

GumbyCT wrote:I didn't quote or misquote anyone - re-reading your link - I standby what I said.

You, my friend, are trying to put a positive spin on getting your hand caught in the cookie jar. Why is that DME no longer in business?

mattman wrote:......... I guess I should have clarified a bit better. I'm not talking about any of this happening all the time or even on a regular basis. I'm talking about snagging parts to keep a small handfull of extras around. A few here and there is all anyone I know does. And you are correct - we should ask.
........

So mattman, your position in the past was "just a little bit" of stealing was OK. What is your position now?

Well, as I said here AND as I said in the earlier thread - I absolutely took to heart what people here said and we started asking patients.

However - I have to really stress this. You do NOT have any comprehension of the average CPAP patient. The *only* reason we ever started keeping any extras (And again, I also want to stress this was not all the time) was because they were being thrown away.

I honestly, genuinely saw thousands of dollars of items being thrown away month after month when I also knew good and damn well (because we took care of them as well) there were many patients without insurance who needed those exact same items.

You really don't have any idea what most patients are like. They are NOT the patients you see here. I'd say that fully 80% of the time if a patient was setup at my office they would get up to leave and leave every bit of paperwork, boxes, instructions, packaging etc there and ask me to throw it away. I'd have to FORCE a lot of people to at least take home their paperwork and the instructions. I'm not exagerating.

So you tell me how awful my mindset was when, instead of allowing *SOME* of this stuff to get thrown away I kept it around so I could give it away to others in need.

However - I also still stand by my apology. You're correct. I had no right to do so without explicitly asking ahead of time. I changed that and began doing so.

You make it sound like we were preying on innocent people, rubbing our hands together and trying to think of ways to screw people over. All anyone was ever trying to do was stop useless waste and help people who needed it.

mattman

jules wrote:If a client were to be asked if they wanted to donate extra pillows or cushions (unused sizes) to others in financial need, that would be one thing. However at the DME I went to this was not the case. They were open that if I wanted more than one I had to pay for them (had to pay for the first - not included in the mask price even), and they were going to sell the other pillows from the box to others.

That is absolutely, unequivocably wrong. Horrible, dishonest and shouldn't happen. You should damn well be given what you paid for. And if someone DOES recover unused pieces from a product that was sold they damn well have no friggin business selling that part.

mattman

It wasn't until I purchased some CPAP equipment (backup machine, replacement mask, accessories, ..) online that I realized that my DME was short-changing me. My DME had removed items from the box/package before they shipped it to me. I mentioned my observations re my two prior DME shipments to the RT that was ordering my F&P standalone Humidifier from the DME. She told me to be sure to check two things when the package arrived: 1) make sure that the box wasn't a Respironics logo'd box as the DME was shipping Respironics humidifiers irregardless of what was ordered, and 2) don't let the delivery person leave until you open the box and ensure that nothing is missing (I knew that two water chambers should be present along with the short hose connection).

I guess that I was lucky the 3rd time as the box did contain the F&P Humidifier (with all accessories) that I wanted and the RT ordered.

Now that I have my machine, mask, and humidifier from my DME, I am now purchasing my CPAP equipment from CPAP.COM and CPAPAuction as I don't want the surprise and suspense of opening a DME delivered box not knowing what I may find missing!

cinco777 wrote:It wasn't until I purchased some CPAP equipment (backup machine, replacement mask, accessories, ..) online that I realized that my DME was short-changing me. My DME had removed items from the box/package before they shipped it to me. I mentioned my observations re my two prior DME shipments to the RT that was ordering my F&P standalone Humidifier from the DME. She told me to be sure to check two things when the package arrived: 1) make sure that the box wasn't a Respironics logo'd box as the DME was shipping Respironics humidifiers irregardless of what was ordered, and 2) don't let the delivery person leave until you open the box and ensure that nothing is missing (I knew that two water chambers should be present along with the short hose connection).

I guess that I was lucky the 3rd time as the box did contain the F&P Humidifier (with all accessories) that I wanted and the RT ordered.

Now that I have my machine, mask, and humidifier from my DME, I am now purchasing my CPAP equipment from CPAP.COM and CPAPAuction as I don't want the surprise and suspense of opening a DME delivered box not knowing what I may find missing!

Well that sucks and I don't blame you for sure! Out of curiousity, what was missing?

I was also repeatedly billed for canulas and O2 tubing (was on O2) that were included as part of the package. I was billed for refills for the E tank which was there for their convenience. I fought all of those. I spent 2 hours a month trying to get the O2 bills straightened out. Once I was taken off O2, I dumped that DME very hard and fast.