This Noob's been ripped off - need advice.

I don't recall that the following questions have been asked yet......

How did you happen to choose that particular DME?

Did you sleep doctor give you the physical prescription for your CPAP equipment?

Did you NOT check all these financial issues out with your insurance provider before you signed your name on the dotted line?

If your DOCTOR sent you to (or sent your prescription to) that particular DME, then you MAY have bigger problems......particularly if he's financially involved with that DME......getting him to do anything advantageous on your behalf.

You need to get out of that contract as soon as possible and get your prescription in hand (the physical document), if you don't already have it.


Den

Only thing I can add to this is:

The thing everyone forgets is that the DME does NOT determine the prices. The Insurance Company sets all of that. It's completely out of the provider's hands.

The DME company is not ripping off the insurance company. They don't have control over what they are told to bill.

This is an important point because if these fees are 100% accurate (Which I really really REALLY don't think they are) then that means *anywhere* this person goes and uses his insurance the charges will be the same. Even if he goes through the owners of this website - if the equipment is billed to Insurance then the owners of this site will bill the $5,000.00 cost.

That being said, I cannot for the life of me imagine that the posted prices are correct.

Even when you consider that the Insurance companies have utterly screwed up the pricing structures it doesn't make sense.

We've all gone over this time and again but consider: Insurance companies set a contract that they will pay, for example, 40% of the price they have pre-determined for a product. Instead of staying there though, they then determine a submitted amount high enough to put the 40% reimbursement where it should be.

So if the actual amount they pay is $1,000 that means the submitted amount will be set at a whopping $2,5000!! (2500 x 40% = $1000)

But even with that, how they get things like $1000.00 for a mask. I've never in my life seen any contract that even remotely comes close to that even for the submitted amount, much less the actual paid amount. Even the most insane contracts I saw never had equipment priced at $5,500.00. Not even in the neighborhood.

The first thing I would suggest is to talk to the DME company. Don't go in there with guns blazing accusing them of ripping you or someone else off. That's only going to make things utterly unproductive and get you no where. Especially when you consider they don't have any control over these prices to start with anyways.

The only thing I can possibly think of is that the 5500 charge is maybe for the sleep study? Maybe, I don't know.

I just honestly can't fathom how any contract is going to have even a submitted amount that high.

mattman wrote:I just honestly can't fathom how any contract is going to have even a submitted amount that high.

I have the copy of the paper work that shows the "retail price" for my Bi-PAP AutoSV. (I know this is a more expensive machine.) It shows the purchase price as $6995 and the monthly rental price as $650 per month. I was initially told by the RT at the DME store that the monthly rent would be due indefinitely - $650 per month forever. Later, she corrected the 'rent forever' part of things.

They are only collecting $206.25 per month from my insurance company, however. They will have collected 7 months of rent by the end of this year. Then in January, when my deductible resets, they agreed to a one-time cash payment of $975 from me to finish purchasing the machine. Their $6995 machine will have ended up bringing them $2418.75. I'm assuming that at $2418 they still made a profit. How does this price compare with what you know of, Matt?

But what of the poor sucker that wanders into their office with no insurance and a complicated sleep disorder requiring the Bi-PAP AutoSV? He'll be billed $6995. Plus $245 for the mask, $45 for the headgear (that came packaged with the mask they just sold him), $45 for the hose and $350 for the humidifier. And the will tell him that he needs a new air filter every month and he can buy them there for $10 each.

Thanks,
Tony

Thank you all for your excellent advice. I greatly appreciate all of you taking the time and effort to help me. I will indeed be following Rested Gal's excellent advice. One last question...if I get the DME to take back their machine, should I be expecting that they will refund my insurance company? If they do not refund my insurance company, then the insurance company would likely not pay for the bi-pap or would they? Thanks again, everyone!

In response to mattman's questions: I was referred to a sleep clinic by my ENT (not sleep doctor) for two sleep studies. Each study was billed at the rate of $3,000 each which my Insurance Company knocked down to $1,250 each for their contracted rate. After returning to my ENT following the sleep study, he informed my that my condition was the most severe that he had seen: 3 events per minute; 180 per hour; with blood oxygen levels lower than 70%. He told me I was at an extreme and immediate health risk and that he wanted me on the CPAP as soon as possible. To that end, he had his office staff fax my Rx to the DME who happens to be an affiliate of the lab that performed the sleep study. In fact, the sleep study lab and the DME office are right next to each other back-to-back (left door lab, right door DME) in a duplex office building. The lab tech that performed the sleep studies also works for the DME and she is the person from whom I picked up the CPAP machine. In short, I used this particular sleep lab & DME because that was who I was sent to by my ENT.

I assure you that these rates I stated in my earlier post are accurate. So far the lab has collected $2,500 (insurance) + $500 (my copay). The DME has collected $3,750 (insurance) and apparently I now owe $2,500 for the remaining 40% copay according to the statement of benefits I received from my insurance company. For what it is worth, I was told by the insurance clerk in the DME's office that she had verified the benefits with my insurance company and that my copay would not exceed $800 for the unit, mask & accessories (depending on the mask type I selected). I have not yet been billed by the DME as the insurance benefit was just paid a few days ago.

Lastly, I neglected to mention that the DME did exchange out the mask for me after a few days when I told the technician that the mask was too painful to wear (I still have a mark on my face from where it cut into me). So I started with a F&P FlexiFit 431 ($420 billed to my insurance company) and the DME then gave me a ResMed Swift LT nasal plug mask at no additional charge (and told me that I was only allowed the one mask change out).

$230.00 for the machine new with heated intergrated humidifier. http://www.cpapny.com/ResMed-C-Series-T ... nAodch64LQ Don't pay them any $$. You can get a couple machines here and save $2,000. Actually, find a machine you like, research, and then search the price. Everyone on this forum is about helping save money and sound advice on the proper procedure and machine.

I still think something is somehow getting miscommunicated here. It just doesn't make sense. I honestly think there is more going on here than appears. Insurance and billing is a stupidily complicated subject thanks to the bizarrely archaic systems the Insurance Companies put in place.

DonR22 wrote:Each study was billed at the rate of $3,000 each which my Insurance Company knocked down to $1,250 each for their contracted rate.

This makes sense and is actually right in line with my earlier statement about 40% being about the norm for the difference between submitted amounts and allowable amounts.

DonR22 wrote: The DME has collected $3,750 (insurance) and apparently I now owe $2,500 for the remaining 40% copay according to the statement of benefits I received from my insurance company.

This is the biggest part of your costs and what I think is getting most misunderstood.

For this to be accurate your provider would have to have billed in excess of $9,300.00 FOR ONE MONTH of your machine. You've had this machine for just over 4 weeks per your earlier message so there can only have been 1 billing cycle or maybe in a worst case scenario 2. (The sleep study reimbursement shows an approximate 40% allowable - 3750/40%=9375. Yes we are comparing lab vs dme reimbursement but they won't be that dramatically different)

*AND* they would have somehow had to already collect on the first bill which is extraordinarily unlikely since the average days to pay a claim is still close to 100 days or so depending on the payor.

So I'm back to my earlier assessment that I really think there is more going on here than meets the eye and I strongly advovate talking with your current provider and seeing if they can't help you understand it.

mattman

I think I see the confusion. This machine is not leased. There are no monthly payments. The DME provider sold it to me outright. I own the machine. The DME provider charged my insurance company $5,500 for the c-series tango alone. My insurance plan pays 60% for medical equipment so they actually paid to the DME provider $3,300 leaving me with the other 40% copay. Therefore I owe the DME provider $2,200 for the machine plus additional copays for the mask, and hoses.

What makes me sick is that the DME provider charged my insurance company $5,500 for a machine that costs less than $300 and the provider has already gotten paid $3,300 for it and in all likelihood expects me to pay them $2,200.

So complain to the Better Business Bureau.

Or check with your state government offices on where to direct a consumer complaint.

Take it back and DEMAND a refund!

If necessary, show them the purchasing price from the Internet, where anyone can buy it with a Rx, $230, not $2,000. or $5,000. You shouldn't be paying anything for it, it would be cheaper without insurance at $230. If a company is making a profit at $230 and you know they are or would be out of business, they are making or attempting to make a killing off of you. If you merely gave it back to them and never paid a penny, it's still cheaper to purchase your own. Keep the mask, they are not resellable. No way would I keep it and pay $2,000. or more. Be sure to let them know, that you know, the prices and they were sticking it to you and the insurance. Is it private insurance or Medicare?

Small claims court? Dealing with you in bad faith?

DonR22 wrote:I think I see the confusion. This machine is not leased. There are no monthly payments. The DME provider sold it to me outright. I own the machine. The DME provider charged my insurance company $5,500 for the c-series tango alone. My insurance plan pays 60% for medical equipment so they actually paid to the DME provider $3,300 leaving me with the other 40% copay. Therefore I owe the DME provider $2,200 for the machine plus additional copays for the mask, and hoses.

What makes me sick is that the DME provider charged my insurance company $5,500 for a machine that costs less than $300 and the provider has already gotten paid $3,300 for it and in all likelihood expects me to pay them $2,200.

Well, I have to say... if that all is exactly correct it's crazy.

Those rates are set by your Insurance Company - not the DME provider so remember if you go anywhere else (Including the internet) and have it billed through Insurance the pricing will stay the same. It's not determined by the company doing the billing.

AND - your insurance has set payment roughly TRIPLE even the most generous plans I've ever come across. Friggin crazy.

Another point to remember - the Insurance Companies do not allow a DME provider to offer a lower rate to cash paying customers so you will still be facing stiff prices if you go cash.

So I would absolutely agree with Rested Gal - return the machine to the provider and buy it cash yourself on the internet via a company that does not bill insurance.

Good Luck!

mattman wrote:Those rates are set by your Insurance Company - not the DME provider so remember if you go anywhere else (Including the internet) and have it billed through Insurance the pricing will stay the same. It's not determined by the company doing the billing.

Matt would like you to believe it is your insurance ripping you off and they tell the DME's to multiply all your prices 10x before they will pay. I think that is what IS misunderstood.

More like the insurance saying that is the very most they will consider as a reasonable and customary price. What Matt didn't mention is that when the DME inflates their prices they also inflate what your portion of the bill is. They know this which is why they make you sign a contract.

The thing Matt never mentions is the insurance can't charge you an "upgrade fee" if you insist not to accept their bottom line machine. There is no such fee. Really!

There is one code to bill the insurance for a cpap machine and that's it. Really!!

There have been very good ideas in other threads and if you put them all together a plan comes to mind
Contacting your doctor and have a new prescriptin written is an important step.
Most DME have a 30-60 day policy about equipment and mask.
Tell the DME that you are having problems with the machine especially with you having a 17 it is going to be believealbe that you are still having apnea episodes and that you are still snoring .
Call your insurance company and everything that you do make sure you put it in writing. Your insurance company is there to help you. If you send them a new prescription from your doctor stating that the dme gave you equipment not suitable for your apnea, the insurance company will intercede on your behalf and have your machine replaced. Make sure you know of another DME that you want to use that is in the network. They also might beable to help you get the appropriate equipment.

Also find out who the medical advocats are in yhour area they also can help. Find out if other people have had similar problems with the Dme.

Questions tha I have for you is this.... do you know what other equipment models this DME carries? Find other patients from your doctor who have used this dme and see if the doctor can find out what equipment they have been given from this dme.



Did you ask for assistance from the sleep clinic?