This Noob's been ripped off - need advice.

jules wrote:So complain to the Better Business Bureau.

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

I would seek the advice of your state's attorney general and the insurance commissioner. Ask them questions and follow any and all advice they provide you.

They are there to help you and these days you may find one who now has a cpap. Be sure to ask how to contact your states licensing authority. They do have guidelines the should be following. They could very well have other complaints already. Unless those before you have turned theirs heads enabling you to find out what it's like to be on the receiving end.

There are many good plans above to clean up this mess but make sure it gets documented by the licensing authority. In CT it is the Health Dept.

Good Luck

Really wrote:

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!!

I usually don't pay any attention to this person as they are usually only trolling my posts but I have to respond to this since it could cause someone a lot of headaches if they thought it was true.

Submitted amounts are almost always set ahead of time by the Insurance Companies. I'm sure there are exceptions to that but if they exist they are just that - exceptions. And the part about signing a contract because of it - well I'm pretty sure most people know that's not the case.

The biggest thing I wanted to respond to though was the upgrade part. I'm not sure why that's even relevant to the topic at hand but whatever.

Upgrades are very often specifically disallowed under many of the contracts signed by a provider. Heck up until last year Medicare didn't allow it at all. Now they do allow it but only in certain cases and under very strict guidelines (All paperwork has to be written up BEFORE equipment is ever provided, for example. So if you start out on one device a provider can't then upgrade you later on). To make matters worse, in many cases where the idea of upgrades isn't specifically addressed, the contract wording is vague enough that a lot of providers don't want to do upgrades for fear of legal action down the line. There absolutely have been cases of providers charged with insurance fraud for providing upgrades even though it was in the patient's best interest to do so.

MattMan, forgive me, but I do NOT buy it. IF the insurances have that much control as you maintain you do - you must be in a special area of the country where they are experimenting. What makes it MOST unbelievable is that ANY insurance company would okay such OBSCENE prices and rates for such crappy equipment!

Gumby has the right idea. Contact your state attorney general, state licensing bureau, etc., etc. This DME deserves to be drummed out of business.

Slinky wrote:MattMan, forgive me, but I do NOT buy it. IF the insurances have that much control as you maintain you do - you must be in a special area of the country where they are experimenting. What makes it MOST unbelievable is that ANY insurance company would okay such OBSCENE prices and rates for such crappy equipment!

Gumby has the right idea. Contact your state attorney general, state licensing bureau, etc., etc. This DME deserves to be drummed out of business.

That's why I've been saying all along it just doesn't make sense.

I agree with you 100%. But look at this another way -

Insurance companies only pay claims as outlined in a contract. NOTHING gets paid that isn't on a contract. A business can get a prescription from a doctor for a new car that the doctor states is medically neccessary. It's not going to get paid though - because it's not on a contract.

There is NO way the costs previously posted would have been paid had it not been on contract. Hence my earlier comment about having the most insane insurance policy in history

Insurance companies absolutely have the control. They set the contracts - you either sign them or you don't get the business. Period. Why do you think so many doctors have decided to close their practices? Between their own costs for insurance (Malpractice especially) coupled with the insane hoops patients insurance makes them go through and it's just not worth it anymore. Believe me, from having been on that side of it for a long, long time. There are days when you just walk away thinking "Screw it, why even bother anymore." Spend countless hours collecting paperwork that shouldn't be neccessary just to provide something that I don't always agree with. All to wait a year sometimes just to get paid. Sounds like fun doesn't it?

GumbyCT wrote:I would seek the advice of your state's attorney general and the insurance commissioner. Ask them questions and follow any and all advice they provide you. . . .

Good advice, here.

All the argument over whether it is the DME or the insurance company setting prices doesn't matter to you. Let the state attorney general figure out who is ripping you off. (My personal opinion is that it is probably the DME, but my opinion doesn't really matter either.)

Wayne

Slinky wrote:What makes it MOST unbelievable is that ANY insurance company would okay such OBSCENE prices and rates for such crappy equipment!

Agreeing, I think they would limit any amount payable by contract NOT the other way around. Let's face it Insurance Co.'s are also in business to make money.

mattman wrote:That's why I've been saying all along it just doesn't make sense.

Finally, something we can ALL agree about.

Slinky wrote:MattMan, forgive me, but I do NOT buy it. IF the insurances have that much control as you maintain you do - you must be in a special area of the country where they are experimenting. What makes it MOST unbelievable is that ANY insurance company would okay such OBSCENE prices and rates for such crappy equipment!

Gumby has the right idea. Contact your state attorney general, state licensing bureau, etc., etc. This DME deserves to be drummed out of business.

Really!!

mattman wrote:That's why I've been saying all along it just doesn't make sense.

I agree with you 100%. But look at this another way...

Is this what talking out of both sides of your mouth really looks like? Really??

Really wrote:

Slinky wrote:MattMan, forgive me, but I do NOT buy it. IF the insurances have that much control as you maintain you do - you must be in a special area of the country where they are experimenting. What makes it MOST unbelievable is that ANY insurance company would okay such OBSCENE prices and rates for such crappy equipment!

Gumby has the right idea. Contact your state attorney general, state licensing bureau, etc., etc. This DME deserves to be drummed out of business.

Really!!

mattman wrote:That's why I've been saying all along it just doesn't make sense.

I agree with you 100%. But look at this another way...

Is this what talking out of both sides of your mouth really looks like? Really??

You hit that squarely on the nail head!

My DME was one that told me Medicare would only pay for a basic machine, not an auto. They said I would have to pay a $300 upgrade charge if I got the auto. I figured to call the insurance and see if they would pay for one if I purchased it on the Internet which would in reality be cheaper than a DME. I also asked for the newer Pr One System over the M series. He told me they had seen it at a show and the M series was a better machine. Since Phillips purchased Respironics he thought they were producing a cheaper machine to increase their profits because insurance would eventually pay less with Obamaism. He went on to say, they would not stock the newer machine because it was still unproven. He said they would order me one if that was what I wanted. He also said he would waiver a $300 upcharge for either machine. So, I got the bipap auto M series about 2 weeks ago at no charge to me. Maybe that was what you were talking about?

Oh, horsepuckies that Medicare won't pay for an upgraded device. If the dang device is the same HCPCS code as the one originally offered the reimbursement is the same. Its just that the DME doesn't want to cut into their own profit margin by providing a somewhat more expensive device that is the same HCPCS code. I certainly had no problem upgrading from a bottom of the line Respironics Plus to a fully data capable Resmed S8 Elite back in October of 2006. And since I had a history of returning that Plus and dumping a sheister DME provider I didn't get any argument when I was switched to a bi-level and insisted on the Resmed VPAP Auto in early 2008. They were well aware I would refuse and go elsewhere if I didn't get what I wanted (of course, what I wanted was w/in reason - for instance,I wasn't insisting on a bi-level when my script called for a CPAP).

Slinky wrote:Its just that the DME doesn't want to cut into their own profit margin by providing a somewhat more expensive device that is the same HCPCS code.

I agree with that 100%. When I didn't go for it and put them off, they came back with no upgrade charge. Also they said the Rx only said bipap, not auto.

Slinky wrote:They were well aware I would refuse and go elsewhere if I didn't get what I wanted

I believe that was the reason they said I could get either machine and they would waiver any upgrade fee. I guess they knew I could get it elsewhere and something was better than nothing on profit. I did go by my doctors office and got an upgraded prescription, stating auto bipap and even the PR System One on the script, but I got the M series by choice. So I guess everyone should learn before leaping.

Yeah, but that isn't the way the sleep medicine system is set up to work. It is set up to keep you totally uneducated and in the dark about the various choices and options in brands and models of xPAPs so you don't know any better and accept the bare bone devices they pawn off on you at top dollar.

I''ve come to the conclusion that it is more lucrative for some of these local DME suppliers to keep their CPAP clients uneducated and if 50% of them end up non-compliant, oh well, these DME providers make enough profit on the other 50%.

Cheaper for them than the wages of a GOOD RRT who knows xPAPs and how to properly fit a mask, cheaper than going thru the hassle of a lenient mask exchange and providing fully data capable xPAPs .... and w/all the current publicity about sleep apnea there should be lots more uneducated newbies to fleece coming their way.

Patrick A wrote:

Really wrote:

Slinky wrote:MattMan, forgive me, but I do NOT buy it. IF the insurances have that much control as you maintain you do - you must be in a special area of the country where they are experimenting. What makes it MOST unbelievable is that ANY insurance company would okay such OBSCENE prices and rates for such crappy equipment!

Gumby has the right idea. Contact your state attorney general, state licensing bureau, etc., etc. This DME deserves to be drummed out of business.

Really!!

mattman wrote:That's why I've been saying all along it just doesn't make sense.

I agree with you 100%. But look at this another way...

Is this what talking out of both sides of your mouth really looks like? Really??

You hit that squarely on the nail head!

Makes you wonder when there is only one person on the internet who has this intimate knowledge of the internal workings of ALL insurance companies. Really!!

Slinky wrote:Oh, horsepuckies that Medicare won't pay for an upgraded device. If the dang device is the same HCPCS code as the one originally offered the reimbursement is the same. Its just that the DME doesn't want to cut into their own profit margin by providing a somewhat more expensive device that is the same HCPCS code. I certainly had no problem upgrading from a bottom of the line Respironics Plus to a fully data capable Resmed S8 Elite back in October of 2006. And since I had a history of returning that Plus and dumping a sheister DME provider I didn't get any argument when I was switched to a bi-level and insisted on the Resmed VPAP Auto in early 2008. They were well aware I would refuse and go elsewhere if I didn't get what I wanted (of course, what I wanted was w/in reason - for instance,I wasn't insisting on a bi-level when my script called for a CPAP).

Do you mean ICD9 code? AlsoI had one of those bottom of the barrel Respironics Plus from "ARO" what a joke that was and what a joke they are "ARO".