So.... 2 DMEs walk into a bar....

I found a good DME that is in-plan with my insurance. I'm 100% covered in-plan. UNfortunately, they don't dispense Resmed equipment. They're a really small DME. So I call another one preferred by the new sleep doc's office. I start asking questions. I ask if they dispense Resmed S9 auto and they start to tell me there's a $200 or $250 upcharge.
Heeeeere we go again.

"Really? What billing code is that?"
"Excuse me?"
"An auto CPAP is still a CPAP and is covered under the E0601 billing code. If you're a participating provider, how can you charge more than insurance allows for that billing code?"
"Well we'd have to call Nova for pre-authorization"
"OK, I guess this is one of those conversations I'll need to have with my doctor."

But first I'll be calling my insurance company. If I'm 100% covered for in-plan providers (no co-pay, no deductible), then I shouldn't have to pay a DIME for a machine. I'm going to ask the insurance company what they allow for E0601. IF it is a 13 month rental at $101 per month (which is what I suspect it is), then the DME will collect $1313 for an S9 that they MUST be buying below $850 because I can buy it out of pocket for that. The heated humidifier is in a similar situation and between the 2 items, the DME would collect something on the order of $572 profit and that's based on MY cost. I know their cost is lower. Well over 50% markup. Not too shabby.

I hate this part. It's like buying a used car from a sleazy salesman.

But think how many times that must work for them!

Lizistired wrote:But think how many times that must work for them!

Oh I think you're quite right. When I was brand new to this, the DME sent me home with a $300 machine for which they collected $1365 and they never talked to me after they dropped off the machine until I called THEM and told them I was on to their little wheeling and dealing and I wasn't paying them $20 a month any more (my "co-pay"). So they merrily went on charging my insurance company the $85 and "forgave" my co-pay.

Seriously?

Some of these places are unbelievable. They just rip people off until someone calls them on it. Then it's "oops, your right" and that one person gets taken care of and everyone else continues to be ripped off.

This is one of my pet peeves. Don't get me started... hehehe

When I went DME shopping, both places I went to had M-series machines on display. I wonder if that's what they would have given me if I hadn't done my homework.
Buyer Beware!

yardbird wrote:I found a good DME that is in-plan with my insurance. I'm 100% covered in-plan. UNfortunately, they don't dispense Resmed equipment. They're a really small DME. So I call another one preferred by the new sleep doc's office. I start asking questions. I ask if they dispense Resmed S9 auto and they start to tell me there's a $200 or $250 upcharge.
Heeeeere we go again.

You call that a good DME?

I tend to believe that any DME could order 'ANY brand equipment' they want - IF they want "your business". Ask your insurance.

Maybe you should setup a sting?

I'm tempted to say obviously these guys don't operate in a free market, because if they did, free market forces would shake out the bad guys and leave only those who provide the best deal for consumers. But I won't say that.

Oops, I just did.

GumbyCT wrote:You call that a good DME?

I tend to believe that any DME could order 'ANY brand equipment' they want - IF they want "your business". Ask your insurance.

Maybe you should setup a sting?

Well I thought they werew good based on the pricing for the new mask. They weren't ripping off my insurance. But it turns out their offerings are limited to a very narrow choice of manufacturers for CPAP stuff because the vendor THEY get their stock from doesn't deal with all manufacturers.

And you're right, I find that odd. They dispense M series respironics machines for autos. .... which is why I have to go DME shopping again.

In talking to friends who have recently started to use machines, I am amazed at the ignorance and indifference they display. They obviously haven't done any self-education and don't want to know more or talk about their therapy. That's why DMEs can get by with murder. When I asked questions and refused the first machine my DME tried to give me and told them why, they were flustered into a string of lies and evasions. Most of their customers blindly accept what they offer. I've stopped trying to get a support group started where I live because no one cares!

Just got off the phone with my insurance company. They are EXREMELY helpful and pleasant to deal with and seem to genuinely CARE that I'm asking questions of the providers in order to save money (theirs AND mine!)

I told them that this DME is telling me there is an "upgrade charge" for the S9 Autoset because it has "special features". I told the insurance company rep, "It's an E0601 billing code. Can the DME charge the patient more than the allowed insurance if they are IN-PLAN and participating?"

The answer was , "No, they can't. If they're participating, they're under contract to accept payment from us as payment in full. Patients would be responsible along with any co-pay if that is part of the patient's plan, but on your plan you have 100% coverage for this so they can't charge extra."

So.... we'll see how this all plays out.

Forearmed is forewarned, people.
Don't let them snow ya.

Good for you for not letting yourself be taken advantage of.

Tell the DME you don't intend to pay the upcharge and if they have a problem with that you'll let the fraud dept of your insurance company decide. Even better if you do it in writing, cc to the insurance company. That usually gets the DME's attention.

Just fired off an email to the insurance company so that I (hopefully) get a written response. Explained the situation without naming the DME, explained what machine I want and provided the billing code it's covered under (E0601) and asked point blank if an in-plan DME is allowed to Balance Bill a covered purchase. I guess I have to wait to see what response I get back.

Meanwhile if they tell me the DME *can* do this, I just won't be getting a new machine. I'd rather pay out of pocket and work with an out-of-plan provider and deal with deductibles and partial reimbursement, than deal with a shyster DME.

I just purchased a F/P flexi fit 432 from our DME; who now say there will be an UPCHARGE on replacement cushions.
Their excuse--it's more expensive--$95;. I called BCBS and they said,"They can't do that"
I'm planning to buy from cpap.com ($44.95) until my 2012 deductible is satisfied; and I told them so.

chunkyfrog wrote:I just purchased a F/P flexi fit 432 from our DME; who now say there will be an UPCHARGE on replacement cushions.
Their excuse--it's more expensive--$95;. I called BCBS and they said,"They can't do that"
I'm planning to buy from cpap.com ($44.95) until my 2012 deductible is satisfied; and I told them so.

Makes ya wonder if "They can't do that" then how do they continue to get away with it? Doesn't it?

yardbird wrote:

chunkyfrog wrote:I just purchased a F/P flexi fit 432 from our DME; who now say there will be an UPCHARGE on replacement cushions.
Their excuse--it's more expensive--$95;. I called BCBS and they said,"They can't do that"
I'm planning to buy from cpap.com ($44.95) until my 2012 deductible is satisfied; and I told them so.

Makes ya wonder if "They can't do that" then how do they continue to get away with it? Doesn't it?

Because most people don't question anything and don't bother to read the EOB statements they get in the mail. Try asking friends how much an office call is. Mine just state their co-pay. They have no idea what the dr charges. Or that the charges vary depending on your insurance and so does your treatment. That's why we are out of the loop unless we fight to stay in, and health care costs continue to skyrocket... and the healthcare industry continues to make billions of $$$$$$$.

It's just so tiring to have to play this game. I know, I know.... I've been a hose head almost 20 years. I should be used to it. It just frosts me that we HAVE to be "used to it".

I won't give in though. Heck, I've already been dead. Doing this stuff is easy by comparison.