Possible Insurance Fraud?

chunkyfrog wrote:I had a dentist who gave a 5% discount for payment in full at time of service.
He would not deal directly with any insurance company; only worked on folks with no insurance.

My father is a Dentist here in California...he mentioned to me that he can get in big trouble for waiving co-pays/co-insurance.

Most dentists will only take PPO-type insurance....and only then very selectively. Most don't take HMO-type insurance. The ADA has been dedicated to preventing insurance companies from doing to them what they've done to medical doctors.

In searching for a new DME, I've been told several times by several online and local B&M suppliers that even though they are not "in-network" with my insurance, they can get me my equipment annually at little or no cost to me.

When I inquired about how that would be possible when I have deductibles and co-insurance, their response is that even thought they are out of network, they don't bill me for the difference if my insurance doesn't pay them.

If they are "out-of-network", they do not have a contract with your insurance company and can charge whatever they like.
Our host site charges much less for masks than my DME but it works out to about what my DME actually gets from my insurance - the DME just sends insurance a bill for a lot more. I'm assuming that these DMEs want to charge in a similar way. It is not at no cost to you, but at no "extra" cost to you. In other words, they charge $150 for a mask that your DME charges $400 for and don't bill you for the difference! Maybe I'm misunderstanding but it seems legal to me. Sorry if I'm missing something.

I spoke with my doctor this morning and he didn't have a copy of my sleep study. I will call the original DME on Monday.

I found that American Homepatient is an in-network provider, so I'm going to chat with them Monday. I also discovered that I must rent my equipment since BCBSTX won't pay for Durable Medical Equipment, just Rental Medical Equipment. In that case I'm buying my PR S1 outright and using the insurance to cover my consumables.

I firmly believe one of the reasons insurance is so dang expensive is that DMEs are charging way too much...and the carriers aren't paying attention to the real market costs of equipment.

I just don't understand why BCBSTX forces me to rent at nearly $300 per month when a brand new machine (in this case PR S1) can be purchased for $600-$800.

Cotay wrote:I just don't understand why BCBSTX forces me to rent at nearly $300 per month when a brand new machine (in this case PR S1) can be purchased for $600-$800.

Most insurance requires you to rent for a certain number of months, after which you own the machine. Local DMEs get a lot more money than online DMEs, but they get the money dribbled out over time, are providing rental, not outright sales, and, in theory, provide more hands on service.