DME ripping me off?

I had some similar problems with my DME before getting my machine. Unfortunately for me, I needed a very expensive ASV machine so I was going to be paying a good chunk of money from my own pocket. While normally not aggressive, I became aggressive. The girl I spoke with on the phone several times was being very vague with details. With the help of the folks here (and much help from Pugsy,) I pushed and found out that the DME wanted to give me the older model machine, which I declined. Before I even walked in their door I told them the exact machine and mask I wanted and they ordered it for me. When I met with the respitory therapist to pick up my machine, he turned out to be a really nice guy that seems genuinely concerned for my welfare and being successful with my treatment. I spent 90 minutes at my appointment, most of the time was him explaining everything about the therapy, machine, and mask in detail.

If it was me, I would call my insurance company and ask if there is another DME in the area. Make sure they will cover a new machine if I switched to a new DME and start a new machine rental. Then I would call the DME and tell them after doing some research I'm unhappy with the outdated machine model they provided and that I'll be switching DME's unless they switch the machine for the new model that I want. Now their options are to either give you the new machine or lose you and their profit to another DME.

alpha752 wrote:I tried. I called and was told that this was the model they had and that I could get reports from my RT. I tried to argue a bit but obviously wasnt going to get anywhere. Thats one of my frustrations with them. Now that I see I am paying much more then I should, I am even more irritated with them. Thats why Im wondering if I might be better off buying my own stuff from cpap.com, and taking the gamble with the insurance reimbursement later.

rite of passage
noun
1.Anthropology . a ceremony performed to facilitate or mark a person's change of status upon any of several highly important occasions, as at the onset of puberty or upon entry into marriage or into a clan.
2.any important act or event that serves to mark a passage from one stage of life to another.

3.passage into the world of cpap-acquisition of data capable machine

Go the distance.

I am on my 3rd week of CPAP usage and thanks to the information gathered on this board I was able to find out that I was also given a brick at the rent to own price of a top of the line. I called my DME and explained that my doctor is meeting with me in a month and is fully expecting to see all my stats, not just how long i used the machine. They quickly replied back to bring it in and they would even exchange it out.

So I would recommend contacting your DME and asking for a full data machine asap!

Getting ripped off by a DME? That almost never (read, always) happens!

I am particularly peeved when someone gets told "no leaks" "everything is fine"....and the machine is a brick and doesn't report leaks at all.
To me that's leaving the door open for a lawsuit as in malpractice (if DMEs can be sued under those conditions).
That's a blatant lie about therapy results when asked a pointed question about leaks.
OP in this situation doesn't like confrontation but if it were me and/or family member of mine...they would be kissing my butt about the lie. What if the leaks were so bad that the therapy was totally ineffective and a person goes merrily along thinking this is as good as it gets and has a stroke or heart attack because of the damage done by untreated sleep apnea...and in the records the person was told "you don't have any leaks"...and they can't prove it.

It's kind of like when I asked the girl I spoke to on the phone at my DME what model they wanted to give me. She wouldn't answer, skating around the question, until I pointedly asked "Is it the s9?" She then reluctantly admitted it was the "S8" and that it "did the same thing as the S9." I guess they generally do the same thing, (as in both being an ASV machine) but obviously the S9 is more advanced. I was annoyed by her statement, but I just told her "I want the S9." Now I have my S9 and I'm happy.

mine groaned too when i brought my rx that specifically said the machine AND cost

I'm sure that a brick is just fine for many, many people, but some of us have more complicated sleep issues, and we *need* the data to get the proper support. Just because you have apnea, doesn't mean you *only* have apnea, and a machine with data can help with that. Obviously though, if you're having problems after treatment, the data becomes more important; that's where a good trial machine with data comes in. If that goes well, in many cases a brick is sufficient.

That, and extra $ in their pocket

Basically the insurance is going to be a rip off right? The way I see it, even if they do pay 80%, they are paying that percentage of the MSRP of the machine, which is $1500-2k. So my deductible will be about what I can get a machine for at cpap.com. Masks arnt so expensive that the insurance is really needed, especially not at 1 a year, or whatever crap my insurance allows. Cushions, filters and tubing are pretty cheap.

So is there a good reason to even mess with the insurance at all? All they are letting me do is finance the cost of the machine over 13 months, because what I pay in deductibles is what I would pay on the internet. The more and more I look at it, it seems like I would be better off just getting my own supplies online... or am I missing something?

alpha752 wrote:Basically the insurance is going to be a rip off right? The way I see it, even if they do pay 80%, they are paying that percentage of the MSRP of the machine, which is $1500-2k. So my deductible will be about what I can get a machine for at cpap-dot-com. Masks arnt so expensive that the insurance is really needed, especially not at 1 a year, or whatever crap my insurance allows. Cushions, filters and tubing are pretty cheap.

So is there a good reason to even mess with the insurance at all? All they are letting me do is finance the cost of the machine over 13 months, because what I pay in deductibles is what I would pay on the internet. The more and more I look at it, it seems like I would be better off just getting my own supplies online... or am I missing something?

That was essentially what my calculations came up with nine years ago.
I was ready to purchase everything out-of-pocket, but then I asked my insurance provider if they would reimburse me. They said they would and since I was considered to be "in-network", they reimbursed me for 80% of what I paid CPAP-dot-COM. So, I used the invoice from CPAP-dot-COM and made up one of my own and used it to bill my insurance provider. They then sent me a check for 80% of my invoice. Not everyone can do that with their insurance provider, but it doesn't hurt to pursue it. Tell them everybody will save quite a bit of money.
Since then, I've purchased everything out-of-pocket


Den

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Wulfman... wrote:

alpha752 wrote:Basically the insurance is going to be a rip off right? The way I see it, even if they do pay 80%, they are paying that percentage of the MSRP of the machine, which is $1500-2k. So my deductible will be about what I can get a machine for at cpap-dot-com. Masks arnt so expensive that the insurance is really needed, especially not at 1 a year, or whatever crap my insurance allows. Cushions, filters and tubing are pretty cheap.

So is there a good reason to even mess with the insurance at all? All they are letting me do is finance the cost of the machine over 13 months, because what I pay in deductibles is what I would pay on the internet. The more and more I look at it, it seems like I would be better off just getting my own supplies online... or am I missing something?

That was essentially what my calculations came up with nine years ago.
I was ready to purchase everything out-of-pocket, but then I asked my insurance provider if they would reimburse me. They said they would and since I was considered to be "in-network", they reimbursed me for 80% of what I paid CPAP-dot-COM. So, I used the invoice from CPAP-dot-COM and made up one of my own and used it to bill my insurance provider. They then sent me a check for 80% of my invoice. Not everyone can do that with their insurance provider, but it doesn't hurt to pursue it. Tell them everybody will save quite a bit of money.
Since then, I've purchased everything out-of-pocket


Den

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Wow, I didn't honestly expect any insurance company would do that! My insurance website does say they will pay 80% after a deductible, for "out of network". I guess tomorrow ill be calling them to see if that applies to internet purchases too. Thanks!

alpha752 wrote:

Wulfman... wrote:

alpha752 wrote:Basically the insurance is going to be a rip off right? The way I see it, even if they do pay 80%, they are paying that percentage of the MSRP of the machine, which is $1500-2k. So my deductible will be about what I can get a machine for at cpap-dot-com. Masks arnt so expensive that the insurance is really needed, especially not at 1 a year, or whatever crap my insurance allows. Cushions, filters and tubing are pretty cheap.

So is there a good reason to even mess with the insurance at all? All they are letting me do is finance the cost of the machine over 13 months, because what I pay in deductibles is what I would pay on the internet. The more and more I look at it, it seems like I would be better off just getting my own supplies online... or am I missing something?

That was essentially what my calculations came up with nine years ago.
I was ready to purchase everything out-of-pocket, but then I asked my insurance provider if they would reimburse me. They said they would and since I was considered to be "in-network", they reimbursed me for 80% of what I paid CPAP-dot-COM. So, I used the invoice from CPAP-dot-COM and made up one of my own and used it to bill my insurance provider. They then sent me a check for 80% of my invoice. Not everyone can do that with their insurance provider, but it doesn't hurt to pursue it. Tell them everybody will save quite a bit of money.
Since then, I've purchased everything out-of-pocket


Den

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Wow, I didn't honestly expect any insurance company would do that! My insurance website does say they will pay 80% after a deductible, for "out of network". I guess tomorrow ill be calling them to see if that applies to internet purchases too. Thanks!

You need to be careful how you word it. Almost none will pay from an invoice from an online Internet seller if you send it to them that way. The invoice needs to come from YOU and they have to consider you to be "in-network". Otherwise, it might only be 60% at best. But, that's still better than "a poke in the eye with a sharp stick". You would need to make out an invoice with you as the billing party and them as the party being billed. The invoice from CPAP-dot-COM comes with all of the insurance codes on it, so basically all you need to do is copy it and change the bill-er and bill-ee.
What I did was to say that I wanted to buy the equipment I WANTED from an Internet seller and the prices were much lower than the local DMEs. And........would they reimburse me? I had already burned up my deductible on the sleep study and other doctors' appointments that year, so the rest was "gravy".


Den

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Pugsy wrote:I am particularly peeved when someone gets told "no leaks" "everything is fine"....

AH-HA!! Now I know why you don't like me!!

No leaker....Sheriff

Todays progress- I called the insurance company. They will only reimburse me for purchases from a tier one provider, internet is not considered tier one. So basically I would have to outright buy a machine from a DME. Not unexpected.

I called and left a message for the respiratory manager of my current DME explaining my concerns.
The Insurance company gave me the names of a couple of other DMEs I can check out.
cpap.com is calling my Dr. office to get my prescription. So worse case I just pay out of pocket.

I feel better knowing I have options. Im going to wait for the call back from the current DME. If unsatisfactory, I will call another DME and ask LOTS of questions. If that still doesnt work, Ill just buy what I want from cpap.com.

Thanks for all the help and advise everyone.

alpha752 wrote:Todays progress- I called the insurance company. They will only reimburse me for purchases from a tier one provider, internet is not considered tier one. So basically I would have to outright buy a machine from a DME. Not unexpected.

I called and left a message for the respiratory manager of my current DME explaining my concerns.
The Insurance company gave me the names of a couple of other DMEs I can check out.
cpap-dot-com is calling my Dr. office to get my prescription. So worse case I just pay out of pocket.

I feel better knowing I have options. Im going to wait for the call back from the current DME. If unsatisfactory, I will call another DME and ask LOTS of questions. If that still doesnt work, Ill just buy what I want from cpap-dot-com.

Thanks for all the help and advise everyone.

You should have just asked them if they would reimburse you (or for a percentage of your purchase) for an out-of-pocket purchase.......and not stipulated where it was from. What difference does it make to them where you get it?

But, yeah, even with a purchase from an online seller, you would first have to purchase it (like on a credit card) and then (possibly) get reimbursed for it.

Like I said, you have to be careful how you word these questions to the insurance provider's staff.


Den

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I think (and I may be incorrect) that it's getting much harder to get reimbursed for out of pocket purchases because nowadays the insurers want to have contracts with specific providers so that they can negotiate the cost. So you may have an 80/20 plan--but they have a negotiated contract rate with X provider to provide the equipment for (example) $500. The insurer know their fixed cost for this item will be $400, whether you get the brick or the Cadillac. EVEN if you can get it for $400 online so the insurer's share is only 80% of that, they may not want to do all the paperwork with you at a different rate--their savings is eaten up in the levels of review they have to do. In addition, the contracted DME has to provide service and follow-up which benefits the insurer, the online supplier does not.