friggin' insurance.

RedThunder94 · Post by **RedThunder94** » Sat Jun 10, 2006 12:50 pm

well i just checked on my insurance co's website and saw that the claim for my machine was finally processed by them, and as it turns out they want me to pay for all my stuff at the provider rate

here's what i'm looking at.

Claim Detail

Provider Name: M Wooley

Date of Service: 05/12/2006

Total Charge: $656.00

Total Benefit Paid: $0.00

Total Patient Responsibility: $579.99

Date Claim Received: 05/29/2006

Status: Processed

Date Processed: 06/08/2006

Individual Service ? Total Charge ? Network Discount ? Allowed Amount ? Patient Copay ? Deductible ? Not Covered ? Paid by Plan ? Remark Code ?
Medical Supplies $260.00 $3.96 $0.00 $ 0.00 $ 0.00 $0.00 $0.00 D5
Medical Supplies $225.00 $64.66 $0.00 $ 0.00 $ 0.00 $0.00 $0.00 D5
Medical Supplies $100.00 $5.05 $0.00 $ 0.00 $ 0.00 $0.00 $0.00 D5
Medical Supplies $36.00 $1.13 $0.00 $ 0.00 $ 0.00 $0.00 $0.00 D5
Medical Supplies $35.00 $1.21 $0.00 $ 0.00 $ 0.00 $0.00 $0.00 D5

Remarks?
D5 We Used A Network Fee Because You Used A Network Provider. Your Benefits Are Lower, However, Because, According To Our Records, We Did Not Receive Notification For This Service. You Are Not Responsible For The Difference Between The Amount Charged And The Amount Allowed. You Are, However, Responsible For The Deductible And The Coinsurance Amounts That Have Not Been Met.

Patient Pays: $579.99

Satisfied Year to Date ? Deductible ? Out Of Pocket ?
EVARISTO 162.80 162.80
Family 162.80 162.80
Plan Year
EVARISTO 300.00 1000.00
Family 600.00 3000.00

so just cause i did not let them know i needed this it's gonna cost my my left nut? according to the insurance handbook i got from work i do not need a prior authorization for dme under 1,000, so why are they gonna deny my claim for that same reason? i already called them but they aren't there, have to wait till monday, i am appealing it though, but i dunno how far it will go, i still think i got a good deal if i end up having to pay for everything out of pocket though, heck, a brand new remstar auto w/cflex and heated humidifier and a comfortfull 2 and a comfortgel mask for under 6 bills, i don't think that's too shabby. but what's the point of having to pay for insurance if they aren't going to honor my claims even if i adhere to their policies. gives me a headache just thinking about it, lol. i guess i'm lucky they took the hit for the sleep study though, it only costed me 15 dollars.

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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, DME, auto

ufo13 · Post by **ufo13** » Sat Jun 10, 2006 1:38 pm

RedThunder94:

Sounds to me like YOU have UHC as I have! They screw up so much I have become an expert on doing thier employees jobs! If you are with them or even if you are not (whichever ins you have) call the number on your insurance card---but DO NOT DEAL WITH THE PERSON WHO FIRST ANSWERS YOUR CALL- Just request (INSIST) to speak with a CLAIMS SUPERVISER! In my experence (a-lot of screw ups) that is the only person who will get to the bottom of things and usually get the right info inputed and correct the mistakes made more times than not! The initial person (customer service?) will keep telling you all has been taken care of each time you try to get something straightened out but DO NOT RELY ON IT! THEY MOSTLY DO NOT HAVE A CLUE! (Once in a while you WILL GET A GOOD ONE) but in general it gets tiresome after awhile!

Hope this helps,

Steve,
ufo13

Guest · Post by **Guest** » Sat Jun 10, 2006 2:08 pm

looks like one month rental and supplies - my DME billed for mask, headgear, filters (2 kinds), hose, machine rental, humidifier rental on first bill with ongoing machine rental and humidifer rental

get an itemized statement from the DME too !!!!!!!

RedThunder94 · Post by **RedThunder94** » Sat Jun 10, 2006 2:44 pm

ufo13 wrote:RedThunder94:

Sounds to me like YOU have UHC as I have! They screw up so much I have become an expert on doing thier employees jobs! If you are with them or even if you are not (whichever ins you have) call the number on your insurance card---but DO NOT DEAL WITH THE PERSON WHO FIRST ANSWERS YOUR CALL- Just request (INSIST) to speak with a CLAIMS SUPERVISER! In my experence (a-lot of screw ups) that is the only person who will get to the bottom of things and usually get the right info inputed and correct the mistakes made more times than not! The initial person (customer service?) will keep telling you all has been taken care of each time you try to get something straightened out but DO NOT RELY ON IT! THEY MOSTLY DO NOT HAVE A CLUE! (Once in a while you WILL GET A GOOD ONE) but in general it gets tiresome after awhile!

Hope this helps,

Steve,
ufo13

wow, yeah, i got uhc, i will speak to the claims supervisor monday. thanks for the info.

RedThunder94 · Post by **RedThunder94** » Sat Jun 10, 2006 2:52 pm

[quote="Anonymous"]looks like one month rental and supplies - my DME billed for mask, headgear, filters (2 kinds), hose, machine rental, humidifier rental on first bill with ongoing machine rental and humidifer rental

get an itemized statement from the DME too !!!!!!!

same guest · Post by **same guest** » Sat Jun 10, 2006 3:06 pm

just a guess is all and I can have the wrong things for the costs

Mask
Medical Supplies $260.00

CPAP - one of 9 to 12 monthly payments - somewhere along the line someone will need some complaince information for them to buy it out but rent to own is common over outright purchase
Medical Supplies $225.00

Headgear
Medical Supplies $100.00

and these two are humidifier rental and hose (and humidifer would be same number of payments as CPAP)

Medical Supplies $36.00
Medical Supplies $35.00

so ongoing monthly bills would be for the $225 and either $35 or $36 not to mention some for filters and other supplies as you need them

since the total price for machine (purchase when it happens) exceeds the $1000 that is where they might be flagging it but you need to make a few calls on Monday

brasshopper · Post by **brasshopper** » Sun Jun 11, 2006 8:17 pm

...I'd return the machine and get a better deal somewhere else. Just a thought.

RedThunder94 · Post by **RedThunder94** » Sun Jun 11, 2006 8:24 pm

that's what i plan to do, was it my resposability to get pre-approval for the machine in the first place? i didn't even know the results of my study or that they had prescibed me a machine till i got a call from the dme on the 11th of may, this is the first time i have had to deal with insurance in this manner, never had a problem before. so i'll see what happens, i really don't wanna have to return it if i don't have to, they were so nice about everything and then to have to give it back to them just cause my stupid insurance screwed up makes me feel bad lol.

Guest · Post by **Guest** » Mon Jun 12, 2006 6:35 am

Call the billing department at the DME. Mine was really nice and helpful in helping me get a problem claim fixed (Turned out my insurance somehow planted my wifes SS# onto one of my mask claims and so it was denied).

RedThunder94 · Post by **RedThunder94** » Mon Jun 12, 2006 3:00 pm

well i called them and spent half an hour on the phone and they said that my deductable will apply but that they will pay the remainder, less 20%, and that i was now approved for the rental, but since i wanna buy the machine not rent, that i or the dme billing department needs to call the care coordination department to get the approval to buy it, and that the rental will just be for 90 days or so and then it can be purchased. i'm just waiting for a call back from the dme billing office, boy i hope this machine lasts a while, no telling when i can get another. lol, i just hope it is the right choice.

Linda3032 · Post by **Linda3032** » Mon Jun 12, 2006 3:07 pm

That sounds like the right course to me - especially since you have a good machine.

If for any reason it all falls through again, try to negotiate with the DME to simply buy the machine from them - at a reduced rate. Especially since they are the ones that messed up (in my opinion) in not getting it pre-approved in the first place. Perhaps they will reduce the cost to you, rather than take back a "used" machine.

RedThunder94 · Post by **RedThunder94** » Mon Jun 12, 2006 3:57 pm

well i got that call back from the billing office, and unfortunately according to the dme insurance bill lady uhc does not support out right purchasing they will only do a 15 month rent to own so come january i will have to cough up my 300 dollar deductable, but i got an itemized statement and my script faxed to me here, so the charges are

c-pap heated humidifier: 260
fullface mask: 225
c-pap rental: 100
c-pap tubing: 36
c-pap headgear: 35
and c-pap filters: 20

but at least she put me at ease by telling me that my out of pocket per month will be 15-20 bux a month, at least until january then i guess i get to foot the rental for a few months or at least until my deductable is met for 2007 then it's back to 15-20 bux a month until the 15 months are up. and then it's all mine,

but at least on the brightside if the machine screws the pooch anytime in the next 14 months i can trade it in on a new one, i guess that's alright. and now that i have my script i don't have to be on the lookout for a decent used machine as a backup/travel machine, i can just buy one new online or maybe even go ask any dme if they got any deals on a decent used machines.

Guest · Post by **Guest** » Mon Jun 12, 2006 4:23 pm

you didn't say what the total cost of the machine would be after 15 months (to you after adding in meeting your deductable in Jan/Feb...). ?? If I remember correctly you are in month number 1. You really should look at that before you pay even a rental copay for another month.

If you decided to get out now. The mask, hose and filters should be already purchased (they rarely rent to buy those). So you are really only out the rental of the unit and the humidifier if you choose to make a change.

RedThunder94 · Post by **RedThunder94** » Mon Jun 12, 2006 5:13 pm

the dme is charging 100 bux a month rental times 15 months is 1500 plus the humidifier mask and tubing, but 137.83 is what's left of my copay this year, plus the 20% of the allowable 579.99 is 226.26 is what i have to pay for this month, plus say 20 x 6 months is 120, plus the 300 deductable which i may or may not have to pay towards the machine depending on any medical procedures that i may have to have next year, plus another 5 months of 20 dollar rental copays comes out to about 746.26 give or take a few bux. even allowing a total of 760 it's still not too bad for all that i have gotten, granted i could take the hit all at once i would still have to pay the dme the 226.26 and then have to cough up the 725 for the new machine all at once, so i'm in too far already to just pick up my marbles and go home.

RedThunder94 · Post by **RedThunder94** » Mon Jun 12, 2006 5:41 pm

and now the plot thickens, lol, i just got off the phone with the care coordination representative and they said all i need to do to get the machine purchased instead of rent to own was find out the total purchase price of my machine and then call them back and let them know how much it will be and then they would issue me a preapproval and then i would just pay the remainder of my deductable and 20% of what's left over and they would pick up the rest. i'm still at a loss, they also said the decision to rent to own or purchase is up to me, i guess i'll call the dme and find out how much my machine is outright and do the math and see if it's cheaper like that or if the rent to own would be more budget friendly.

friggin' insurance.

friggin' insurance.

If they won't pay