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Am I Getting the Royal DME Run Around?
11-25-2013, 12:08 PM
Hi all; I hope all of you are having the best day possible under whatever circumstances you have to live with. My question is this. My doctor prescribed an APAP machine on 11/13. She wants me to trial one for a month. The DME is still telling me as of today that they have no such machines on hand and have no idea when they will have. What the heck? Are they that hard to come by? Made of pure gold or something? Is it time for me to call Medicare and ask them if this is normal operating procedure? Of course, I have the usual proactive miserable rep with the DME for being in their faces since I started this journey. I've always been respectful and have never blown them in to the doctor's office or Medicare, but this little problem has me ticked. Any idea what I should do, if anything? I'm having a really hard time using my CPAP. Thanks, DJ
11-25-2013, 12:18 PM
First talk to the branch manager, then if necessary the regional manager. If no joy find a VP.
While you are waiting for returned calls try your doctor AND his medical group AND your insurance company. Tomorrow decide how high up the food chain to start and go again. I just start by saying I would like a progress check and what time should I come in to get my equipment. Be friendly, get a laugh if you can, but be persistent. If the don't recognize your voice when you call, you haven't been calling often enough. Yes, I mean each of them.
I've gotten to be friends with the guy who owns the DME where my equipment came from. After visiting this forum I began looking into upgrading. I was warned it would be difficult.
Well, it turns out that it's a money issue. Can you imagine that. My DME said that Medicare and lots of insurance companies will only pay for the basic machine. I asked him I could just pay the difference and she said "sure". He said my next problem would be in getting a new RX from my sleep doctor. He said that he thinks they don't want patients accessing their data and possibly the settings.
So, I went to the doctor, trying hard to be diplomatic. I tried not to focus on the ability to change the settings, but I was having problems with cpap that they had not been able to address. I emphasized the other qualities of the machine. Then they said it, "you know that your insurance will not pay for it". I said that was fine, that I had an arrangement with my DME to take care of that. They wrote the RX, I went to the DME, paid about $100 difference and went home with a shiny new Autoset the same day. One thing I've learned is to show up in person, don't phone. It's harder to tell someone no when they are looking you in the eye. Just be polite but persistant.
Sorry, my point being that the DME cannot collect any more money for the more expensive machine, so it's simply a money thing.
11-25-2013, 02:43 PM
(11-25-2013, 01:09 PM)drgrimes Wrote: Well, it turns out that it's a money issue. Can you imagine that. My DME said that Medicare and lots of insurance companies will only pay for the basic machine. .The DME is greedy one. Medicare pay for CPAP by a billing code E0601 (Bi-level machines E0470) and pay the same amount for any machine, be it a brick or top end machine http://www.healthcare.philips.com/asset....-guide.pdf
Anyway, Glad you got the machine of your choice
11-25-2013, 04:18 PM
DME's are just greedy. I tried till I was blue in the face to get a full data machine and the DME would not, stating that insurance only requires compliance and therefore that's all they could give me but, if I wanted to pay the difference, I could have one. So I bought my own, brand new for an awesome price. I returned the brick at the beginning of the month and they're still charging me for a full month. It's all about the money.
11-25-2013, 05:43 PM
at one point I was so frustrated I considered just buying what I wanted online. I think it was around $800-900. So I was happy only having to give $100 difference. Yes, i'm sure with all DMEs it's about the money, maybe with the doctors too.
Well I've learned one thing, rather than turning into a grumpy old man, I have to focus on something good. I think I will have a glass of wine.
Uh, I don't think that DME's can collect from the patient more than the insurance pays and/or copays or % of the ALLOWED AMOUNT according to your plan. Also, that is not accurate that insurance won't pay for auto sets. They will, they do, all the time. The DME just makes more of a profit if they sell you a machine that is not an autoset or even more of a profit if they sell you a brick. It is best to get a script with a specific machine and all that you want to go with it (climate line tube, etc.) because the DME has to provide what is on the prescription.
I know it may have been easier for you to pay the $100 and be done with it but, they are not supposed to do that. This is why they have contracted amounts with the insurance companies. I found out my insurance company also charges the provider a % of the allowed amount.
11-25-2013, 06:07 PM
In a word, yes you are getting the run around from your present DME. You have gotten some great advice already in this thread. Become a Nudge to your DME, insurance company, state insurance commissioner, etc. until you get a resolution to your issues.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
11-25-2013, 06:22 PM
Me50 you may be right. I would not debate something I know little about, but it seems to me that if insurance or medicare pays for something basic and the patient wants something above that, the patient should have the option to buy anything they have an RX for.
I do know that if I have an RX for something not covered at all by medicare, or insurance, I have to option to buy it outright. My wife has some Rxs for some things considered cosmetic. Sometimes the insurance pays a minimal amount or none at all. She still has the option to pay the difference. Isn't a DME similar to a pharmacist?
11-25-2013, 06:40 PM
(11-25-2013, 06:22 PM)drgrimes Wrote: Me50 you may be right. I would not debate something I know little about, but it seems to me that if insurance or medicare pays for something basic and the patient wants something above that, the patient should have the option to buy anything they have an RX for.
all providers contracted with an insurance company has a contracted amount they are allowed to collect for the services. They are allowed to collect copays according to that contract but not extra money from the insured. All CPAP machines use the same code; bi-level machines a separate code for all bi-level machines. The provider will try to provide the least expensive machine in order to get more of a profit. Sometimes, if the medication copay is more expensive than the provider charges, a patient can choose to bypass insurance and pay what the provider charges for that prescription. However, that is doubtful to be the case with a CPAP/BI-LEVEL, etc. unless the patient has a deductible that hasn't been met. However, in the original post, the poster said they paid $100 in addition to what the insurance paid or that is my understanding. If that $100 wasn't a copay, then the insurance was not allowed to do that. That is my understanding anyway. That is the way my insurance works.