Was diagnosed with severe obstructed sleep apnea while hospitalized with congestive heart failure last August. Hospital DME and O2 monitor kept me going. Physician prescribed BiPAP for home use as a condition for release. Did the sleep study within the first two months, physician evaluation report, and the BiPAP from the provider had a modem to verify my usage. Different from many in a patient would get a referral from a physician to go to a sleep lab, etc.
I have Medicare as my primary and also have a secondary insurer.
Five months after the first diagnosis and prescribed DME, Medicare denied payment to the provider for the DME as "not medically necessary".
My opinion is that the \DME provider failed to gather available info from my secondary insurer and failed to submit required information requested by Medicare. I've appealed the Medicare decision and submitted as much documentation as this layman understands. My physicians are left wondering.
During the interim, my secondary coins policy is to pay 50% of the DME cost when Medicare denies the claim. Leaves me with a huge copayment to the provider that I feel is both improper and unnecessary.
A CPAP in lieu of BiPAP was delivered April 11. Titrations in January using both CPAP and BiPAP determined that I could tolerate the CPAP. My AHI to begin was 48 and night oxygen dropped to less than 70.
So, April 11, the provider delivered the DME referred by my secondary insurer, only 3 months after receiving the first of two prescriptions from my physician. The only reason the provider finally reacted was because I scheduled a pick up of the BiPAP to stop the rental charges. My secondary insurer supplied a loaner CPAP due to the continued proplem with the DME provider. The scheduled pick up was cancelled by the provider and later accomplished on April 11, when new DME was finally delivered.
The previous August 2012 delivery of the BiPAP DME as rental and purchase accessories resulted in a total charge of near $750. The latest delivery of different DME, but identical accersories, amounted to a charge of $3000. The difference is, for example, the Quatro full face mask was $178 or so last August. The same mask with the new delivery in April of 2013 is $980!
Because the billing dispute is ongoing with the provider, I feel that delivery of new DME was purposefully delayed for near 3 months. Also, due to the Medicare denial, I feel that provider purposefully inflated the new accessory costs in retribution. I'm informed that Medicare will pay for the replacement DME at 80%, as should have been accomplished in the first place. Still trying to understand what's different. Maybe the latest documentation submission will be properly. Not as happened following the original emergency hospital admittance?
A phone call from the provider's representative kind of said "I'm not used to a patient questioning my decisions." That's because the original correspondence informed me that the provider followed ALL procedures when submitting documentation to Medicare.
A recent call to Medicare resuted in asking me if I wanted to file a complaint about the provider. I informed Medicare that a complaint seemed appropriate. The Medicare rep suggested a 3 way phone conference with the provider. After 2 hours of being directed to mail boxes, the Medicare representative and I agreed that communication with the provider was impossible.
I'm now out of pocket for a week and know that Medicare sent a reply to my home address that I've yet to review. I'll get back to my residence next week. Ha, ha, I told the provider's rep that I wouldn't return to my residence until next week, yet I get a call daily to discuss the issue.
Sure would like to know if my experience with a provider is normal and if it would be identical with other DME providers.
It goes without saying that the coins even with Medicare paying at 80% leaves my latest out of pocket paying almost as much for the S9, etc. purchased outright off the internet. The monthly rental for the ResMed S9 from the provider is $875 or there abouts. The past billing dispute now amounts to more than $1000 out of pocket.
Have I gone wrong in my thinking?
As a new member, I'm hoping that I haven't stepped on any toes or violated any protocols. Just would like to know . . .