Sleepster, just so you understand, I'm not doubting what you're saying, I'm simply saying that what you are being told may not be "the whole truth and nothing but the truth"...
(02-03-2013 08:53 PM)Sleepster Wrote: This was what the DME told me when I got my first CPAP.
It does not surprise me at all that the DME told you this. They lie (or misinform) all the time. Just because a kind and helpful DME representative tells you something does not mean it is the truth. Many local DME companies have established policies and procedures that are designed to extract as much money from patients as possible using all means available to them. This does not mean that their front-line sales staff is always dishonest - rather, they are giving you a line of baloney that was given to them by their employer. They may actually believe the lies they were fed by their manager.... this is why you need to be talking to a DME manager, not to a low-level staff member.
Quote:The point is this. If the insurance company only allows a specific amount for a specific type of machine the patient has to pay for anything over and above that.
No they don't. All U.S. insurance companies must follow CMS guidelines and use the same billing code for CPAP/APAP. Those guidelines have standard CPAP reimbursement to the DME set at $1500 (this applies to REMstar Plus, REMstar Pro or REMstar Autos equally). So, your DME received $1500 from the insurance company, guaranteed, for whichever of the 3 machines was dispensed to you.
DME policies and/or insurance company policies have nothing to do with that payment amount. They cannot overrule CMS guidelines and oversight. Neither do they make the decision on what type of CPAP machine you receive - that is really up to you, ultimately, as insurance will pay $1500 towards the cost of a either a REMstar Plus, Pro or Auto (or S9 Escape, Elite or AutoSet in the ResMed world). Insurance pays out the exact same amount for each of those 6 machines.
Here's what I think is happening:
The DME is free to "con" you into paying additional amounts beyond the $1500 they receive from insurance and/or Medicare. They do this quite often, actually. There is no law to prevent that, as far as I know. But again, you don't have to be victim of the "con". If you ask your insurance company for a complete and final accounting (in writing) of all payments made to your DME on your behalf, (and they actually agree to give it to you), you will see that they have already paid the DME $1500 for your REMstar Pro, which is much higher than the retail cost of the machine.
The insurance company isn't going to intervene on your behalf if they learn that the DME tricked you into paying additional fees, because they have no interest nor legal responsibility to protect you when a DME attempts to squeeze more money from you. It's simply not their role, nor is it their responsibility. It is your responsibility as the customer and end-user of the machine. You have more power than you think.
Quote:I will check with my insurance company and make sure that what the DME did is allowed by their policies and procedures.
Again, insurance company policies cannot override CMS rules and regs. They gave your DME $1500 according to the CMS guidelines, and when the DME gave you a REMstar Pro, they made more profit than if they had given you a REMstar Auto.
Quote:Here's the information from my DME invoice:
For my original Remstar Pro with mask, hose and filters the coinsurance amount was $290. The upgrade fee was $100.
That's fine. Heck, a DME has the right to ask
you to pay an additional $100,000 if they want to. It doesn't mean that you have to pay it.
Quote:My original point was, and still is, that the DME does not necessarily make a greater profit in all cases by sticking the patient with a brick.
I see what you're saying, but I still contend that when they are being paid via insurance and/or Medicare, they do make greater profits by giving out "dumb bricks" if we are talking about simple CPAP or APAP.
Quote:Maybe he was telling me lies, but this is the paperwork that was filed with the insurance company, so I don't see how that's possible. This is a large DME that services the greater Houston area and my insurance is the uniform group insurance for the state of Texas. Neither of these are little fly-by-night outfits! Like I said, I'll check with the insurance company and see if I can find out some more about it.
The insurance company and/or Medicare could not care less about "upgrade fees" that a DME has charged you. They have no duty nor interest in protecting you from unwarranted DME fees, as long as it's not them
paying the fees. They only care that they have complied with CMS regs by paying out no more than the standard $1500 to the DME-- nothing more, nothing less. The insurance company is not an advocate for the patient, nor are they required to be one.
Going to the insurance company to address this issue is sort of like going to the local McDonald's restaurant manager to complain that your neighbor Joe (who works as a cashier at the McDonalds) has a dog that keeps peeing on your manicured lawn: the McDonald's manager might sympathize with you... heck, they may even talk to Joe about it, but the manager's primarily role and interest is selling hamburgers, and he doesn't really care that your neighbor's dog has ruined your lawn. If you don't like your neighbor's dog peeing on your lawn, you need to talk to your neighbor about that, not a disinterested third party. And trust me, when it comes to DMEs screwing over patients, Medicare and the insurance companies are completely disinterested third parties, although they do hire "pleasant" and "likeable" customer service reps who try to convince you otherwise.
I could be totally wrong on this, but based upon what I've heard from actual DMEs and a large number of frustrated patients, I don't think I am wrong about how the system works
Anyone else: please feel free to add your additional experiences and knowledge on these issues.