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[Equipment] dme overcharges?
#1
dme overcharges?
Occasional lurker but first post so apologies in advance if I'm not current on rules/etiquette or previous answers to similar questions.  Also sorry for long post but hoping it's enough background to focus responses.  498 nights under my belt using resmed autoset a10.  Lots of questions but will start with this:  

Been arguing unsuccessfully for months with DME provider regarding initial purchase (pricing) of this machine.  Interested in learning more about how this works & hoping to find some authoritative source I can use to support my position.  I read Archangel's wiki page and many of the links there but did not see my questions addressed, at least not directly.

1.  DME provider billed insurance by medicare code including codes for exhaulation port, humidifier & humidifier chamber (among others).  Exhaulation port is built into resmed's airfit mask system which they also charge for.  Humidifier is built into the machine and included in the machine price charged by every online vendor I checked.  Humidifier chamber is also included in the machine price although periodic replacements are recommended and can be purchased by separate code. 

My contention is that separate codes for these items are appropriate for machines for which these items are options, not standard equipment.  I argue that they cannot charge me for parts neither they nor I can buy separately (except when buying parts for replacement/repair).  They tell me their hands are tied, that they have to bill certain codes no matter what, but refuse to identify whatever it is they believe controls how they bill.  They say take it up with insurance.  Insurer says take it up with DME provider.  State insurance commission says we don't regulate non-Medicare DME providers.  It seems DME providers say they are limited by Medicare AND Medicare is only a guide in cases with individual insurance coverage.

2.  DME provider billed insurance at more than twice online & insurer contracted allowed amounts.  Not at all clear why since DME provider knows & tells me in advance what the contracted allowed amounts are.  In any event, they apply state and local sales tax against this inflated figure.  Explanation of Benefits from insurer simply carried over those tax amounts even though actual contracted allowed amounts are significanly less. DME provider seems to acknowledge this but continues to tell me they're charging everything correctly.   

The amount in contention is more than $500 at the insurer's lower allowed amounts. Since we have a very high deductible, it's all out of pocket. I hesitate to think there's fraud here but it has crossed my mind.

Has anyone figured out how to successfully contest DME provider charges?
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#2
RE: dme overcharges?
Short answer, No... I still can't figure out how CareCentrix (billing agent for my dme) is charging. Every month I have to pay a different amount for the same thing. It's mind boggling. I stopped ordering supplies from them because it's cheaper in the long run on amazon.
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#3
RE: dme overcharges?
The bottom line is did you sign a rental or rent to own agreement? If you did check what it says. If you agreed to their conditions then you have to pay what they charge.
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#4
RE: dme overcharges?
I have a Medicare Addvantage plan. The DME bills outrageous  amounts and the insurance knocks it down to what they allow. My copays are always much smaller than what I would pay an on line supplier. I have a Resmed airsence 10. My DME also billed separately for the humidifier but as I recall, insurance either did not allow the charge or the amount allowed was small. I had a monthly copay of $9.50 for 13 months. I think an out of pocket cost of $123.50 for the machine with humidifier was acceptable. I'v.e never seen anything to indicate sales tax is included. I'm careful not to buy anything that my insurance would not cover as I would then be liable for the inflated  DME price.
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#5
RE: dme overcharges?
That's weird, I never actually signed any kind of agreement or anything. It all just kinda happened on the back end. That's scary.
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#6
RE: dme overcharges?
I'm a bit jaded from my first sleep "doctor" / DME experience, but I'll just pipe in and say I DO think what you're experiencing is fraudulent, and I do think many DMEs operate this way. They seem to be in it for the money, without regard to the human in front of them.

(Not all DMEs, of course.)

This pain with insurance and DMEs is the main reason I've been ordering so many of my supplies through Amazon.
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#7
RE: dme overcharges?
I suggest you google you DME to see if they have a fraudulent history. I checked mine and found some bad news. This is the link to a post about it http://www.apneaboard.com/forums/Thread-...-Bad-DME-s

Check Craigslist, amazon and ebay as well as the supplier list for equipment.

Good luck.
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#8
RE: dme overcharges?
1. There is no code for an integrated machine, so Medicare allows the DME to charge for both a machine and separate humidifier as though it was not integrated. Your initial humidifier bin is included either the machine or humidifier cost, as you discovered. My mask, either the P10 or the Dreamwear, is billed as 3 different parts even if it comes in a combo pack - The mask, the headgear and the pillows. I don't know how full-faced masks are billed, but some have extra parts.

2. I call it 'fantasy billing'. They can bill whatever they want, but the insurance company/Medicare is only going to pay the contracted price. Pricing with medical bills is NOT TRANSPARENT which is an issue to take up with the legislature. Contact your state government and ask them why your machine/supplies are being taxed at a retail rate when the items are being purchased at a much lower, contracted rate. It could very well be a requirement to tax medical equipment/supplies at a retail rate only, it varies so much from state to state. For instance, I don't have to pay sales tax on my medical equipment purchases, but I do have to pay a 2.5% medical tax on said purchases, but that is the actual purchase price and not a retail price.

3. It's unfortunate that you didn't compare stuff before contracting to purchase your machine locally. However, you can't compare pricing with DME and online vendors as online vendors don't deal with insurance or their requirements - one of the reasons why they can offer lower prices. The fact that they offer one price for the entire unit, humidifier and all doesn't matter.

I am very sympathetic. My brother has had to pay hundreds of extra dollars because he doesn't ask in advance or do any research. The best you can do at this point is negotiate with the DME about significant reductions in future supplies (which is where they make their money). If they won't negotiate, which they might not be able to do, simply don't buy anything further from them until you have met your deductible for the year. Get your supplies online - cheaper too.
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#9
RE: dme overcharges?
(04-01-2018, 02:53 PM)Mosquitobait Wrote:  The best you can do at this point is negotiate with the DME about significant reductions in future supplies (which is where they make their money). If they won't negotiate, which they might not be able to do, simply don't buy anything further from them until you have met your deductible for the year.  

Technically, there are other options. I was so disgusted by my sleep "doctor" / DME, that I brought my machine back to him and returned it.  He tried to rebuff me, but I said "It's a rental, right?" and I told him I'm done renting it.  :-)  Marched myself (and a copy of my sleep study & prescription) to a different DME and had a new machine (the one I wanted) the same day.
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#10
RE: dme overcharges?
(04-01-2018, 08:31 PM)Hydrangea Wrote:
(04-01-2018, 02:53 PM)Mosquitobait Wrote:  The best you can do at this point is negotiate with the DME about significant reductions in future supplies (which is where they make their money). If they won't negotiate, which they might not be able to do, simply don't buy anything further from them until you have met your deductible for the year.  

Technically, there are other options. I was so disgusted by my sleep "doctor" / DME, that I brought my machine back to him and returned it.  He tried to rebuff me, but I said "It's a rental, right?" and I told him I'm done renting it.  :-)  Marched myself (and a copy of my sleep study & prescription) to a different DME and had a new machine (the one I wanted) the same day.

Yes, but perhaps you didn't notice that he's had the machine over a year.  For most people, that is well past the rental stage.  I also don't know what his agreement said. 

FWIW, and not really relevant but just felt I needed to say it, I actually added on my agreement that I will not be responsible for any rental costs over 30 days should Medicare not pay. I had read on here about some folks ending up paying hundreds of dollars of rental costs when it turned out that the DME didn't send their Medicare paperwork in.  I refuse to be beholden to some big corporate outfit who can't get their act together or worse, deliberately withholds that Medicare hasn't been paying.
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