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Getting the run-around
#1
Getting the run-around
My wife was recently prescribed a CPAP. Her pulmonologist sent her prescription to a DME company owned by the hospital they are a part of. They said that they were not going to file it with our insurance because we have not met our deductible yet. They were more than happy to set up payments and us pay full price out of pocket. I contacted blue Cross and they said that it would have to be filed to count towards our deductible. They also said that the pulmonologist would have to submit a pre-authorization for a 90 day rental and once compliance was established, they would require a second pre-authorization for continuation of coverage. I contacted the pulmonologist office and informed them of this and they said my wife had to come in for a follow-up appointment and that it was a requirement of blue Cross for the pre-authorization. I knew that was a complete load of crap and contacted blue Cross to verify what their requirements were. I was told that since her diagnosis had been determined and a prescription sent to a DME company, that a follow-up was not a requirement for blue Cross. What should I do about this shady scenario? I made blue Cross aware that these entities in their network were engaged in this fraud.
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#2
RE: Getting the run-around
Can you return the machine?  You can often find new, top-end Dreamstations on Amazon for less than $500.
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#3
RE: Getting the run-around
I hope someone else has some good, practical advice for you, but I just wanted to say, I feel for you. I've had a similar stupid situation when first diagnosed. I ended up buying a machine online and my insurance provider was happy because it saved them a good chunk of money (did I mention the DME wanted to charge $2200 for a Dreamstation?). In doing so however, the DME was no longer wanting to have me as a client, so now I'm on my own, which is by far better. Perhaps the doctor could refer your wife to a different DME?
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#4
RE: Getting the run-around
We didn't purchase the one from the dme company. We got a top end DS from Amazon for $385. Blue Cross won't reimburse for that even though it is a win-win for both parties. They can get a pre-authorization for another machine and we can get a backup, but don't really see the need right now. I'm just upset that they are trying to nickel and dime us over this thing and flat out lie to us to get our money.
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#5
RE: Getting the run-around
The doctor is mainly the problem. I could get another dme by transferring the prescription, but unless the doctor files a pre-authorization, insurance will not cover it. The doctor's office claims that for them to do that, my wife is required to come in for an appointment because insurance requires it. I confirmed with my insurance that that is not the case.
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#6
RE: Getting the run-around
I suggest you demand copies of all test results and prescriptions that you are entitled to under HIPAA. These documents are important to your long term care, and should be transferable to your new doctor. Hopefully you are dumping this one. I use my primary care physician for all CPAP/apnea needs.
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#7
RE: Getting the run-around
(06-28-2017, 06:43 PM)Hannerbob Wrote: They said that they were not going to file it with our insurance because we have not met our deductible yet.

Unfortunately, shady behavior like this is all too common. I would write a letter of complaint to the insurance company and send copies to both the doctor's office and the equipment supplier's office and do no future business with either of them.
Sleepster
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#8
RE: Getting the run-around
My suggestion is to call Blue Cross and ask to do a 3 way conversation with the doctor's office manager if you want a machine. Otherwise, congratulate yourselves on buying a machine from Amazon and avoiding the whole mess. Your primary can write you a prescription for supplies that you may need from online suppliers. In the meantime, find out from your insurance company what other DMEs are in their network. If you find that you otherwise use up your deductible this year from an unexpected illness, you could get your backup machine completely covered. Remember to switch over to that one when you do.
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#9
RE: Getting the run-around
Hi Hannerbob,
WELCOME! to the forum.!
Hopefully you will get your insurance problem straightened out soon.
Good luck to your wife with CPAP therapy.
trish6hundred
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