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Insurance Frustration
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penbate Offline

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Posts: 5
Joined: Nov 2013

Machine: ResMed S9 Elite
Mask Type: Nasal mask
Mask Make & Model: Philips Wisp Nasal Mask
Humidifier: ResMed H5i
CPAP Pressure: 12
CPAP Software: ResScan

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Sex: Female
Location:

Post: #1
Insurance Frustration
Well, I called my insurance company yesterday to find out what the schedule was for replacing items. I don't trust my DME at this point. They told me that I did not have to be on a rental plan for 13 months that they would pay for it up front. I said great because I have already met every deductible this year because I had a hip replaced. They told me to just have it submitted in full and they would pay me in full. Well that sounded easy didn't it.

I called the DME and they sent me to the warehouse who sent me to billing. Billing didn't have a record of purchase because it was too soon. Then called back to my insurance company and they said that if it starts off as a rental then they have to pay it as a rental. I called my DME back and talked to a supervisor. They said they have never had an insurance company pay for the machine in full. That 99.9 percent check for compliance and none pay in full. I told her that I wanted the entire bill sent to the insurance company and not a rental. I want my $1500 deductible for next year. She has no clue on what to do. I started this process on Wednesday. Today I called and she said she has not come up with a solution.

At this point I know more about the machine, how to change my settings, how to read my settings and what the settings mean than the DME rep. I downloaded the software last night and read all my readings.

I then asked about ordering a battery. The insurance said they would cover it in full. I just have to find a DME that will order it for me. My DME said they only do the machines and the masks. Now I have to figure out how to find a DME that will order the battery.

I am pretty frustrated at this point. I called another DME today and they said they could not order the battery for me. Any ideas on who to call to order a battery for my machine?

UPDATE:

Get this. I have repeatedly called my insurance company to verify that I can outright purchase the CPAP machine. I can either purchase it or rent it. So I have been working for a week with my provider to have them stop the billing of a monthly bill that I would have to pay for a year or to bill it up front and be done with it. My deductible has been met. Well here is the new story.

After I called the provider they said they sent an email to billing. This was after a week I have not heard anything. I called her in the morning and in the afternoon and all I got was “I sent billing and email”. So I called my doctors office and talked to the sleep clinic. I talked to a woman and told her that my insurance will purchase it and no billing and that I have met my deductible and I want this done this year. They will also pay for a battery and I want that ordered. She was so shocked that she never heard of not being put on a 13 month plan. She said she would call the provider for me and find out what is happening.

The provider told her that because I have an out-of-state Blue Cross Blue Shield policy they have to submit it to the instate BC/BS policy and that they will reject an outright purchase. I told her then to submit it directly to my insurance company and be done with it. That I pay good money for this policy and this is what my benefits are. She said she was unable to do that. That Michigan has a policy that it needs to bill out for 13 months. I told her that this was unacceptable. I wanted to purchase it.

Now my insurance company gave me 250 other DME’s in my area (I have called 20 or so of them) and none of them provide CPAP equipment. If I order on line then I am responsible for it 100% because I am out of network then. I am screwed.

What the clinic told me was that the provider was trying to bill it through an Ohio office so that it would not go through Michigan’s red tape in their billing requirements. Is this a bunch of poop or what. I am furious that I have spent almost a week on this and have not gotten any results. When I talked to the provider they offered to come pick up the machine so that they did not have to deal with me any more. Instead of doing their job they wanted to come and pick up the machine. I told them that I had until the 11th of this month before that could happen. Now I am on search for a DME in my area that is in-network.

I want to scream. I have talked to my insurance yesterday and they have not come up with any solutions either. I don’t want to say anything about them billing through Ohio for fear that I will get screwed with that route.

Any suggestions would greatly be appreciated.
12-04-2013 08:37 AM
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me50 Offline

Advisory Members

Posts: 2,559
Joined: Aug 2013

Machine: resmed S9 VPAP Auto
Mask Type: Nasal mask
Mask Make & Model: Wisp and Silicone Head gear
Humidifier: resmed H5i
CPAP Pressure: 18/8
CPAP Software: SleepyHead

Other Comments:

Sex: Undisclosed
Location: USA

Post: #2
RE: Insurance Frustration
Before I was eligible for medicare (have to wait 2 years), I had BCBS out of state. Yes, the claims are processed by the BCBS in my state according to the plan benefits of the BCBS out of state contract. BCBS paid for my CPAP machine outright with no rental.

If you are talking with the DME, I would suggest going up the chain of command because whoever you are dealing with right now clearly doesn't understand or they don't want to understand so they can continue to get the monthly fee for rental which pretty much adds up to more than the machine actually costs over a 13 month period.

Just curious, who is your DME?
(This post was last modified: 12-04-2013 08:50 AM by me50.)
12-04-2013 08:45 AM
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PaulaO2 Offline
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Posts: 8,057
Joined: Feb 2012

Machine: S9 Autoset
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: H5i
CPAP Pressure: 14-20
CPAP Software: SleepyHead

Other Comments: Ehlers-Danlos Syndrome, Hypermobility Type; chronic sarcasm

Sex: Undisclosed
Location: western NC, USA

Post: #3
RE: Insurance Frustration
Tell the DME to pretend you are paying for this yourself and to send you the bill. You then send the bill to the insurance company. Your DME sounds like a bunch of ants who can't act if they can't follow the path.

Or, ask the insurance company if they have any online suppliers they can work with. Or can reimburse you for an online payment. Wait, you said you already did that. Never mind.

PaulaO2
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www.ApneaBoard.com


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12-04-2013 04:17 PM
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penbate Offline

Members

Posts: 5
Joined: Nov 2013

Machine: ResMed S9 Elite
Mask Type: Nasal mask
Mask Make & Model: Philips Wisp Nasal Mask
Humidifier: ResMed H5i
CPAP Pressure: 12
CPAP Software: ResScan

Other Comments:

Sex: Female
Location:

Post: #4
RE: Insurance Frustration
Well, I thought I would update you on my progress. My DME refused to bill it out as a purchase and will only bill it out as a rental. I had them come and pick up the machine. I called a DME recommended by a friend and they are willing to bill it out as a purchase. They said they did it with another patient and it went fine. I logged onto my BC/BS account and it shows paid in full. So what I was told about it by my insurance company was that it is the employer that decides what benefits you get not the state. So if the employer offers the product to be purchased then they will pay for a purchase and I have no compliance issues. Although I am on approximately 10 hours of sleep a night I have no compliance issues. So, my machine is paid for 100%. The previous DME left all the used supplies with me so I have those to use for 3 months. And the new DME fitted me for a full face mask in case I get a cold. So I am swimming in extra supplies and I have a new machine fully covered. So for all those out there that have an insurance company that will pay for your product as a purchase remember it is the employer that decides how to pay for it not the local BC/BS. Get the rejection and send it to YOUR insurance company.
12-15-2013 03:17 PM
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