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Uncooperative DME
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bwexler Offline

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Posts: 563
Joined: Mar 2012

Machine: PRS 1 BiPAP autoSV Advanced, with Heated Tube humidifier
Mask Type: Nasal mask
Mask Make & Model: Sleepweaver Élan
Humidifier: Resperonics Heated Tube humidifier
CPAP Pressure: Max pressure 25.0 cm H20, Max
CPAP Software: SleepyHead EncorePro

Other Comments: CMS 50i with Software for SpO2

Sex: Male
Location: San Marcos, CA, USA

Post: #1
Uncooperative DME
I have been trying for a month to get a new cloth cushion for my SleepWeaver Élan.
I was working with a regional manager for my DME. He started out optimistic and suggested he would have what I wanted in a few days. All he had to do was reach out to his counterpart in purchasing and cut through the beaurocracy. After a month of trying he explained they have no relationship with SleepWeaver and would have to order 1000 pieces to get me what I want, and they will not do it because they have seen no demand. How could they if their RTs have never seen it and their customer base does not know about this site.
The insurance company says I have to deal with the medical group, who only deals with two DMEs. Neither one deals with SleepWeaver.
I know I can pay out of pocket, but that is why I pay premiums to the insurance company.
Any ideas welcome.
06-13-2013 12:56 PM
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Shastzi Offline

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Posts: 1,174
Joined: Dec 2012

Machine: ResMed S9 Autoset
Mask Type: Full face mask
Mask Make & Model: FitLife Total face mask
Humidifier: F&P HC150 with Hybernite heated hose.
CPAP Pressure: 15cm-20cm H2O (auto)
CPAP Software: SleepyHead Other Software

Other Comments: CMS50-F wearable Oximeter; Software: SPO2 Assistant

Sex: Undisclosed
Location: Florida, USA.

Post: #2
RE: Uncooperative DME
Free Advise is seldom cheap.

things like this happen when an insurance company is running the show.
You may just have to pay for some things out of pocket and try to take an income tax write off if you can.

I would think the insurance company would re-imburse you directly if you made a proper claim.
(Be warned though. They make money by trying to weasel out of paying for claims.)

Good luck!

"With ordinary talent and extraordinary perseverance, all things are attainable." - Thomas Foxwell Buxton

Cool
06-13-2013 02:04 PM
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cbramsey Offline

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Posts: 900
Joined: Mar 2012

Machine: ResMed S9 Autoset
Mask Type: Nasal mask
Mask Make & Model: ResMed Mirage FX
Humidifier: ResMed H5i with ClimateLine
CPAP Pressure: 6 - 12
CPAP Software: ResScan

Other Comments: Supreme Overlord of Web Darkness

Sex: Male
Location: NC, USA

Post: #3
RE: Uncooperative DME
I hate to say it but you may be stuck with paying for this out of your own pocket.

An option would be to consider one of the online suppliers on the Supplier List to try to minimize your expense.

Another option would be to contact your insurance provider to see if you can contact another DME. Explain your situation to them. Threaten to get your state insurance commissioner involved. Sleep-well

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
06-13-2013 02:32 PM
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bwexler Offline

Advisory Members

Posts: 563
Joined: Mar 2012

Machine: PRS 1 BiPAP autoSV Advanced, with Heated Tube humidifier
Mask Type: Nasal mask
Mask Make & Model: Sleepweaver Élan
Humidifier: Resperonics Heated Tube humidifier
CPAP Pressure: Max pressure 25.0 cm H20, Max
CPAP Software: SleepyHead EncorePro

Other Comments: CMS 50i with Software for SpO2

Sex: Male
Location: San Marcos, CA, USA

Post: #4
RE: Uncooperative DME
The insurance company claims they would be happy to pay, but the medical group must approve the purchase from the DME of their choice, which does not carry SleepWeaver.
I officially started the second ( or is it the third) round of negotiation with the insurance company grievances coordinator advocating my position.
I am trying to be patient, but I am not very good at it.
06-13-2013 03:02 PM
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cbramsey Offline

Advisory Members

Posts: 900
Joined: Mar 2012

Machine: ResMed S9 Autoset
Mask Type: Nasal mask
Mask Make & Model: ResMed Mirage FX
Humidifier: ResMed H5i with ClimateLine
CPAP Pressure: 6 - 12
CPAP Software: ResScan

Other Comments: Supreme Overlord of Web Darkness

Sex: Male
Location: NC, USA

Post: #5
RE: Uncooperative DME
(06-13-2013 03:02 PM)bwexler Wrote:  The insurance company claims they would be happy to pay, but the medical group must approve the purchase from the DME of their choice, which does not carry SleepWeaver.
I officially started the second ( or is it the third) round of negotiation with the insurance company grievances coordinator advocating my position.
I am trying to be patient, but I am not very good at it.

In my opinion, your medical group needs a "Cranial Rectal Extraction". Laugh-a-lot They work for you, not the other way around.

Good luck with negotiating with the insurance company. Sleep-well

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
06-13-2013 03:34 PM
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Paptillian Offline

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Posts: 474
Joined: Jun 2013

Machine: S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: Swift FX
Humidifier: H5i
CPAP Pressure: 4 - 10, EPR x2
CPAP Software: ResScan SleepyHead

Other Comments:

Sex: Male
Location: Pennsylvania, USA

Post: #6
RE: Uncooperative DME
(06-13-2013 03:02 PM)bwexler Wrote:  I am trying to be patient, but I am not very good at it.
Keep up the vigilance and be a nuisance to them every single day. I learned the hard way. The past 6 months has taught me that lesson.

I tried patience. I tried filing formal appeals, writing letters, sending years' worth of requested medical records (which I had to pay to obtain), and even threatening to get the media involved. I tried following procedures and waiting for them to work it out. It never happened. Each time I would call they would run me in circles for an hour. The department that I needed to speak to (Appeals) was conveniently never answering their phone and "couldn't be reached" even by the customer service reps. I've had customer service people hang up on me. I've been told that my appeal forms and records were lost and couldn't be found. I've been told that I would get a call back from a manager or someone that could help me, and I've waited like an idiot, believing that I was going to hear back. My sleep doc. advocated on my behalf and was also given the run-around to the point that he lost his cool in the office one day.

In the end none of that mattered. My issue got attention when one day I set several hours aside and decided to keep a customer service rep on the line for as long as he could hold out. He kept telling me that his manager was in a meeting and would call me back. I kept telling him that I would wait. He put me on hold several times, each time coming back and telling me that the person was busy and would call me back. Each time I told him I would wait. He explained that he needed to get off the line with me so that he could take other customers, and I told him that I am not finished and wished to wait. I tied up his phone long enough that eventually he "found" a way to get in touch with the person in Appeals. I spoke to the person, explained my case, made him look up my appeal documentation and records on the spot. A couple weeks later I had my authorization.

That's a long-winded story but sir please take it from me that you have to stay on these people until they work for you because they are motivated to avoid responsibility. An insurance company is a big investment firm who is their own client! The insurance part of it is just how they get revenue to invest. Anyone who tells me "they only invest in order to keep your premiums as low as possible" hasn't had to spend time on the phone with one.

I empathize with you. For 6 months they monkeyed me around and played with my health.
06-14-2013 07:18 PM
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Shastzi Offline

Advisory Members

Posts: 1,174
Joined: Dec 2012

Machine: ResMed S9 Autoset
Mask Type: Full face mask
Mask Make & Model: FitLife Total face mask
Humidifier: F&P HC150 with Hybernite heated hose.
CPAP Pressure: 15cm-20cm H2O (auto)
CPAP Software: SleepyHead Other Software

Other Comments: CMS50-F wearable Oximeter; Software: SPO2 Assistant

Sex: Undisclosed
Location: Florida, USA.

Post: #7
RE: Uncooperative DME
If you have ever watched "The Incredibles" you will see a good example of how insurance claims get handled.
(by weaseling out)

Remember too, they NEVER lose money. Ever. No matter what you hear.

So...

There is always the baseball bat up the long johns ploy to get their attention.

Big Grin

"With ordinary talent and extraordinary perseverance, all things are attainable." - Thomas Foxwell Buxton

Cool
06-15-2013 06:43 PM
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