Yet another BAMBOOZLED sucker - I got a brick, now what?

[Nicholas]

I phoned my health insurance (United Health Care) this morning ahead of this afternoon's ENT visit (where I'll have the discussion advised above by Opal and Bonjour). I inquired whether the DME had yet submitted the claim for the CPAP. The rep informed me that there are a couple claims pending for the date of service of my sleep study, but they are still being entered, so she wasn't able to see any details (i.e., she couldn't confirm whether one of those claims was, in fact, for the CPAP machine - although I'm assuming one of them is).

In light of those claim details not yet being available, I inquired generally about UHC's "compliance" policy regarding CPAP machines. She placed me on hold to research the issue, and when she returned, she told me she was able to find "no such policy" dealing with "compliance" surrounding CPAP machines, nor had she ever heard of CPAPs being monitored for a 4hr/night minimum usage requirement. This is an interesting development, imo. I next inquired whether there might be somebody within UHC I could speak with who has CPAP-specific knowledge who could speak more deeply about the matter, but she said no.

Furthermore, she was also unable to yet confirm whether or not UHC has already paid the claim (which they are likely to pay in full with no OOP from me because I've already reached my OOP max for this year). I certainly hope the claim has NOT been paid yet. Knowing how slowly insurance companies tend to move, there's a good chance it hasn't, but if it has, that may mean I'm stuck with the brick because I doubt insurance would pay for another machine *EVEN IF* my ENT agrees to change the order to the new machine. Fingers crossed.

I then explained to the rep about being unsatisfied with the machine delivered by my DME and inquired about what to do regarding possibly obtaining a different one. I asked what would be the insurance implications of returning the machine. Without claim details, she regretted that she was altogether unable to advise me on the matter.

So, on to this afternoon's ENT visit.

P.S. my delivery ticket for the CPAP shows the machine's cost to be $15,000.00 WTF????? I'd be surprised if UHC hadn't negotiated a price a few powers of 10 lower than that.

[OpalRose]

Nicholas,
I can't suggest strongly enough that you connect with someone "knowledgeable" with your insurance.   Be forcefull until you get answers.  It's not acceptable to have one person tell you it's a rental and yet another tell you it's a purchase.  

You also need to verify with insurance, not DME,  if they require compliance.  

Don't depend on a DME to give you accurate information.  

Let your insurance know you will be returning machine and why.  You do not have to deal with any particular DME, you can switch.  First, is to get your doctor or ENT to write a script stating the exact machine you want with a pressure range written on it.  

Find a DME that will work with you.  Good Luck.

[Hydrangea]

Good for you for calling your insurance. Sounds like they were mostly helpful.

My insurance person got quite a laugh when I asked about compliance. She told me if they required people to prove they used the machines consistently, nobody would get machines... implying that very few people actually use their machines consistently. And so, no, my insurance doesn't require compliance. While I was glad to hear that, it made me even more mad at, & distrusting of, my DME *and my doctor* that had told me compliance was required.

The mark-up on machines through DMEs is disgusting. You can pay out of pocket through any of the vendors listed here, or even through Amazon, for a much more reasonable amount.

[Sleeprider]

This is so much easier to prevent than to fix.

Get your ENT to change the prescription to a range of pressure and auto CPAP. Problem solved. Use whatever argument suits you, including any discomfort and uncertainty over your therapy.

[Nicholas]

This past Thursday, I had my follow-up with my ENT doc. During the follow-up, the ENT went over the results of my sleep study with me (which I had already obtained and learned about in-depth prior to the visit). The ENT didn't seem to be aware that a DME had already delivered my CPAP machine ahead of this follow-up visit, and when I informed him that I'd already taken delivery of a machine, the doc sounded surprised.

I then brought up to him that I was unsatisfied with the machine and its features and desired to return it for a new one. This is when things seemed to get a little wonky. The doc explained to me that he personally doesn't know much about the actual machines and their features, but he instead refers his patients to his go-to DME (this is disappointing). He said he had no problem with me wanting to exchange for a whichever machine I preferred and that his go-to DME (who is NOT the same DME who sold me my brick) would assist me with all of that. That plan didn't quite sit well with me, so I persisted in asking, "What if getting a new machine requires you signing a different prescription?" His response (my paraphrase) was simply, "If another prescription is required, then my DME guy will get with me on it."

And so he had this DME call me. I spoke with Michael, with whom I was actually pretty impressed. When I explained to Michael that I had already been stuck with a brick by a different DME, he explained that he might not be able to do anything about it (duh - that what I was trying to get across to my doctor). I explained to Michael that the DME who provided my brick was the same company who did my sleep study. He then explained to me that my sleep study provider is not supposed to also be my DME, but they sneak around this rule by selling me the machine under a different tax ID number and not telling me. At the time they delivered my brick, it didn't cross my mind that there'd be any reason I'd want to get my machine through anyone else - I was trusting (which, for better or worse, is how I am by default - because I'm an honest person and, naively, generally expect others are, too).

So, basically here's what I've come to realize: my DME was very underhanded in the way they went about selling me my machine, essentially undercutting the other DME to whom my doc would've preferred to refer me.

So, while my doc's "go-to" DME can't really do anything about the fact that another DME has already sold me a brick, they are going to assist me (even though I'm not their client) in playing the game correctly with other DME in order to try and get the better machine. Michael referred me to the owner of his company (they're a mom-and-pop) to help further advise me.

The next step is to approach my DME and sweet talk them somehow into taking the brick back withdrawing the claim. Who knows - it could be that I'm overthinking all of this and they might end up being super cool about all of this and just want to make me happy. But I also need to be prepared for it not going that way. Tomorrow, I'll speak with the owner of my doc's preferred DME, and she will advise me on how to best play the game and get the machine I want - and she's willing to help me do that EVEN if it means getting taken care of without having to actually become her client.

Anyways, enough out of me right now. Tuesday I'll post the latest development to this unfortunate and trouble saga (which all would've been avoided had I found this forum before getting my brick). Thanks again to everyone here on the board who has been supportive so far and has offered wise suggestions.

This

[Sleeprider]

Good luck Nicholus. Keep us posted.

[Gideon]

It sounds liker this 2nd DME is a winner.  As a minimium I would tell them you want all your future dealings with them.  That is new masks, tubing, etc. which insurance will allow you to periodically replace.

Keep after the other DME.

After and if the new DME cannot help,
I would consider the pester strategy, How did I do last night, I felt funny in the morning, why?  What does my data look like.

[Crimson Nape]

Nicholas,
Unless I read your post incorrectly; The Sleep Lab/DME gave you a CPAP without having a prescription first?

[Nicholas]

Nicholas,
Unless I read your post incorrectly; The Sleep Lab/DME gave you a CPAP without having a prescription first?

I may not have explained well: the Sleep Lab/DME *did* have a prescription before they gave me my CPAP. However, I believe the way they went about *getting* that prescription was on the sneaky side. They themselves filled out the Rx form completely and faxed it over to my doc with just an asterisk on the signature line. What I imagine happened was that some office employee retrieved it off the fax machine and handed it to the doc and said, "Here, sign this." And the busy doc probably just signed it without really looking.

That's probably why the doc seem to act surprised when he learned during our visit that I already had a machine.

[Nicholas]

UPDATE: so my doc's go-to DME simply advised to contact *my* DME and just tell them what I wanted. I did just that, and thankfully, there was no push-back from my DME at all. The rep simply said, "No problem. Just have the doc update the Rx, and we'll be glad to swap out your machine." That was easier than I thought. I've requested that the doc send it over, which he said he'd do. Will update the thread again once everything goes through.

And yes, Bonjour, my plan is to deal with the 2nd DME going forward.