First Problem With The ACA We Have Had. Maybe some fraud as well.

[rsmith6621]

For years my wife has felt like her sleep pattern was not up to date. In March she spoke with her family doctor and he ref. her to a pulmonary/sleep study Dr.

In April she spent the night at the local hospital sleep study unit. Upon her leaving the Dr there gave her a prelim report that she was having 100+ episodes where she was woken because of breathing issues,very high. A week later she went back to the ref Dr to hear the rest of the results and then started the process of getting her a BIPAP machine. It took a month for the medical vendor to get an authorization from our insurance which is part of our states health exchange. It seemed like a done deal with the insurance paying for the monthly rental.

2 weeks ago she went back to the Dr for a 60 day review and was told she had only had one non breathing event since she started using the machine and she is feeling a whole hell of a lot better as well.

WELL! yesterday she called the medical supply place to schedule a time to have her mask adjusted since it is leaking air. The technician was looking through her file and then told her that insurance had actually not approved the machine and told her to return it ASAP and to pay the 3 months rental charge. The machine rents for over $200 a month......BUT you can buy the machine outright for just under $2000. The initial insurance letter said they would pay $200 a month to rent for the time we are on the policy. Do you see something funny here that is wrong with the picture?

She called her sleep Dr after the call to the medical supply call in distress. Basically before she got the machine she was having heart issues feeling like her chest was being squeezed, within the first two nights that problem was gone.

Wife was ready to surrender the machine today and accept that one night she would just stop breathing and die in her sleep. I said HELL NO not until the supply company and her Dr have exhausted every avenue. She is worried about the possible bill that could be sent, I told her let them bill us, I will call the consumer advocates at the local TV stations and get them involved.


So if this was your situation what would you do.

1. call the insurance company yourself.
2. return the machine
3. file a concern with the states insurance commissioner


Your thoughts.

[cbdo2007]

1. Start by calling the insurance company and asking them why they didn't pay it.

Then let us know what they say. Sounds like you have documentation saying they would pay for it, so have that in hand when you call. It certainly isn't President Obama's fault like the media would have you believe.

[Ms. Toad]

2. First step -

Find your policy and see if they specify particular DME suppliers. Insurance companies (all, not just ACA) tend to limit who they authorize to provide DME equipment. (We have to receive diabetic supplies from one specific vendor - anyone else and we have to pay out of pocket. Period. Our policy is not a marketplace policy. And - this is not the first time we have bumped into the typically limited DME provider restrictions.

Once you know what your policy provides, call the insurance company and find out (1) if they actually denied it and (2) why they denied it (inadequate documentation, too few episodes per hour, out of network DME provider). Often the communication between insurance companies and providers stinks. We just had a CPAP fight with our (again, non-marketplace) insurance and the DME provider. It took me a month to get the right parties to communicate with each other. The DME provider was merely looking on the insurance website and had decided it was out of network and refused to provide a new mask. They told me they repeatedly called, and had been repeatedly denied by insurance - when I talked with insurance, they insisted they had not had a single call from the DME provider.

If the issue is in network v. out of network, you will need to obtain the DME provider's EIN (tax ID). That is what insurance companies use to determine whether a provider is in or out of network. Once I got the DME EIN, and verified with the insurance company, and got to a supervisor in the DME company, she finally called and confirmed we were in network.

If they denied it as not medically necesary - file an appeal. Be prepared to bring your doctor into the appeal - s/he will likely need to provide medical documentation of the need. You will have two layers of appeals - the first to the insurance company, and the second to the state's insurance commissioner.

Whether you return the machine in the meantime depends on your tolerance for paying the monthly fee if you lose. I have never lost anything I have chosen to fight - so it would have to be a pretty large fee for me to return a machine that I felt was medically necessary since I'm confident in my ability to (1) understand what I am entitled to and (2) convince the powers that be that they have made a mistake. It sounds as if you may not have that confidence yet - so you may be more cautious about the possibility of losing and being out of pocket $200/month.

Whatever you decide, don't pay the bill until the dust settles. Communicate with the billing entity & let them know that the bill is under dispute with insurance. Medical providers will understand insurance disputes, but once money is in their hands they are both reluctant and incompetent about giving it back. I once spent about 200 hours resolving what ultimately boiled down to a $100 dispute with one of the biggest and reputable hospitals in the US. I had paid a bill before I realized that the insurance company had not properly processed it - and when the insurance company sucked back some of the money they had paid, in order to pay through a different tier, the hospital credited the insurance company with the money I had paid - and I had to fight to get it recredited to me.

Good Luck.

[bobalew]

3. If necessary, You can buy a "Genltly Used" IntelliPAP machine for ~ $ 300.00, and dispense with the

the rental Fees altogether, which, in itself is a SCAM, perpetrated by Your doctor & the supplier. Usually the Doctor Buys the machine, then charges your Insurance provider for the 'Rent". usually they hope to continue this income stream for at least 6 months ( At least this has been my experience of it). I use a website/vendor known as 'Second Wind CPAP" for my machine needs. I'v bought several machines over a 7 year period (One for Home & One for Travel), at very reasonalble prices (One at 275.00 & one at 175.00) and they were & still are excellent machines. You will have to take it in to you doctor for settings, or as most manuals are available on-line, once you have a pressure setting, you can set it up yourself. This is no Mystery, and the system, unfortunately in play these days is designed to max out profits for the machine makers & the Pulmonary physicians. Don't be ripped off! My GP, when I want a new machine will simply write me a prescription at my prevoiusly determined pressure level, & I can also buy a well discounted machine on the web. If I need an adjustment Up or down, I increase or decrese the pressure to ensure a good night's sleep. I have been doing this for 9 years & counting, and have the support of my doctor on this. There's absolutely NO REASON for the Pulmonary doctor, or the CPAP Supplier to STEAL from you, and your Insurance provider needs to be reminded that they ARE NOT your DOCTOR. I hope this little bit of info helps you.

[bobalew]

4. Additionally, This is not, exclusively an ACA issue. It happens in the employer based Insurance

Market also.

[Motown_Johnny]

5. First, get your hands on that letter

Then send a copy of it to the company that says the insurance company won't pay. Or walk in and hand it to whoever says the insurance won't pay. Keep the original.

Then call the insurance company and try to get in touch with the person who sent the letter. This could take a while since you never know what days people work or if someone is on a summer vacation.


Once you get a hold of the person who sent the letter, have him/her confirm that the insurance will pay for the machine and then have him/her contact that company directly.


I doubt this is fraud. It just sounds like someone screwed up the paperwork. I seriously doubt that a brick and mortar company with possibly millions of dollars invested in medical equipment would commit a felony just to try and screw you out of $600.00.

If for some reason the insurance company won't pay for the machine, you then have a grievance with that company. So long as the letter says what you think it does then they should pay for the time you have had the machine. Ask for a manager if the person who wrote the letter screwed up and won't fix it.

At that point you may want to switch companies, since your wife's pre-existing condition won't stop you from doing that now, and get a policy that will cover the treatment she needs. That or look into a used machine as was suggested in a previous post.

I hope this is just a paperwork glitch. Best of luck to you. Let us know how things work out.