December 11, 2008
I have two sons with Duchenne Muscular Dystrophy; age 27 and 29 both have lived past their life expectancy of late teens to early twenties. Both require constant care and assistance with all daily life activities. That being said both are wonderful bright young men with outgoing personalities and great attitudes.
Both of my young men need durable medical equipment for a variety of reasons, for now I’d like to talk about David and what I’ve just discovered about DME rentals. David is on a ventilator, to be precise an LTV 950, small, lightweight, size of a lap top ventilator. David has been on a vent since December of 2002.
Recently, we have changed insurance companies, which is another story for another time. However, in changing companies, I for the first time received an itemized statement for the costs of David numerous medical support supplies. Prior to changing insurance companies the only thing I ever saw was a brief explanation of benefits stating Medical/Medical Surgical Supplies.
Now I had a description of what was being paid in a breakdown for specific items. I am only going to refer to a few of the items to provide you with a glimpse of what is happening. We are currently or I should say our insurance company, is being charged $6000.00 per month for David’s vent. My understanding is the purchase price of this machine is $50,000.00. So of course our new insurance company wanted to purchase the machine outright. Here is where it gets interesting, Aetna who was our Insurer for many years, had continued to pay rental on this piece of equipment. The explanation of the DME supplier was that Aetna did not want to pay the maintenance agreement for the piece of equipment because the cost was about the same. So Aetna just continued to rent it, as was their choice according to the DME supplier. Let’s do the math; December 02 to December 08 is 6 years or 72 months at the current rental costs of $6000.00 per month equals $432,000.00. This is part of what is wrong with our Health Care System.
First, why would Aetna continue to pay and not purchase the machine out right and then pay a reasonable fee when maintenance is needed, which by the way has not been an issue. Secondly, why would the DME supplier ever even imagine they should have this kind of a profit, off of someone else’s hardship, it’s a vent for Christ’s sake to keep a severely disabled young men breathing.
In recent conversations with the DME supplier I have learned that they plan to bill the new insurer for the ventilator all over again, or for as much as they can until the new insurer chooses to purchase the equipment. I was appalled and shocked, when I exclaimed my dismay; I was informed that this was two separate contracts with two different insurers. My reply, which would be that of any normal minded person, was that it was the same contract with the same family and the company had already charged enough for the vent to buy a nice house in the area.


In addition to the extortionately inflated price of the vent rental, there are now glaringly clear, other, over charges and erroneous charges. We have been billed for and our insurance company paid for, such items as infusion therapy and oral injectable medications, neither of which we have ever had. We have been billed for and paid for, O2 supplies for David on a sometimes next day basis when we receive O2 every other week. Finally, in terms of equipment, I believe we are being billed for an Oximeter which was originally supplied by another company; $1,000.00 per month for approximately the last 72 months equaling $72,000, this item purchased brand new is barely $1,000.00. We are also being billed for, and again they are being paid for, office visits and home health care visits all the while the rental equipment is on a rental basis and maintenence is supposed to be, according to the DME included.
I feel I am just touching the tip of the iceberg here and I have much research to do to see how far back this goes, I know there are charges of an erroneous nature back to 2006 and now I need detailed records for every year. Which I would assume won’t be easy to get.
I have more than enough to do everyday to take care of two young men who are Tetrapledgic with out having to audit my DME and Health insurer, my mistake was in trusting either of them to do what was right. We have had a very good relationship with our DME supplier they have been kind, courteous and helpful and for the kind of money they have been paid they probably should have been even more so.
If this happening to us, then this is happening to others, this cost and the waste are staggering in their proportions. Let’s stop it now. For DME providers rental for a period of a year should be suffice. After that all rental goes towards purchase; if the individual has an illness similar to my sons Duchenne Muscular Dystrophy, and the doctor has made it clear that this will be a piece of equipment for life, than all rental should go towards purchase. Electric wheelchairs are purchased at $30,000.00 plus for a 5 year period of time after age 21 and then in 5 year increments as needed and assessed for positioning comfort and control. So, why not ventilators?

Clear and concise statements should be provided to insurer and participant, not a brief EOB that is vague and obscured. Extensive penalties should be affixed for gross errors, erroneous charges, overbilling or overpaying. Penalty reimbursement should go directly to the policyholder, why you might ask, because this way you put a watchdog on both insurer and DME supplier. Policy holders for the most part will continuously audit their records, the DME and insurer won’t get a chance to make errors and misjudgments like I’ve seen, before they would be called on by policy holders who stand to gain, instead of lose by catching errors.



I have many other concerns and suggestions as do friends and acquaintances of mine in similar situations. As long as we remain a for profit based health care system we are going to continue to have sub standard care, especially for those most fragile and in need of specialized care. Why do we need any variety at all in insurance health care coverage, simply because of costs to the employer or consumer, you pay for what you get, or more likely what you can afford. Let’s all pay the same, let’s all get the same coverage, regardless of; race, creed, color, background, disability or age. I implore you to fix this system now and I pledge to help in anyway I can.

Sincerely,
Vickie Lee Beard

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Comment by Judy Sumner on July 28, 2009 at 12:42am
We have started buying some of the equipment for our son out of our own pockets because of experiences like yours. We have used our tax refunds to buy things like his air mattress overlay, shower chair and toileting system. We found that it was cheaper for us to do this than to pay our co-insurance portion month after month. We bought these items over the Internet for less than we would have paid over time through our insurance company. It also avoided the hassle! Of course this only works with less expensive items. The cough assist machine & c-pap machines still go through our insurance.
Comment by Holly Cahoon on January 25, 2009 at 4:35pm
I was just complaining to my mother the other day about my insurance company, my son has double coverage, but no, neither one will pay for any repairs to his power chair, can you believe that, that is my son's legs, but they still refuse to pay.... we are currently in the middle of a huge battle as well. It's hard enough dealing with our son's disability, now we get the frustrations of dealing with insurance companies too. Just drives me crazy!
Comment by Vickie Lee Beard on December 17, 2008 at 11:31am
Thanks to all for your suggestions and comments. I have asked several times for copies of statements, I have always been told you have no balance and we'll get something in the mail to you. I have asked Aetna and been told to contact my DME provider. I requested a copy again yesterday, I made them aware I will have my attorney contact them directly if I do not receive a copy of last years statements by the end of the week. I can tell you what I am wishing for this Christmas; a new health care system, the old one is clearly broken.
Comment by Char Burke on December 16, 2008 at 1:02am
Your post is shocking. Did you know that you have the right to challenge those medical claims? Did you know that you can call the Office of Insurance Commissioner and ask for help if you have a complaint filed? Did you know that the Health Care Provider has to respond in a specific amount of time? Get your hands on the health insurance contract and read it. What about writing your newspaper and placing an editorial about it? Do you know any attorney's that would help you sort through this? Some colleges/universities will do pro bono work - free - to help out people....Just some ideas....

Char Burke
Comment by Jennifer Shumsky on December 12, 2008 at 10:59pm
I work for an insurance company but we are also a medicare administrator and follow all medicare rules. Under medicare there are rent to cap rules on DME products, but under private insurance there is not the government involvement regulating it. It's a two way street, medicare is very limiting in what you can get because of the government rulings on pricing and such, so you have to be careful for what you wish for. If we all pay the same, get the same, we all will be stuck in a position that we can't get the higher tech, more expensive equiptment our boys need. The company I work for is lucky in that we also provide secondary insurance so we can override medicare due to medical necessity on some items, but for many people on standard goverment insurance (medicare) that luxury is not allowed.
Many insurance companies do rent DME products for 15 mos and at that point you hit the Rent to cap point that they then "Own" the equiptment, but they own it, you don't. That is something else you always want to check with your insurance company, who ultimately owns the equiptment you get. Also you should be monitoring your monthly statements, you should hold your DME company accountable. They should know by now you can take your very profitable business elsewhere. Also, know that most insurance company's have a set agreement with the DME company's on what they really pay on an item. So what you will see being billed is not what ends up being paid (not that it applies to all, but many have a fee limit). It sounds to me like you really got screwed by both your DME company and your insurance company. You are able to teach us all and remind us all it's once again falling on us to police one more thing in our son's lives.
I actually work as an appeals nurse, so if I can help you in this current fight you are facing in any way let me know. Thank you for bringing this to everyone's attention.
Comment by Vickie Lee Beard on December 12, 2008 at 9:11pm
MommaToo,

Glad u c the problem here, what has happened to u ?
Comment by MommaToo on December 12, 2008 at 11:39am
OMG! Your post has hit a nerve with me. I have had this issue for so long! I now have bills for equipment we never received! I have been on the phone with both provider of equipment and my insurance company. It is ridiculous that they will bill for this type of equipment in this way. This is why its so hard to get the basics for our son's!

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