Oxygen equipment purchase reimbursement

[candg918]

What is the name of your state (only U.S. law)? OK

How can I find the procedure code for a piece of durable medical equipment. Since no preferred provider of our health plan would sell me a oxygen concentrator (claiming it would violate Medicare regulations, even though the person for whom it was being purchased was not on Medicare), I purchased it from an online provider.

The list price of the equipment was $4000. The purchase price online was $2800. The reimbursement for the purchase was $302. This replaces a piece of rental equipment that was billed at nearly $500/month, paid to perferred provider at $130ish/mo. Its online cost was only $600. In the 2 years of use of the rental equipment, it has been "purchased" over 4 times without us actually "owning" the equipment. In addition, it was not portable so it required the rental of supplementary equipment at nearly $1000/week when we traveled by air. Even the rental of a smaller oxygen concentrator that would fit in the trunk of a car was about $150/week. These costs were not covered by insurance.

Before making the purchase, I had been told that it would be reimbursed at the rate of 60% of cost (approx. $1700) if purchased from a non-preferred provider. I was reimbursed at just over 10%. I am being told that the allowable rental cost based on the coding was $52/mo. It is illogical that a piece of equipment costing approx. 4 times as much would be reimbursed at less than 1/2 the original.

Please let me know who can provide the equipment code to verify it was entered correctly? Please also let me know what I should reasonable expect as reimbursement or how I can determine that?

Other than filing yet another appeal with the company, should I pursue it with the state insurance commissioner?

[ecmst12]

You should have done what you needed to do to go through a preferred provider. They are going to reimburse you based on reasonable and customary charges.

[candg918]

Every preferred provider refused to sell the equipment claiming that their Medicare contract prohibited the sale of oxygen equipment even though the equipment was available at the medical equipment supplier. Were they fibbing?

The reasonable and customary sales price was likely more than I paid. List is $4000; I paid $2800.

I suspect that there is a problem with the coding of the equipment/service. I would like to verify it.

Thanks.

[ecmst12]

You can google for CPT code lookup or translation.

The LIST price has nothing to do with the reasonable & customary charge and it is likely MUCH higher then the R&C.