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A doctor's office is not a place I expected to make a large, unplanned purchase. However, I did not raise the right questions and I was duped into buying an expensive durable medical equipment.
Last year, I took my son, who had a wheezy cough, to his pediatrician's office. As is common with air-borne diseases, most of the other kids in the office had the exact same ailment. I could hear the doctors prescribing a broncho-dilator that was supposed to be inhaled using a nebulizer to help clear the chest congestion. No one in our family has asthma, but as I heard two children using and getting immediate relief (so pronounced that I could hear from the adjacent room), I decided the benefits outweighed the risks.
As I had expected, the pediatrician recommended the same treatment for my son. When the nurse packed up the nebulizer, I asked if my insurance would cover it fully, and she said yes. One question I failed to ask was if the durable medical equipment would be out of network.
A month later, the insurance claim arrived stating my out of patient liability was $343. The total billed cost was over $1,000. The insurance paid $125, and billed my deductible, plus my coinsurance, at an out of network rate, totaling $343. An online search indicated that the same model nebulizer typically cost $40-50.
Apparently, a small medical supplies company, which did not have in-network relationship with any insurance company, had struck a consignment deal with my doctors' office where the office kept the products in stock and distributed them to patients, then earned the consignment fee on the "sale." The medical supplier then billed the patients' insurance at a ridiculously inflated amount (over 1000% of the retail price). The insurance company heavily discounted the bill, but still paid the out of network rate (say 50-80% of the total cost). I was liable for the out of network deductible, plus any remaining bill.
I called my insurance company. They suggested I submit a letter requesting to reprocess the claim as in network (even though the vendor was out of network), as I had received it from the doctor's office. This did not seem like a guaranteed solution, so I called the doctor's office next. They said they would take back the nebulizer, offer me a refund and provide a prescription I could submit to my insurance for another nebulizer. This did not make much sense either. Finally, I called the vendor who had supplied the equipment to my pediatrician. As they had been reimbursed twice the amount of their equipment, they were happy to waive the remainder of my liability.
So, even though I got duped into buying a durable medical equipment from an out of network provider at my doctor's office, repeatedly challenging the bill resulted in no out of pocket costs.
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