Help! Supplier inflates bills. $1950 for $868 CPAP machine?!

[sleepy_and_boo]

Hi everyone,

I've been using a CPAP machine since June - the Philips Respironics System One REMstar Auto-Flex with a heated tube humidifier. It does help but I feel I'm getting totally swindled when it comes to how much it'll cost me.

The supplier (arranged through my sleep center) seems to be significantly over-billing my insurance:
-> $1950 for the machine (paid in 10 monthly installments of $195) - I saw the same exact machine listed on several websites for $868.
-> $303 for the Wisp mask incl. headgear - which I saw for $109 online.
-> $566 for spare parts which I was told I can claim every 3 months - but would I have to? ($400 for the humidifier, $82 for the tube, $45 for the water chamber, $39 for filters. I found all of these for much cheaper online.)

In any case, all bills will total $2820. This seems totally excessive. My deductible is $750 per calendar year, but since the 10-month lease started in June, it will go into 2016, so I have to pay 2 deductibles instead of just one. I called the supplier and due to their contract with the insurance they "can not" shorten the length of the lease/recalculate the payments.

Long story short, insurance will pay around half of the $2820 and I'm still left with the other half, precisely $1390. Meanwhile, the cheapest price (with a coupon) I found online for the same exact machine, Wisp mask included, is $799. (That would leave plenty of money for replacement parts...)

In other words, I could've paid $799 for everything out of pocket and without insurance, while with insurance I'm supposed to pay $1390!
I feel totally scammed! What should I do? Have any of you have had a similar experience? How do I get the supplier to charge my insurance a reasonable amount instead of a totally inflated one? Or could I possibly just return the machine and get my money back?

Thanks in advance for your advice!
sleepy_and_boo

[Sleeprider]

And it's very likely you could have purchase the machine directly from an online supplier and paid the out of network deductible, and had a net payment much less. Contracts and allowable prices vary, but when the purchase requires a 13 month rental, you have to figure there is a reason it bridges two deductible periods. The good news is, your deductible is not $1500 individual/$3000 family. A common amount.

Go for the return and make the purchase that makes sense.

[biz64]

Most DME companies will bill the insurance for the max allowable by the insurance company. It's no different than if you went to the hospital, they would bill your insurance for a lot more than if you didn't have insurance and paid yourself. Also, keep in mind that brick and mortar DME companies like your local supplier have a lot more overhead than a company thats only on line or web based, so they need to charge more to turn a profit. There are many people who buy the machines and supplies outright themselves because it ends up being cheaper than paying their deductible, as a matter of fact quite a few people who buy machines from me have insurance but choose not to use it.

[Redonthehead]

Have you received a EOB - Explanation of Benefits - from your insurance? Its relatively common for health providers to submit a "retail" price to insurance, who then knocks it down substantially due to a contract rate.

[Wulfman...]

Check with your insurance provider to see if they'll do an early payout......before your new deductible fiscal year kicks in again.

But, yes, they'll get you coming and going if you haven't done your homework ahead of time.

Typically, the insurance providers have negotiated contracts with the DME suppliers and what they pay MAY not be what they bill them for. But, in many cases, they appear to be over-billing for what they deliver.

In my own case, I purchased my initial equipment out-of-pocket from CPAP.COM and then billed my insurance provider. They then reimbursed me for 80% of the cost because they considered me to be in-network.


Den

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[RubySnooze]

I had the same experience. Was quoted a price just a little higher than I would've paid buying it all online and figured it would be worth it to have (get ready...) some customer service.

DME insisted on full cash payment before they would even place my order. I put the entire amount on my credit card. Months went by and suddenly I started getting invoices from a company I'd never heard of. When I called, it turned out to be the out-of-state parent company of the "local" DME. Charging me a monthly rental ON TOP of the amount I'd already paid.

Cutting to the chase, the whole package cost me almost 3X what I was quoted. I complained to insurance (no help, I have a $5,000 deductible), the local company, the out-of-state headquarters, and the Better Business Bureau (there's an oxymoron) where the HQ was headquartered. No one cares. We are all just another wallet to these guys.

Sprinkles on the abuse cupcake: absolutely none of my adjustment issues were ever addressed by these crooks.

So sorry you're having a similar experience.

[sleepy_and_boo]

Thanks for all your responses! I guess I'll give both the supplier and insurance several calls.

@Sleeprider: the rental period is actually 10 months, not 13, so it would've been possible to do it all in one calendar year if I had started in March.

@biz64: even with the brick and mortar costs, how would the end price more than double? (For example from 868 to 1950 for the machine…) I understand one's gotta make a profit, but billing $82 for a 6 foot plastic tube for example seems just ridiculous. Oh well…

@Redonthehead: I did not get an Explanation of Benefits from my insurance, just the itemized bill from the supplier. That's who I called to explain some of those items to me, why besides the recurring lease charge there was another charge for essentially every part of the machine. (I was told that's for replacement parts which I can request once every 3 months while only being billed for them once every 6 months. Weird that the charge already showed up on the first bill - while I have a brand new machine and wouldn't request any new parts for a while!)

@Wulfman: I'll definitely ask the insurance to do an early payout - the supplier itself claimed this wouldn't be possible. Ugh. I asked the insurance ahead of time what the total cost for the machine would be for me, they said under $900, not mentioning this would only be the case with the whole lease being within one fiscal year. Guess I really should have done more homework

@RubySnooze: wow, your case sounds like a total nightmare and I'm sorry you had to deal with all of this! I used to live in Germany and had insurance administered by the state rather than a private company - my premium was 7.5% of my annual income, which may seem a lot, but this rate is always the same no matter how much you earn, plus there were no deductibles, co-pays, anything. Everything was covered. I'm not used to the tricks of/pitfalls with US insurances! A relative of mine (also German state insurance and no additional private insurance) had a 90k heart surgery followed by a 4 week recovery retreat, including cab ride round-trip. All she had to pay was around $10 a day while staying in hospital, not a cent for the retreat. She didn't even have to file a single claim as hospitals and insurances settle everything with each other!

Thanks again guys... I hope that, while I have the machine to help, I won't lose too much sleep over those bills.

[PoolQ]

Just because they bill a price does not mean the insurance will pay that amount. My bill looked the same but my EOB made the insurance company look like a hero. We were billed $X,XXX, but we only paid $XXX, we saved you $X,000 ain't we great

[Wulfman...]

Thanks for all your responses! I guess I'll give both the supplier and insurance several calls.

@Wulfman: I'll definitely ask the insurance to do an early payout - the supplier itself claimed this wouldn't be possible. Ugh. I asked the insurance ahead of time what the total cost for the machine would be for me, they said under $900, not mentioning this would only be the case with the whole lease being within one fiscal year. Guess I really should have done more homework

Thanks again guys... I hope that, while I have the machine to help, I won't lose too much sleep over those bills.

I know all this is easier to see in hindsight, but......

NEVER.....EVER......take the word of a DME supplier. They're stupid, they lie, they're devious, etc., etc.

ALWAYS check with your insurance in matters like these. And, in the case of disputes, try to get your insurance provider on your side to figure it out or straighten it out.

Unfortunately, another problem is that doctors have been known to have cozy relationships with DME providers and tend to push the patients to those providers......or, they may send them to providers who may be out-of-network with the insurance providers. It can be a real can of worms.

These forum pages are filled with stories like yours.
One of the biggest problem in getting the users educated is getting them the knowledge BEFORE they need it.
Unfortunately, they don't teach these types of things in school.


Den

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[BleepingBeauty]

I wish the OP luck, but since the machine has been in possession for more than 30 days, I think it's doubtful that the DME will allow a return now. Fingers crossed, though...

[sleepy_and_boo]

I will definitely talk to the insurance asap. However, I doubt they would like to change the timeframe of the lease, considering that THEY save money if some of the lease bills come in 2016 and I have to pay another deductible.

Why wouldn't the DME supplier be more willing to shorten the lease than the insurance, given that they would get paid faster? Of course in that case more of the money would come from the insurance than from me (10% co-pay after deductible), but why would the supplier care where the money comes from? Unless of course they have separate deals which have nothing to do with the amount billed to and covered by insurance on the paper sent to me. Ugh, if only one knew what is actually going on between them.

I already left the DME supplier a voicemail asking why they billed such enormous amounts. From the forum responses so far it seems that they would come up with all sorts of excuses though. So I guess I should call the insurance instead, point out how ridiculously high the charges are, and hope that they will be my ally?

@BleepingBeauty: yes, the machine has been in possession for more than 30 days, but the first bill didn't come until now (2 months in), and that was the first "red light" for me. The costs I was told to expect are different from the actual costs, and just now I know I can't afford the machine. Shouldn't that be a valid reason for a return?

[Pugsy]

If it is a lease to own...you don't own it yet.
Check with your insurance company first as to exactly how they do this cpap stuff.
If you don't own it...there's nothing stopping you from returning it (but I doubt they will refund any money or fees incurred for the time frame you have used the machine) and buying the machine elsewhere (and there are options for buying elsewhere if you want to go that way...private party...cpap.com....secondwindcpap.com)
Mask and hose...you will own...the humidifier typically is also a purchase up front cost and if that's the case then you will own it also.
Usually the only thing that gets returned is the blower but check to make sure how the humidifier cost was handled.

[sleepy_and_boo]

Thanks again for your advice, I have good news, guys!

After my voicemail last night, the supplier called me this morning and said there was a "miscommunication" about the billing. The monthly lease amounts are not $195 but now only $74 (that's the most the insurance allows for this equipment).

Even with the lease hitting two deductibles, the whole machine would now cost me a little under $1000 (as opposed to a little under $1400), and that includes one whole set of replacement parts if claimed within the next 3 months.

That seems fair. I'll just have to cancel the "replacement part subscription": they would keep billing $400 every 6 months for up to 2 replacements of every part (incl. humidifier and mask) during that timeframe. But why would I for example need a new mask every 3 months?!

I'll talk to insurance now to see if something can be done about the timeframe of the lease and if I can save a little more.
Phew!

[Wulfman...]

Did/will they put that in writing?

Glad to hear that some of the news may be getting better for you.


Den

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[PoolQ]

The EOB is really very important. For a DME to contract with my insurance company (BCBS) they are required to accept the contracted price as 100% compensation for the equipment. What I pay out of pocket is between me and my insurance company and the DME has nothing to do with it. For example if the contracted cost of CPAP is $1,000 and my deductible is 20%, then I only pay 20% or $200, insurance pays $800 and the DME gets the contracted $1,000 regardless of what they were asking for.

With my insurance IF I went out of network they would cover 50%, so if an online seller were charging $800 for the same CPAP, I would pay $400 out of pocket.

This is the main difference between in network (contracted cost) and out of network (no cost control).

Get your insurance company to send you a copy of your EOB for this, you will always get one sometimes it just takes a while. Make sure your DME is IN network.