How much will should I expect to Pay $$$

[jmcanzo]

I checked with my HMO today, they only cover 50% DME
So what should I expect to pay for a machine and stuff? I talked briefly with my Dr today. (I work at the hospital were they did the study). She said I would probably be better off buying from the internet and gave me some addresses. I go for my second study on March 17. If I go with the DME do they have payment plans?
Not sure how this will all work out.....Nice thing the HMO paid 100% for the sleep studies...

[cflame1]

With a 50 percent coverage... I'd go online.

Depends on what machine... but a lot of times with DME's it will end up over $1500-$5000 for bare bones... the same machine can be had for < $1000 online, at times even less than $500 for a CPAP... it'll be more like about $2000 or less for a Bi-level online.

[bearded_two]

Buying online will be much cheaper than a brick and mortar DME, even with 50% off. A brick and mortar DME will do a 10 month rent to own, but for about 2 or 3 months of rental you can buy a CPAP. Masks are also much cheaper at an onl;ine supplier.

[jmcanzo]

Yikes! Great that the HMO pays the sleep study... but if you can't afford the treatment then it seems to be a waste of money. I do not think the HMO will reimburse me, if I buy off the net...

[unadog]

I do not think the HMO will reimburse me, if I buy off the net...

You will have to run some spreadsheets to see what makes sense for you. Find out what the HMO will pay for.

The problem is that the DME is used to charging the insurance companies large amounts for the CPAP. They charge my insurance company $158 per month, for 13 months, for a machine that **lists** at $600! That comes to more than $2,000.

I believe that is the net (lower) price that my insurance agrees to pay, not the higher amount the DME actually bills. My insurance pays 100%, but I may still just give the DME the machine back, depening on where I wind up with machines (long story.)

So. You can buy a used machine starting at around $200. Or a "better" used machine for $350. Or an older model new machine online for $375. Up to a new S9 Auto CPAP "state of the art" machine online for about $780, if I remember correctly. A bit more for a bi-level.

You will have to self-select based on your situation. It is doubtful though that you will come out ahead buying through a DME (vs. online) if you have to pay 50% of the marked up cost (and no, they won't reduce it if you pay cash, etc.)

Some folks find it is still cheaper to buy online when they have to pay just 20%. That is usually closer though.

Start looking at machines and adding up costs. Folks here can help.

Best,
Michael

[snoregirl]

From my experience at the 50% mark you will be better off purchasing online without insurance. Of course how much better depends on the machine that you choose, and the machine you would have accepted from a brick and mortar DME. I did some numbers back when I got my machine and I recall around 70% reimbursement was where I was better off buying online with no insurance involvement and I was looking at APAP.

[mattman]

Just a quick breakdown....

The issue you are going to be running into is the big problem with the insurance industry the way it is currently setup.

Insurance sets certain prices for equipment. DME providers (online or brick and mortar) do not set any of these prices. They can either accept that insurance and therefore accept what they pay or they don't take that insurance. It's as simple as that.

However, what compounds the issue for you is that the Insurance Companies ALSO have setup a 2-price structure. They setup a billed amount (Called the Submitted amount) and an amount they will actually pay (called an Allowable) that is usually 40%-60% of the billed amount. The prices are also going to be higher since doing business through Insurance is far more expensive than a cash customer by several orders of magnitude (They can take months or even years to pay, you have to keep records for 7-10 years, personal home delivery, etc etc etc)

The real problem for you is that the Insurance companies further (usually) stipulate in their contracts that the DME company (again - online or brick and mortar) cannot charge cash customers less than the insurance company. This means that if the company bills your insurance - they will have to charge you the full submitted amount. This is a stupidly high price since the Insurance companies only have to pay 40% of the cost.

So - you need to run some numbers for yourself. And then you have to determine which will be the most effective method for you. Call your insurance company and ask them for specifics on the submitted and allowable amounts for a cpap, a mask and headgear. Ask them if they rent to own (Called a capped rental) or if they purchase outright. If they rent, find out how long before it converts to a purchase (Or if it never converts).

If you are not comfortable with being in charge of your treatment and handling all the equipment, settings, masks, and money then paying more and going through a local provider may be most effective for you.

If you ARE comfortable being in charge and you are not afraid of doing the research online and really getting into the meat of this therapy than it will almost assuredly be more effective (And cost effective too) for you to purchase your equipment via your own cash online.'

mattman

[unadog]

Hey mattman, can you be my DME?

I'd sure rather give my money to someone I like! And since my insurance pays 100%, which is really nice, I work with the DME, but geez ....

There are definitely a lot of folks who need a DME though. And I am sure a lot of folks are quite happy with the services they receive.

I remember when I was in college I thought my parents were getting ripped off paying $70 a night to stay in a hotel when they visited me. Why not just camp? Guess we are all different.

Cheers!
Michael

[JohnBFisher]

... my insurance pays 100%, which is really nice, I work with the DME, but geez ....

If you are moved to an ASV unit, wait until you see the price they charge the insurance companies. And trust me, you want to sit, rather than stand, when you read the bill. This is not just a suggestion! Even with 100% coverage, like you have, I wondered if I should have a paramedic come and check. I'm sure my heart skipped a LOT of beats seeing those numbers. YIKES!

[unadog]

wait until you see the price they charge the insurance companies.

Yeah, are they charging the full $5,500 list price, prorated over 12 months, right? Or worse than that? I saw somewhere it was $600 or $660 a month or something they are allowed?

Honestly, I wish there was a better way to work with my insurance company! They insist that we go through a handful of approved DME's. I'd buy a used unit for $1,000 and be happy.... In fact, despite the fact that they will pay 100%, I have been buying my own used units (at least on a temporary basis) to try to get ahead of all the bueracracy and red tape! Life just could not wait ... and it is working!

The only consolation is that I think they will come out ahead if they get me off of all my expensive meds!

I already have quit three meds since starting CPAP in December: 1) Lunesta (switched to Ambien, which is generic), which was more than $300 a month, 2) Lyrica, which I **hate hate hate*, made me gain 30 pounds, makes me dizzy, blurs my vision, which was $300+ a month, 3) Savella, which is brand new, just approved last March - I was the first one to get a script from my drugstore. That was more than $300 a month. So I quit $900 of meds since going on xPAP!

Still on my Fentanyl patch, which is also more than $300 a month I told my doctor they should just give me a lump sum and let me swap out for what works best! Hell, I could **live** off of that!

They have taken care of me. And finally something helps, and I am getting better. An important reason to look for the root cause, and not just treat the symptoms!

Cheers - from happy me!

Michael

[JohnBFisher]

wait until you see the price they charge the insurance companies.

Yeah, are they charging the full $5,500 list price, prorated over 12 months, right? Or worse than that? I saw somewhere it was $600 or $660 a month or something they are allowed? ...

Well, they tried to give me some song and dance about it being $18,000. I asked them on what planet they purchased it! But they are not hurting either from my business. They charge $900 per month for 10 months, but manage to accept a measley $600 per month for 10 months. Sheesh!

My insurance also uses a preferred provider option. <sarcasm start>Glad they are saving money!</end sarcasm> I could cut the cost to less than one half of what they are being charged. And it would take me no more than 3 hours to confirm the prices and previous complaince to xPAP therapy. That would amount to $1,000 per hour. Do that just twice a week and they could save some serious bucks.

But they are NOT in the game to save money. Insurance companies like to say that, but it's not really how the system works.

Ah well.

... I already have quit three meds since starting CPAP in December: 1) Lunesta (switched to Ambien, which is generic), which was more than $300 a month, 2) Lyrica, which I **hate hate hate*, made me gain 30 pounds, makes me dizzy, blurs my vision, which was $300+ a month, 3) Savella, which is brand new, just approved last March - I was the first one to get a script from my drugstore. That was more than $300 a month. So I quit $900 of meds since going on xPAP! ...

Now that's a very positive side effect of xPAP therapy! Glad to hear that. It make it easier if you can solve the fundamental issues and avoid a lot of extra medications.

[unadog]

Well, they tried to give me some song and dance about it being $18,000.

To quote my 11 year old, when I tell him he can't have a soda after he just finished eating candy: "OH. MY. GOD."

My insurance also uses a preferred provider option. <sarcasm start>Glad they are saving money!</end sarcasm> I could cut the cost to less than one half of what they are being charged. And it would take me no more than 3 hours to confirm the prices and previous complaince to xPAP therapy. That would amount to $1,000 per hour. Do that just twice a week and they could save some serious bucks.

No kidding! I think thee is a serious oppurtunity for a niche business here.

One focused around **great** customer service - the margins are there - while still saving considerable money. I'll start a thread some day about Deming techniques and customer service - I think you'll like it!

Now that's a very positive side effect of xPAP therapy! Glad to hear that. It make it easier if you can solve the fundamental issues and avoid a lot of extra medications.

It really is great! EVERY MED SUCKS! Every single one of them. Funny too, they are kind of like xPAP, you have to fight to get them, and then you hate them!

But we really are lucky. I couldn't imagine living without decent pain meds. And our lives would be pretty miserable without xPAP.

Now you know where all of those nasty old people came from in stories of years gone by. "That mean old man/lady/witch that lives down the street ...." Some pretty miserable people. And a lot of alcoholics, cigarette smokers, etc. trying to "self medicate" (as much as I hate that term.)

We are lucky!
Michael

[dave21]

It never astounds me that there's always someone out there wanting to make a quick buck. Thankfully in the UK we don't have these DME's that seem to want to up the price by 400-500% in some cases just to make a quick buck off of the insurance companies.

I was watching 'Dog the bounty hunter' and you seem to see the same thing there, someone wants to be bailed out of jail, they can't afford to pay the bail money so they get a bailsbond man to pay the bail and they then pay a high interest rate to the bailsman. Then they decided to not go to court, the bailsbond man then gets a bounty hunter to track them down at additional cost, the alleged bail jumper then has to go back to court, get bailed out again, pay an additional higher interest rate because the bail has now increased in size and they still can't pay it.

I'd suggest this only happens in America but I suspect it does happen in other countries too. I'm not sure what additional benefit if any the DME's provide but it sounds similar to what we would call loan sharks in the UK. People willing to take your money (albeit via the insurance company), charge an exhuberant sum of money to do so and provide little or no service.

PS. Sorry if I offend anyone here (especially if you have a good DME) - not all DME's seem to be that way but from what I read here there seems to be a lot that are.

[mattman]

Just something to remember - all those DMEs are NOT setting the prices. They are all set by the Insurance Companies. See my earlier post.

I've said it before and I'll keep saying it over and over.

I do wish the Insurance Companies could find a way to join the 20th centuary and meet the needs of cash customers along with insurance customers. It sucks the way the model is currently setup!

But then again I suppose if they did that it might loosen their strangehold on healthcare.

[waltschwager]

I had to visit my local purvayor of CPAP stuff ti get a new mask and tank for my Reperonics machine and spenttime with the technician about prices and he told me that the mask that I replace every 5 months or so is billed and almost $200. I just bought a Orion cpap, Bravo nasal mask and a hose fiting fot input of O2 and it cost a bit over $200. I could have gotten the same mask I use online for less than half of what the locals charge. I realize that my main machine has more features and has computer monitoring, but I could have purchase that system with onlne for just over $200 with heated humidifier and monitoring.

Reimbursement rates are negotiated by Medicare and the insurance companies and who knows what goes into that process. There is room for reducing costs. I which that Medicare and the insurance companies whould make it easier for patients directly purchase equipment and get reimbursement, but with all the forms, coding requirements, etc., it is impossible for most people.
I have submitted the receipts and documentation for reimbursement for the recent cpap purchase. It will be interesting if Medicare will quickly precess and pay us,