Prices for Machines

This is probably less of a question and more of a rant, but I hope you might be able to provide some insight as to why I am experiencing such difficulty.

I just got health insurance a couple of months ago and my old CPAP machine is falling apart. I wanted to inquire about a new machine, but I know for a fact that I will end up paying for it because my deductible is $1750 and I haven't had many reasons to visit the doctor. So I called my insurance company and they suggested two preferred medical supply companies that I could go to for the best deal.

Someone suggested that I look into the Airsense 10, so I called company #1 and asked how much one would cost. They said they bill insurance and I told them that I would just end up paying for it anyway because I haven't come close to reaching my deductible. I just wanted to know the cost so I could be prepared to pay the bill. I was on hold for 20 minutes and the woman came back on the line and said for the machine, it would cost $2000.

I asked her why it was so much and she said that I would be renting the machine and after 2 years I would own it. During the two year period, they would cover any adjustments and trouble shooting. I told her that I could buy a brand new AirSense 10 on Amazon.com for $529.00. I said I could buy 4 of them for that price and if I had an issue, I could just toss it in the trash and grab a new one and still save money.

The next place I called said they sell their Airsense 10 for $1000, which is slightly more reasonable, but I had to ask why they were charging almost double what it goes for online. She told me that was the price that my insurance company would be charged. It took 40 minutes to get that answer, but at least the cost was lower.

Does anyone know why having insurance makes these machines more expensive? If anything I thought that I would have a huge discount and savings because my insurance would negotiate on a nationwide scale to get the best prices. I asked my insurance if I could simply buy the machine off Amazon and then have them apply the amount toward my deductible and they said no because they weren't a preferred provider.

I had to get a CPAP. My choices were clear: get a CPAP or have my wife smother me with a pillow in my sleep. I chose life and a happy wife. What I hate about having one is that I feel like I'm getting screwed. A face cushion costs $35. A mask costs $150. The machine costs between $500 & $2000. It's almost impossible to afford on an honest man's salary. Moreover, ALL of the medical supply companies have a 1 star rating...for a reason.

That's my rant. Thanks for reading.

There's a difference between what an insurance company is billed and what they'll actually pay. And this difference can be quite large. My insurance, Medicare at the moment, is billed about $80 by my DME for a set of nasal pillows that I'd pay about $22 for on cpap.com. Medicare actually pays the DME about $22 for this. Over the years, I've seen this sort of pattern, where doctor's and labs try to charge a lot, but insurance only pays a set amount that's usually a lot less than what they charge. The rip is that the same companies, like DME's, that overbill insurance companies, and then take a lesser amount in payment would bill you about the same as they would bill an insurance company, but you as an individual have no leverage to just pay less.

It's a strange system, isn't it?

Time for a blatant plug for the sponsors of this forum.
Cpap.com.
If new price is still too steep, try secondwindcpap.com.
They sell gently used and often zero hour, open box units.
Some long time forum members also move used machines at budget prices.
Note number of posts--a few only register to sell.

If you use a brick and mortar DME, they charge way more (to cover rent, etc). Like you I have a fairly high deductible. I pay cash at online vendors (like Chunky said, cpap.com is reputable and my go to). Unless you are a mask freak, it's hard to cover the deductible for an APAP, mask and supplies. In my experience, what the brick and mortars charge for the (totally unreasonable) replacements do nothing but bilk the insurance companies raising the prices for all.

Just my opinion.

RiverDave

Before you commit...check out Amazon for the Airsense 10 Autoset
https://www.amazon.com/ResMed-37207-Air ... irsense+10

VERY IMPORTANT: The cost billed to the insurer is NOT the amount the insurer will pay and it's also not the amount you will owe if you haven't met your deductible. I call DME billing "fantasy billing". It's what they wish they could get, in their dreams. Your insurance company has a schedule for DME. If the DME is a contracted provider with that insurer, they agree to take only the contracted amount on the DME's schedule. That means they may bill the insurer $2000, but the insurer says that the reasonable cost is only $800 (just an example). That's ALL that the DME is going to get.

If you had met your deductible, the insurer would pay some percentage of that contracted price, typically 80%. And you would be responsible ONLY for the remaining 20% of the $800 contracted price, not making up the difference to the fantasy price.

The fact that you have not met your deductible doesn't matter. If your insurer's price is only $800, that's all YOU have to pay. To charge you more is called "balance billing" and it's illegal in most states and also a violation of the contractual agreement most DME's have with insurers.

So whether you use DME #1 or #2, your out of pocket cost should be the same, assuming they are both preferred providers for your insurance (you should double check, even though your insurer steered you to both). You should be able to find out from your insurer what your expected out of pocket costs should be.

Now DME's generally get higher reimbursement than we can buy the machine for retail because 1) they have a LOT of insidious paperwork to collect payment from an insurer and 2) they ARE on the hook for repairs for a period of time. But you know your way around CPAP and you probably could save by buying your own, especially because there's no point in meeting your deductible so late in the year (but waiting until January might make sense if you do want to use your deductible).

Also beware of this little trap: You may NOT have to do a capped rental as that DME claims. You should check with your insurer to see if they require a capped rental or not (DME's often get this wrong). If you do have a capped rental instead of an outright purchase, it usually spans more than one deductible period. So that means that you will hit two deductibles before the machine is paid for. Self-purchase sounds a lot better when you consider that.

This is probably less of a question and more of a rant

You haven't asked all of the right questions yet.

jameswfalcon wrote: So I called my insurance company and they suggested two preferred medical supply companies that I could go to for the best deal.

Well, you made a good first step. Too many people call a DME first for prices.

jameswfalcon wrote: They said they bill insurance and I told them that I would just end up paying for it anyway because I haven't come close to reaching my deductible. I just wanted to know the cost so I could be prepared to pay the bill. I was on hold for 20 minutes and the woman came back on the line and said for the machine, it would cost $2000.

I asked her why it was so much and she said that I would be renting the machine and after 2 years I would own it. During the two year period, they would cover any adjustments and trouble shooting.

This was not a good second step.

Call your insurance company again. Ask what their contracted prices are for a CPAP machine (HCPCS code E0601). Then ask if their contract allows "balance billing". Balance billing means the DME can require the patient to pay the difference between the insurance-contracted price and the "full price". Many insurance contracts with DMEs do not allow balance billing. (Medicare rules prohibit balance billing. I am assuming you don't have Medicare.)

If your insurance carrier does not allow balance billing, then make sure they have a contract with the DME you want to use. In this case, you can buy from the DME using the insurance prices. The DME bills the insurance company, but you will have to pay the contracted price if you haven't met your deductible.

If your insurance company allows balance billing, shop the internet and pay on your own. Forum members can help.

If you are going with an insurance buy from a local DME, you can run through this same decision process for masks and supplies. HCPCS codes are here - http://www.directhomemedical.com/direct ... -page.html

jameswfalcon wrote:Someone suggested that I look into the Airsense 10

Be careful. You want to make sure to get the ResMed AirSense 10 AutoSet. There are two cheaper models that are not acceptable.

jameswfalcon wrote:
Someone suggested that I look into the Airsense 10, so I called company #1 and asked how much one would cost. ...the woman came back on the line and said for the machine, it would cost $2000.

I asked her why it was so much and she said that I would be renting the machine and after 2 years I would own it. During the two year period, they would cover any adjustments and trouble shooting. I told her that I could buy a brand new AirSense 10 on Amazon.com for $529.00. I said I could buy 4 of them for that price and if I had an issue, I could just toss it in the trash and grab a new one and still save money.

The next place I called said they sell their AirSense 10 for $1000, which is slightly more reasonable, but I had to ask why they were charging almost double what it goes for online. She told me that was the price that my insurance company would be charged. It took 40 minutes to get that answer, but at least the cost was lower.
I had to get a CPAP.

One critical component in your process that seemed to be missing: which model were you/they specifying? There are four different AirSense 10 models:
1) AS10 CPAP (fixed pressure setting, not auto - the lowest rung on the ladder - minimal data)
2) AS10 ELITE (fixed pressure setting, not auto - up a rung on the ladder - full data)
3) AS10 AutoSet (auto pressure setting - allows configuration for fixed pressure use - up one more rung on the ladder - full data - It also allows the response algorithm to be selected between standard and a 'soft' setting that originated in the pattern of the 'For Her' model)
4) AS10 AutoSet For Her (Duplicates the latest AutoSet in operation but is styled somewhat differently, ostensibly to appeal to a more supposed feminine design aesthetic )
There are several more models that fit in the AS10 continuum but are named differently: AirStart (a brick whether straight CPAP or APAP) and more sophisticated and specialized AirCurve. When you get a machine from the DME associated with your insurance, for the most part all the CPAPs and APAPs will be billed to the insurance under the same billing code even though the DME buys from the vendor on a sliding scale that correlates with the retail price and complexity of the machine. Thus, the DME has a strong incentive to deliver to you the least feature-rich machine that costs them the least but they can sell for the most profit. Consequently, it is in your best interest to get your doctor (or dentist, for that matter) to write your script with the most detail posible to insure you get what you want, not what the DME decides is in their best interest.