Real cost of machine

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
jjhall
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Re: Real cost of machine

Post by jjhall » Mon Apr 20, 2015 11:49 am

I'm going back and forth with my insurance right now trying to see if I can save money by going through our hosts for my supplies. I'm not done with the conversations yet, but here is what I have found so far.

I have Blue Cross. Our hosts are considered "out of network." Purchases made will apply to my deductible, up to their maximum allowable amount (which ironically is higher than what cpap.com will charge for every item I've looked up so far.) Once the deductible has been met, they will pay/reimburse at a rate of up to 50% (rather than 70% as with "in-network" providers) of the maximum allowable amount. For example, it appears (I'm still trying to confirm) my insurance will allow $66.42 for a mask seal. Our hosts charge $54 for the particular mask seal I need. If I go through our hosts, assuming deductible has been met, I'd get reimbursed for 5o% of it, leaving $27 out of pocket. If I go through my local DME, they charge $92.40 for it, but "reduce" the price down to the max of $66.42. This leaves me paying 30% of that, or $19.93.

What I'm thinking is going to be the best bet for me is to use our hosts next year (we're already at our family deductible basically this year) to purchase my supplies until the family deductible has been met, then switch over to using my local DME as my co-pay will be less that way. I am talking with my HR department, and they seem to be on-board, to try to talk our insurance provider into dropping the different payback rate for non-network providers, since the real benefit to using in-network providers is there is a cap on what is paid. In cases like this where the original prices are below the maximum allowable amounts, it doesn't make sense for anyone other than the local DME to treat the online provider differently. Covering our hosts at in-network rates would mean less payout for me, and less payout for our group policy, potentially reducing premiums for everybody.

Long winded response, but I just wanted to point out how much obfuscation goes on between the DMEs and the insurance companies. Of course every e-mail I've had so far says "We advise you to always choose in-network providers as they will represent the best rates. Going out-of-network could mean significant out-of-pocket expenses for the member." I'm slowly building a concrete case to show evidence that this is not in fact true, and hopefully my employer can use this as leverage for next year's negotiations.

Keep pushing back on your insurance, and enlist the help of your employer if you can, if you can't get straight answers from them as to the prices and reimbursable amounts.

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Janknitz
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Re: Real cost of machine

Post by Janknitz » Mon Apr 20, 2015 2:25 pm

Your insurer should be able to tell you what your out of pocket costs should be for a particular HCPCS code item. That's what you need to ask them--"what will my out of pocket costs be for this code? Is it a purchase or a rental? How long is the rental period?"

Don't forget to figure in your deductible. Most insurers do something like Medicare--rent to own in 10 to 13 months. This means you may get stuck for a second deductible when January 1 rolls around. Others limit the rental period to 3 months to ensure compliance, and then purchase the machine from there. Whether you will have one or two deductibles matter. And SOME insurers (not many!) require ongoing perpetual rental, with that deductible hitting you in the face EVERY year. In that case, it's almost always better to buy your own.

While you're talking to your insurer, confirm whether "balanced billing" is permitted. This means that if the insurer's contracted price for a BIPAP is (for example) $2,500 but the DME's price is $3,500, the DME is permitted to charge you the difference. In MOST cases the DME is NOT permitted to balance bill. Some states prohibit it by law, and almost all insurance contracts prohibit it as well. But that does not stop the DME's from trying to get the difference from unsuspecting patients. So you should know whether or not it's permitted BEFORE you let the DME talk you into paying a penny more than the insurance allowable amount.
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archangle
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Re: Real cost of machine

Post by archangle » Mon Apr 20, 2015 2:51 pm

If your insurance is a "PPO" style plan, be sure the DME is "in network." In network providers can only charge the amount permitted by the insurance company.

You're beginning to understand why we refer to them as the medical mafia.

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amenite
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Re: Real cost of machine

Post by amenite » Mon Apr 20, 2015 5:42 pm

I just got the "final" bill from my former DME. I fired them in January 2015. This is for supplies provided in first half of December 2014. My insurer had paid them before the end of that month and it took this DME almost four months to send me a bill for the co-pay amount. A few of the highlights:

Nasal Application Device A7034
Billed Amount: 272.00
Plan Pays: 49.00

POS Airway Pressure Headgear A7035
Billed Amount: 54.00
Plan Pays: 13.75

The two items above combined sell at retail today for $99 - less than one third the $320+ the DME billed:
https://www.cpap.com/productpage/resmed ... dgear.html

Additionally they chose to send out a bill for costs they were 90% compensated for over three months ago and it arrived in today's mail. It says on it "Due 4/24/2015" and carries no postmark. Good scam to rack up late fees on the unsuspecting. Three business days to make the payment. Shady business IMO.

So my experience is this:
Assume up front that every one of these DMEs is out to get you and will try to take every last penny out of your pocket that they can get away with. Make that your starting point in any DME interaction. Or any medical provider for that matter. You don't have to be a jerk about it. Just let them know you won't take any BS and stick to that. And know in advance what you are entitled to and at least a ballpark of what your liability should be based any benefits you are due.

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archangle
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Re: Real cost of machine

Post by archangle » Wed Apr 22, 2015 4:39 pm

amenite wrote:I just got the "final" bill from my former DME. I fired them in January 2015. This is for supplies provided in first half of December 2014. My insurer had paid them before the end of that month and it took this DME almost four months to send me a bill for the co-pay amount. A few of the highlights:

Nasal Application Device A7034
Billed Amount: 272.00
Plan Pays: 49.00

POS Airway Pressure Headgear A7035
Billed Amount: 54.00
Plan Pays: 13.75

The two items above combined sell at retail today for $99 - less than one third the $320+ the DME billed:
https://www.cpap.com/productpage/resmed ... dgear.html

Additionally they chose to send out a bill for costs they were 90% compensated for over three months ago and it arrived in today's mail. It says on it "Due 4/24/2015" and carries no postmark. Good scam to rack up late fees on the unsuspecting. Three business days to make the payment. Shady business IMO.

So my experience is this:
Assume up front that every one of these DMEs is out to get you and will try to take every last penny out of your pocket that they can get away with. Make that your starting point in any DME interaction. Or any medical provider for that matter. You don't have to be a jerk about it. Just let them know you won't take any BS and stick to that. And know in advance what you are entitled to and at least a ballpark of what your liability should be based any benefits you are due.
Are they asking you to make up the difference? Usually, the insurance sends out an EOB statement telling what the provider is allowed to bill you, if they're "in network."

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Mask: Swift™ FX Nasal Pillow CPAP Mask with Headgear
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control
Additional Comments: Also SleepyHead, PRS1 Auto, Respironics Auto M series, Legacy Auto, and Legacy Plus
Please enter your equipment in your profile so we can help you.
Click here for information on the most common alternative to CPAP.
If it's midnight and a DME tells you it's dark outside, go and check for yourself.

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amenite
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Re: Real cost of machine

Post by amenite » Wed Apr 22, 2015 5:06 pm

archangle wrote:
Are they asking you to make up the difference? Usually, the insurance sends out an EOB statement telling what the provider is allowed to bill you, if they're "in network."
No makeup, they've been paid the agreed upon amount by the insurer and this is a three months old outstanding co-pay amount. The point is they are billing triple the going rate for the mask and headgear. They also had/have a habit of submitting the billing from one of their several shell companies that happens to be out of network for me. Which means there is no agreed upon amount, so I would get billed for 20% of triple the actual price of the gear (20% of whatever they decide the price should be). Then have to spend an hour or more dealing with them and my insurer on the phone to straighten it all out.

Final note - these "invoices" have no date on them. They have a "Service Date", and "Late After" or "Due By" dates, but there's no indication when the invoice was actually generated or mailed out. Seems like this would help to muddy the waters if someone is looking to collect late fees. Or to make it seem like you're a nice guy for forgiving some late fee that was bogus in the first place. I wonder if that's somehow illegal? If not it should be.

3winks
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Re: Real cost of machine

Post by 3winks » Fri Oct 23, 2015 11:02 am

UPDATE--- Well I got my new machine in April and I just received my bill for the amount they stay I owe--- they billed the insurance company for 2889.00 which is 1800 dollars more than you can by it online for--my amount is 520.00 I do not have the money to pay them--I knew this was going to happen and I had made at least 4 calls each to the dome and the insurance co. And no one would tell me anything. Do I have any options. The people that are selling them online for 999.00 aren't losing money so how does the dme get away with charging 2000 more.

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Pugsy
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Re: Real cost of machine

Post by Pugsy » Fri Oct 23, 2015 11:27 am

How much of that 2889.00 did the insurance actually allow or pay anything on?
What is your co pay percentage?
Is there a deductible involved and if so how much? Meaning did you meet your deductible for this year?

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Janknitz
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Re: Real cost of machine

Post by Janknitz » Fri Oct 23, 2015 11:53 am

Good, people have you on the right track here

To summarize:

NEVER, NEVER, EVER pay the DME's full retail price. It is pure fantasy on their part.

When prescribed a new machine, the recommended approach is as follows:

1. Determine the HCPC Codes for machine, humidifier and chamber, and any special hoses (i.e. heated hose).
2. Contact your insurance company. You want to know the following information: *
a. Will the insurer purchase the machine outright or require you to rent it? (keep in mind the humidifier is almost always an up front PURCHASE--only the blower unit is rented).
b. If a rental, is it a rent to own, or rent forever arrangement?
c. If rent to own, how long is the rental period.
3. What co-pays and deductibles do you owe? When do you have a new deductible to meet (usually the beginning of the year)?
4. Can the DME "balance bill"--that is charge you the difference between the insurer's allowable amount and their fantasy retail price? (in most states this is illegal, and even where it is not, most--not all--insurers prohibit DME's from doing this by contract).
5. Finally, ask if you have a choice of DME's to get full coverage? Also whether they would reimburse you for an out of pocket purchase from an online supplier.

With this information, you can accurately calculate your out of pocket costs and determine if it's a better deal to take the insurance (with all the headaches that includes) or just purchase it yourself out of pocket online or through something like Secondwind.com.

Don't forget about the deductible that may have to be met each calendar year. Especially in the latter months of the year like October, your "deductible clock" may be reset January 1. That could really bite you in the butt.

*If your insurance is Medicare, you have a mandatory 13 month "rent to own" period. Medicare sets the rate and you only need to pay 20% of the Medicare rate (your secondary insurance MAY cover this).
What you need to know before you meet your DME http://tinyurl.com/2arffqx
Taming the Mirage Quattro http://tinyurl.com/2ft3lh8
Swift FX Fitting Guide http://tinyurl.com/22ur9ts
Don't Pay that Upcharge! http://tinyurl.com/2ck48rm

PoolQ
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Re: Real cost of machine

Post by PoolQ » Fri Oct 23, 2015 12:35 pm

comparing on line to brick and mortar is always a non-starter for any product. On line will always be lower cost. Period.

I was actually so disgusted with my DME that I considered going into the business, after looking into it not a chance I would ever do that.

Office space in expensive areas, licensed staff to be a DME, RT on staff, annual inspections of facility, locked and secure area for the prescription material, paper work out the wazoo, responsible that the prescription is valid, in office support for customers, at least "exempt" certificate for anyone touching the prescription product, on and on and on.

The ONLY reason to use a DME is when Insurance is billed AND they are in network, period. This is what they are for, not for retail sales. What they say the price is does not matter, the price will be under contract and you only pay 20-30% of contracted price. The contracted price includes support after sale AND going in or them coming out to your house to be fitted.

The EOB from your insurance company will tell you what they paid and what you have to pay, if your bill from the DME says different then call them and then call your insurance company. The DME is under contract to accept what the EOB says as payment in full, PERIOD.
Sleeping MUCH better now

Janknitz
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Re: Real cost of machine

Post by Janknitz » Fri Oct 23, 2015 1:44 pm

Oops, I was responding to older posts on page 1.

In any case, don't pay the amount that the DME says you owe until you have confirmed with the insurance company what it is you actually owe. Whatever the insurance company paid, your share should just be a fraction of that. Get it in WRITING.
What you need to know before you meet your DME http://tinyurl.com/2arffqx
Taming the Mirage Quattro http://tinyurl.com/2ft3lh8
Swift FX Fitting Guide http://tinyurl.com/22ur9ts
Don't Pay that Upcharge! http://tinyurl.com/2ck48rm