Is this Normal? - DME Related

BeanMeScot wrote:I do have physical possession of my prescription(s). I'm the one that told the doctor what to write (gleaned from here, of course)! I guess it is too late on the no substitution thing though. Homelink is in some other state so I faxed them a copy.

Please keep us informed of your progress.

Den

gasp wrote:Very nicely I would say "I can't accept a substitute machine and that my doctor and I had an understanding on what he was prescribing and this is not it." If that fails, then adding "I will have to contact my doctor and let him know that you want to substitute another machine than what he wanted and have him get back to you. I'm certain he'll want to speak to the manager. Whom should I say he should call?"

That's a classic, gasp! What a beautiful, polite (yet strong) way you phrased it. Perfect!

Right on, Gasp! How I wish I was that quick thinking, tactful and diplomatic!!!

I like the polite brush off, too!

I called the DME Homelink last Thurs and my case worker said she had just gotten approval. I haven't heard anything from anyone since then. I just called my insurance to verify what I have to pay and if I go in network (which is Homelink) then I have a $750 deductible and then everything is covered at 100%. That's a yearly deductible but the lady said that if I meet it on or after Oct 1st, it will count through the next year. We are already over a week into Sept so I think I will wait until Oct 1st to get my machine. Going out of network is $2250 deductible and 70% out of pocket with a max of $5k. They said I would only have to rent the machine for a few months (to check compliance, I'm sure) before they would buy it for me rather than paying rental over the long term. So it sounds like in network would work out better (unless someone is seeing something I'm not). I know sometimes it is better to go out of network, moneywise.

The DME they have apparently assigned me to is Hi-Tech Healthcare. Anyone ever heard of or dealth with them?

You might want to check what it would cost to buy one from cpap.com. It could be cheaper than what getting it with insurance.

Catnapper wrote:You might want to check what it would cost to buy one from cpap.com. It could be cheaper than what getting it with insurance.

Without the mask, I am at $738. I will definately be over $750 out of pocket if I use CPAP.com. So I won't gain anything by doing it out of pocket. With insurance, once I pay the $750, they will pick up all other costs for the next 14 months.

Once the 14 months are up, it would be better to use my Flexpay account if I don't need to buy a machine. The masks and parts would be cheaper through CPAP.com.

Catnapper wrote:You might want to check what it would cost to buy one from cpap.com. It could be cheaper than what getting it with insurance.

This may be true - or you may find that the reduced billable amount your DME charges your insurance company, and then your percentage of that might be lower. Mine was. The DME should know what they bill your insurance company for any given machine. They won't be able to say what you will pay, but they certainly know how much they would receive for a machine.

If you have the time and inclination, you could ask for a pre-authorization of coverage which would have the DME submit a certain machine for billing and receive a reply as to if the insurance would pay for it and if so what amount. Then if you know what your percentage is for durable medical equipment, you'd know your cost.

I just posted this elsewhere - it may help:
"Your summary of benefits, supplied by your insurance company, may help define what your costs are on durable medical equipment. For me, I pay a percentage of the 'allowable' amount. That means my DME has an agreed contract price with my insurance company to charge them X amount of dollars for durable medical equipment, and then I pay a percentage of that reduced agreed upon amount.

This is common, but you need to check with your insurance company to know. You should have a good sized booklet that describes your coverage. If not, you can call and ask for one. You should also have or ask for a summary of benefits. In addition, I would call and ask what your benefits are for durable medical equipment. You don't need to discuss certain machines, etc, just durable medical equipment. Let them know you're writing the info down and to please go slowly so you can get the info and understand it."

So the beat goes on.

I had decided to wait until Oct 1st since I have a $750 deductible and if I meet it after Oct 1st it counts for the entire next year. I get an email today saying we will be changing insurance providers as of Jan 1st. We will have Blue Cross Blue Shield of Nebraska (BCBS). So now I don't know what to do because I don't even know what my coverage will be under the new insurance. Any thoughts?

BeanMeScot wrote:So the beat goes on.

I had decided to wait until Oct 1st since I have a $750 deductible and if I meet it after Oct 1st it counts for the entire next year. I get an email today saying we will be changing insurance providers as of Jan 1st. We will have Blue Cross Blue Shield of Nebraska (BCBS). So now I don't know what to do because I don't even know what my coverage will be under the new insurance. Any thoughts?

Could you give us a summary of where you're at in this process.....? Do you even have any equipment yet?

Are you located in Nebraska? (or is that just who they contracted with?)

Den

Wulfman wrote:

BeanMeScot wrote:So the beat goes on.

I had decided to wait until Oct 1st since I have a $750 deductible and if I meet it after Oct 1st it counts for the entire next year. I get an email today saying we will be changing insurance providers as of Jan 1st. We will have Blue Cross Blue Shield of Nebraska (BCBS). So now I don't know what to do because I don't even know what my coverage will be under the new insurance. Any thoughts?

Could you give us a summary of where you're at in this process.....? Do you even have any equipment yet?

Are you located in Nebraska? (or is that just who they contracted with?)

Den

I am not in Nebraska. My parent company is. I don't have any equipment yet. I was waiting because my current (but soon to end) insurance had a $750 deductible but if it was met after Oct 1st, I wouldn't have to pay again in 2009. All that, of course, is out the window now. Now I will have BCBS and have no idea what my coverage will be and no one can tell me. I've tried human resources but they say they have no information yet about the new policy.

Well, BCBS has been reported to be good about reimbursing their insured for out-of-pocket DME expenses (like buying from CPAP.COM and submitting an invoice to them).......but if you're going to be starting over (deductible) in about a week, you may be about as well off buying out-of-pocket anyway.

Den

Wulfman wrote:Well, BCBS has been reported to be good about reimbursing their insured for out-of-pocket DME expenses (like buying from CPAP.COM and submitting an invoice to them).......but if you're going to be starting over (deductible) in about a week, you may be about as well off buying out-of-pocket anyway.

Den

Any idea what their deductible is for CPAP?

BeanMeScot wrote:

Wulfman wrote:Well, BCBS has been reported to be good about reimbursing their insured for out-of-pocket DME expenses (like buying from CPAP.COM and submitting an invoice to them).......but if you're going to be starting over (deductible) in about a week, you may be about as well off buying out-of-pocket anyway.

Den

Any idea what their deductible is for CPAP?

Most group plans are negotiated between the employer with the insurance provider. Typically, the deductibles are in $250 multiples and can apply to individuals and/or to "family". Some large companies and states are self-insured and contract with an insurance entity to manage their programs.
As far as CPAP (DME) goes......that may be part of the rest of the medical coverage/deductible or it may even be separate.
Some people have employers who pay 100% of their insurance premiums and they have no deductibles. Those folks are few and far between these days, but there still seem to be some out there.


Den

Wulfman wrote:

BeanMeScot wrote:

Wulfman wrote:Well, BCBS has been reported to be good about reimbursing their insured for out-of-pocket DME expenses (like buying from CPAP.COM and submitting an invoice to them).......but if you're going to be starting over (deductible) in about a week, you may be about as well off buying out-of-pocket anyway.

Den

Any idea what their deductible is for CPAP?

Most group plans are negotiated between the employer with the insurance provider. Typically, the deductibles are in $250 multiples and can apply to individuals and/or to "family". Some large companies and states are self-insured and contract with an insurance entity to manage their programs.
As far as CPAP (DME) goes......that may be part of the rest of the medical coverage/deductible or it may even be separate.
Some people have employers who pay 100% of their insurance premiums and they have no deductibles. Those folks are few and far between these days, but there still seem to be some out there.


Den

If I had to guess, I would say we will be self insured. They have done it before. We only got out of it because they were using Mutual of Omaha and there weren't enough doctors in the network where were are. They mentioned something about taking some kind of health test where you had to answer questions about your health. I know in the past, they used that kind of thing to decide how much you paid for insurance.

With the situation changing in a few months, I might consider renting a machine until your insurance changes and you can understand just what the coverage will be.
BCBS is generally pretty decent insurance -- the deductible will totally depend on your companies negotiations with the insurance company and the package you're provided.
I certainly wouldn't delay treatment any longer than necessary -- if you can get a rental at a decent rate I think that's what I'd do in your situation.....
But I may be prejudice -- I can't imagine not having a machine anymore.......
If you decide to go the cpap.com route, don't take the price off the web site -- call them to find out what the "real" price is -- they're stuck with the MAP (minimum advertised price) pricing just like all the others.

Good luck, and let us know how you're coming along!!!!!!
cheers
goose