Insurance Price Unavailable

[CyberPro]

Hi,
I went to two major DME providers with my 'script and both refused to tell me how much they would bill for a Resmed S9 Date Autoset.
My company is self insured and our profit sharing bonus each year is determined, to a large degree, on medical costs.
Is this standard industry practice?
I intend to file a complaint with the Better Business Bureau and Cigna.

Please advise, thanks.

Frank

[Slinky]

Good on you, CyberPro!!!! It is ridiculous that a patient can't be informed as to the BILLING price of the equipment they intend to purchase. Whether they are paying via insurance or out of pocket is immaterial. More patients have to be more pro-active in filing bonified complaints w/the proper agencies and authorities.

[Roman Hokie]

If the DME is "in-network" a lot of times those prices are negotiated with your insurance provider (even if you're self-insured). You should be able to contact your insurance provider for the same information giving them the make and model of the equipment as well as the DME provider's name. "In-Network" providers offer their services and equipment on a contract-based price before any deductibles, copays, and split (90/10 or whatever) cost arrangements. Anything outside of the actual contract price is between the insurance provider and you. And you probably know that, even self-insured, your "provider" is really just a plan administrator.

They can give you the "list" price and should be able to give you the contract price as well. If not, your carrier should have that.

[Wulfman]

Hi,
I went to two major DME providers with my 'script and both refused to tell me how much they would bill for a Resmed S9 Date Autoset.
My company is self insured and our profit sharing bonus each year is determined, to a large degree, on medical costs.
Is this standard industry practice?
I intend to file a complaint with the Better Business Bureau and Cigna.

Please advise, thanks.

Frank

When I got my equipment five years ago, I purchased all of it (out-of-pocket) from CPAP.COM and then got reimbursed (80%) by my insurance provider......also self-insured. In other words, I bypassed the local DME shops.
If your insurance provider wants to save money (and it sounds like they do), they will probably work with you to do this. What I did was talk to them before-hand and then after I received my equipment, I made out an invoice with me as the billing party and my insurance provider as the party being billed......and submitted it to them. Since CPAP.COM includes all of the insurance billing codes on their invoices, I was able to essentially duplicate it on my invoice.


Den

[mattman]

I'm curious as to how the conversation went and how they refused to tell you the price.

What I'm getting at is I know in a great many occasions, it's difficult bordering on impossible to give any sort of quick answer to a patient when they would come to me with a prescription for a new piece of equipment.

In a nutshell, if someone called me and said 'I have a prescription for a CPAP machine and I have Cigna. How much will it cost' I absolutely would be unable to answer that question. I would have to answer that question with something along the lines of 'I'm sorry but I can't answer that without a lot more information. If you want to get me your doctors name, a copy of your Rx and a copy of your insurance card I can do some research and call you back'.

And yes, on at least a few occasions I've had the patient come back with 'Well I'm not giving you any of that until you tell me how much it is'.

The reason is due primarily due to the convoluted ways in which Insurance plans are structured combined with a very healthy dose of being gun shy. Other factors come into play too: Does the patient actually qualify for what's being ordered (Which would need things like a copy of the sleep study), does that specific plan require pre-auth or other info (Only way to find out is to get all the required documentation and then call the insurance company directly).

In other words, I actually *cannot* answer the question of 'How much will it cost' without having everything in my hand required to file the claim and then calling the insurance company directly. It *cannot* be answered in less than 30 minutes.

And yeah, I've had more than a few cases where, early on in a desire to try to make everyone happy I've told someone something like 'Well, in most cases Aetna pays $800.00 for a cpap so your portion may be something around $100.00 but it can vary'. Then come to find out that while the patient does have Aetna - they do NOT have DME coverage on the plan so actually none of it gets covered. So when we actually get the order and call the patient and tell them that it's not covered - they go ballistic. They yell and scream and file complaints with the doctor, the Insurance Company and the local BBB all saying I deliberately lied to them because I told them it would only cost $100.00 and that I was committing insurance fraud. And yes, that's a very specific case that happened to me. I can come up with others. It sucks but yeah, after I got burned a few times I stopped doing it.

So again, while NOTHING excuses piss poor customer service, I'd really like to know if both companies just flat out said "I'm sorry but we aren't allowed to tell you" or if it was more of a misunderstanding that they couldn't answer without a lot more information.

[PetrusKy]

In other words, I actually *cannot* answer the question of 'How much will it cost' without having everything in my hand required to file the claim and then calling the insurance company directly. It *cannot* be answered in less than 30 minutes.

Can you answer this question: "how much do you intend to bill the insurance company for this particular machine?" It should be a constant, correct?

[Kevin G.]

When purchasing my ResMed S9 I enquired about the price. The guy from accounting at the DME agreed that the price would be about $830 (a cost I found on the internet). They then billed my insurance carrier $2,400. The Insurance company stated that the price they will be getting with my contribution would be $659.

I guess that they were hoping that the insurance carrier didn't know the market price and were hopping that they would make a killing. What about the people who do not have insurance?

[LSAT]

They will bill the manufacturers retail price....they will be paid the price that has been negotiated up front.

[Roman Hokie]

Wait, what? They billed your insurance $2400? For what?

[Kevin G.]

Billed my insurance company $2,400 for a ResMed S9 Autoset machine that they told me would cost approximately $830.

I have trouble believing that the $2,400 is manufacturer's list price.

[Slinky]

Sorry, but as I understood the question was what is the BILLED price, not what is my insurance's price or my copay price, etc. What is the BILLED price is easy enough to understand. Or do DME's bill BILL different insurances different prices??? Now THAT would be interesting from a legal standpoint.

[Wulfman]

Wait, what? They billed your insurance $2400? For what?

According to some information previously posted by the DMEs who frequent this forum.......

The DMEs base the co-pay (amount paid by the user) on the "billed amount" and not on what the insurance provider actually pays.

So, in the long run, the insurance pays for the cost of the machine to the DME and the end-user pays about the same amount......which is PROFIT for the DME.


Den

[Roman Hokie]

I think they can bill different insurance companies differently depending on their contractual-relationships. At least that's the way it is with regular medical care. Say a network doc's rate to Joe Consumer is $200. His network negotiated rate might be $150. However, another "out of network" doc is "retail" $200. But the Reasonable and Customary is $160. Well, then he's going to bill you $200. You can mail the claim to your provider who will only reimburse you for your portion of the $160. The $40 remaining is yours to suck up.

[Slinky]

Wulfman, I "think" it depends on the specific contract between DME and any one particular insurance.

For instance, w/Medicare there is the BILLED amount (which is the DME's 'pipe dream'), then there is the Medicare ALLOWED amount (which I would expect to be the equivalent of a contracted amount w/insurance), then there is the PAID amount which in Medicare's situation is 80% of the ALLOWED amount, and then there is the COPAY amount which in Medicare's situation is 20% of the ALLOWED amount.

There are SOME insurances that also include in their contract w/the DME providers that the provider can NOT base the copay on the BILLED amount and can ONLY base the patient's copay on the ALLOWED/CONTRACTED amount.

[CyberPro]

Hi Again,
I apologize for not being explicit.
I am not a newbie.
I had a copy of my sleep study with me but was not asked for it.
Per my request,my doctor wrote my 'script explicitly for a Resmed S9 Autoset with a Humidifier and a Climate control hose..
I stated to both DME's that I did not require a mask as my Quattro was fine.

I have ordered my Resmed S9 from CPAP.com one hour ago. This decision was based on Mr Goodman's response to the newbie that recently brought "Compliance Software" while expecting full data capability.
Incidentally, I think it was perfectly acceptable to post his experience with CPAP.com on this forum.
After all, are we not here to help one another avoid mistakes and share our experiences???

Thank you to all who have commented on my original post.

I would also appreciate a PM with information on obtaining the latest Resmed "Full Data" software that supports the S9

Frank