Why pay a deductible?

It's the beginning of the year and my supplier called and I ordered some supplies. I ordered 1 pillow and they sent 5. I hadn't met my deductible (its low and Medicare, $216?). My bill included all of that ($232). When I check prices on Amazon and elsewhere I could avoid the deductible and save money. When I question them about the prices they charge they tell me Medicare approves these by contract. This reminds me of my drug plan. It's cheap but is no better than GoodRx, but worse for anything above a tier 1 drug. I go outside the drug plan and save the $435 deductible using GoodRx[/img][/img][/img][/img] and the much cheaper 90 day supply. Maybe it makes sense when you replace your machine (every 5 yrs for Medicare). Am I missing something here or is 'insurance' sand the Dme ripping off both me and Medicare..?

The deductible is small change if you need surgery or get cancer.
Do you feel lucky?
The bullfrog and I see SHIP every fall before renewing our part D contract.
Deductibles are a fact of life--most people have them.
Those that do not pay dearly for it.

Onyer6 wrote: ↑

Thu Feb 09, 2023 2:39 pm

I ordered 1 pillow and they sent 5.

I'll say there is your problem. Why would you want five pillow masks at once? I've been using the same mask for 16 months and have no plans of replacing it any time soon.

It isn't exactly unheard of for companies to rip off insurance because they know they're getting paid. Local CPAP seller was going to bill my insurance $2250 for the AirSense S11 even though it's ~$1,000 everywhere else.

You know that you can return unordered, unopened supplies from your DME for a refund? If you return 4 of the 5 cushions, you'll ease your burden a bit. I've found that my DME will send me all that Medicare will pay for as many times a year as Medicare will allow, and they last me a LONG time. I've told my DME to only send what I ask for, the rest will be returned. We've reached an understanding at this point, but it did take a few overwhelming deliveries from my DME before I realized that they were maxing out to what Medicare would pay for. Stupid, they can store them at their place, I don't have space for all that unused junk *smile*. And if I switch masks, which happens, then I have a cr*pload of useless supplies to store.

Return the supplies and tell the DME that if they ever send something that was not ordered, you will switch to another DME. You're the customer. In many cases you have a choice who to buy from. Check with your insurance to see if the DME must be in their network.

Fugalrix wrote: ↑

Thu Feb 09, 2023 7:15 pm

It isn't exactly unheard of for companies to rip off insurance because they know they're getting paid. Local CPAP seller was going to bill my insurance $2250 for the AirSense S11 even though it's ~$1,000 everywhere else.

They can bill the insurance company any amount they want to. But insurance companies only pay the amount that is in their contractual agreement. You can be assured that no insurance company is paying anywhere near $2250 for a ResMed AirSense 11 AutoSet.

By law the supplier isn't supposed to send more than you ask for, so return some and get a refund. Medicare now prohibits DME's from providing unnecessary supplies.

If you think you're not going to go over your deductible all year, then you aren't stuck buying from the DME for supplies in the first place. BUT, if you are still in the capped rental period for your machine, or stuck with a perpetual CPAP rental on a Medicare Advantage plan from a DME, one way or another you are going to exceed your deductible for the year.

Don't forget the coverage for DME and supplies is 80% of the Medicare allowable. Either you or your supplemental insurance still have to cover the remaining 20%, even after the deductible is met.

Remember DME is Part B if you're on traditional Medicare. So this is a different deductible than your hospitalization deductible which is $1600 for days 1 - 60, and a different deductible than your Part D drug plan (up to $505, plus co-pays for higher tiers). Part B is for DME, out-patient lab and X-ray, outpatient care (doctor and therapies), and home health, so you still may have to pay your Part B deductible if you see your doctor for more than fully-covered preventative care, or need lab or X-rays. You can decide if it's worth it to have your deductible met for the year or if you'd rather meet it with other services.

If you have supplemental ("Medi-Gap") insurance, you should wait to see what they cover on this bill before you pay the deductible. Some supplemental insurances pay the entire deductible for you. Never pay a medical bill until you've gotten an Explanation of Benefits (EOB), because you may not owe the deductible or all of it.

Definitely don't get what you don't need. For the deductible question; for my family we always meet the deductible and most of the time the limit each year. We usually buy on insurance so that amount is applied to meeting the deductible otherwise it is just extra spend somewhere else.

Fugalrix wrote: ↑

Thu Feb 09, 2023 7:15 pm

It isn't exactly unheard of for companies to rip off insurance because they know they're getting paid. Local CPAP seller was going to bill my insurance $2250 for the AirSense S11 even though it's ~$1,000 everywhere else.

Insurance companies are not stupid...they make LOTS of money. As Granny mentioned before, they have an agreed amount that they pay regardless of what is billed. Usually the DME will bill the (rediculous) MSRP. For the AS11, I would guess that the agreed upon payment is about $ 700. If you have a 20% co-pay, you would pay $140 and the insurance company would pay $560.