More expensive with insurance? WHAT?!

[sventory]

I don't get this, am I being fleeced here or what? on cpap.com I can get teh airsense 10 and a mask for around 1050 (900 + 150 for an expensive mask) with no insurance? But I just got the price for my insurance to cover it, they cover 80% of medical equipment, I pay 20% + a dedutble, the deductible is 242 and then I have to pay 95 dollars for 12 months for lease to own (which I might add, if I decide go go for an S9 or other all that money is WASTED they don't give you credit /exchange program), FOr a total of 1140? That's 90 dollars more and WITH INSURANCE? So the insurance is paying roughly 4500 dollars for what? So a licensed person can spend 30 minutes to fit me for masks? Unless I am missing something here it seems like a huge ripoff. Can someone enlighten me?

[rjezuit]

I went to a local store to get some mask parts. My 20% was more than buying it online and paying full price. It's how insurance works, and why it is so expensive.

[chunkyfrog]

Medicare will pay slightly more for my Airsense by the end of the capped rental period; (than the price at cpap.com)
masks are a little less with Medicare, pillows are about the same, and filters are about double.
Compared to BC/BS, Medicare negotiates a heck of a deal for themselves--and retirees!
I bought supplies and extra machines from our sponsors for about three years before I retired.
If my cancer had been discovered before Medicare, my out of pocket would have been in excess of a new car.
With Medicare, my premiums are "it".
Small wonder, the "blues" sent me reminders to buy supplies when their pet DME was not selling me anything.
Sometimes it makes you say "huh"?

[PoolQ]

Much of it depends on what insurance plan you have, not what insurance company your plan is with. Each plan covers different things at different rates, this is why plans cost different amounts a month. DME's are for the insurance industry and not for retail walk-ins. To be in network they have a negotiated cost for everything they offer and it has nothing to do with any price they may quote.

When you chose a policy you get to pick deductible amounts and out of pocket levels, this means that not everything will make money sense to use insurance for. I personally maxed out my out of pocket in January of this year, so everything is free for the rest of the year. I would rather still be paying out of pocket though

Insurance is the same game for anything car, house, health-they are betting that you wont need it and you carry it so if something big happens you wont get wiped out. You want to get sticker shock have the quote a max out of pocket at $500 and no copay for office visits $$$$$, you can get it if you want to pay for it.

Anything that a DME quotes is worthless until you get an EOB from your insurance company, the EOB will tell you what they paid and what is left for you to pay out of the in network cost.

[Elapid]

I spent about 50% less buying my ACPAP and equipment from CPAP.COM rather than a DME through my insurance. Now nobody but me and my Pulmonologist have anything to do with my therapy or equipment. I have found it best to keep the insurance out of my business as much as possible, especially when it saves me money.

[sc0ttt]

Wow, not my experience at all.

Even if insurance didn't pay anything, I'd still be ahead with their negotiated price.
(This is from about 1-1/2 years ago)

I pay 20% + a dedutble, the deductible is 242 and then I have to pay 95 dollars for 12 months for lease to own

Are you sure you're not counting things twice? Why would you have to pay to purchase and pay to lease? Isn't it either-or?

[kteague]

Does anybody know if a 20% co-pay is based on the billed amount or the insurance's allowable amount?

[LSAT]

Does anybody know if a 20% co-pay is based on the billed amount or the insurance's allowable amount?

Insurance allowable amount

[Wulfman...]

I don't get this, am I being fleeced here or what? on cpap.com I can get teh airsense 10 and a mask for around 1050 (900 + 150 for an expensive mask) with no insurance? But I just got the price for my insurance to cover it, they cover 80% of medical equipment, I pay 20% + a dedutble, the deductible is 242 and then I have to pay 95 dollars for 12 months for lease to own (which I might add, if I decide go go for an S9 or other all that money is WASTED they don't give you credit /exchange program), FOr a total of 1140? That's 90 dollars more and WITH INSURANCE? So the insurance is paying roughly 4500 dollars for what? So a licensed person can spend 30 minutes to fit me for masks? Unless I am missing something here it seems like a huge ripoff. Can someone enlighten me?

That's why we continually tell new users to "DO THE MATH!" before they sign any contracts or commit to these deals.
They're not always a "ripoff", but it's quite likely it won't always come out to the user's benefit.
Often, the costs, considering the co-pays and deductibles, will come out to be about equal to buying out-of-pocket online, but then you have to deal with a brick and mortar DME and there are many horror stories about them screwing up billing and other problems......plus, the user will need to prove their compliance to the DMEs so the insurance provider will pay them. Then, you have the situation with hitting the end of the year and a new deductible starting over on January 1. That will "double dip" the user on that cost.
Additionally, it can also depend on what the "REAL" (contracted) prices that the insurance providers end up paying the DMEs, too. Sometimes the prices listed aren't what the insurance provider actually pays.

Welcome to the DME and insurance world.......


Den

.

[LSAT]

Wow, not my experience at all.

Even if insurance didn't pay anything, I'd still be ahead with their negotiated price.
(This is from about 1-1/2 years ago)

I pay 20% + a dedutble, the deductible is 242 and then I have to pay 95 dollars for 12 months for lease to own

Are you sure you're not counting things twice? Why would you have to pay to purchase and pay to lease? Isn't it either-or?

Most new people are not aware of how insurance works

[Wulfman...]

Does anybody know if a 20% co-pay is based on the billed amount or the insurance's allowable amount?

Another option to that question is the "contracted amount/price", too.
There's so much these entities try to keep from the users and it's sickening.


Den

.

[sc0ttt]

Here's my insurance breakdown... I'm not sure how they figured my portion of the CPAP unit, but you can see I paid 20% of the negotiated price for the pillow and mask.

[MarylandCPAPer]

Does anybody know if a 20% co-pay is based on the billed amount or the insurance's allowable amount?

It depends. If your insurance plan prohibits "balance billing," then it is 20% of the insurance allowable amount. If the insurance plan does not prohibit balance billing, you could end up having to pay the balance of the price the DME quotes as their price, plus your co-pay, no matter what the insurance's allowable amount is. There are numerous variations on this theme, varying per insuracce plan.

WIth Medicare, it is 20% co-pay based on Medicare's allowable amount. If you are on Medicare and your income is low enough, you may qualify for QMB or SLMB through your state, which may pay your Medicare premiums and co-pays. Check your state's SHIP site if you are in the US if you are low income. There are various state programs that may help pay for prescriptions and medical care.

[garagelogician]

It's not so much that you would be getting ripped off with insurance, but it is a good illustration of the dysfunction of government intervention in our health care system. Insurance (and the regulations that go along with it) increase overhead and make everything more expensive. CPAP.com saves you money because they don't have to pay for the cost of dealing with insurance billing.

In my case, I'm on a high deductible health plan (my employer self-insures and purchases re-insurance to cover the company) and I have an HSA that I contribute to and my employer provides a matching contribution. I'm a young guy, otherwise healthy and haven't (knock on wood) had any significant health costs this year. So when it came time for me to get a new machine this year, I got my doctor to just write me a script for everything I need and then I bought it online with my HSA funds. I saved a bunch of money and I'm the one in control of my health care decisions and costs. I was even able to submit my receipts and insurance codes to my insurance so that it counts towards my deductible for the year, in case I'm unlucky enough to have additional costs later this year.

Don't count on insurance to save you money or cover routine costs. Your car insurance doesn't cover tires or oil changes.... Why should health insurance be any different? Insurance works best as a safety net, to protect you from large costs.

[PoolQ]

Since my wife actually does medical billing for a living I can tell you that the paperwork and complications of medical billing has nothing to do with the government any more than any other business. It has only to do with what the insurance company has committed to pay for and what it will not pay for. In the past if they could get you to pay your premiums and get so frustrated with them that you paid out of pocket, they win.

In California the state has said that MediCal payments will be adjusted based on customer satisfaction, you tick off your customers and the total state payment is reduced. It is still stunning how helpful my insurance contacts have been! They have actually put me on hold while they resolve a billing issue right while I am on the phone. They ask me if I am happy with their performance! Stunned.