Suggestions for a "good" DME in Portland, OR area

[Blue Waters]

Hi all,

I'm about to start shopping for a new APAP! This'll be my third one. I'm currently using Resmed S9 and it's six years old now. My girlfriend says sometimes it makes "animal howling like noises" at night! Something in it might be getting loose at higher pressures.

I've been OK with Resmed machines and I'm eyeing the Resmed AirSense 10 AutoSet...

So I need to get a referral to the Sleep Disorders Clinic and get a prescription with Resmed AirSense 10 specified along with a specific nasal pillow. I used Swift FX, overall good but too much air coming out disturbing the girlfriend sometimes. Airfit 10, diffuse air exhaust but more prone to "hissing" and air leaks I think. So I'm thinking about trying the new DreamWear Gel Nasal Pillow. I like the fact that the air intake is at the top of the head...

I have insurance with Moda Health and I picked 3-4 DMEs from their in network list. I have some deductible and 20% copay. I got my Resmed S9 through another insurance company and the DME I went to at the time was Apria! At that time, I wasn't aware that the the "rental" period being 13 months would trigger another deductible payment. And then Apria was charging $40-50 maintenance fee every six or twelve months and I wasn't sure what they were maintaining! Then I lost my insurance, and they forced me to pay that fee again. And when I didn't pay they started calling me and leaving weird messages like:

"This is Apria Healthcare calling. We are notifying you that we need to collect the wireless modem from your CPAP equipment. Please give your equipment to the Apria driver and we'll send back your device after the modem is removed". And there was no modem attached!!! Anyways, I had enough of them and paid the final bill and I wished some very unhappy things for the decision makers at that company....

I called 3-4 DMEs companies in Portland area trying to get an estimate of how much the new APAP will cost me. None of them gave me any solid answers. They tell me to call my insurance company. Not only that, I got the feeling that once they get the prescription, the process will start, I won't have any time to make a decision about price.

Meanwhile, my insurance company is also being vague or maybe the phone reps are not knowledgeable. One rep told me today, actually DMEs won't be able to charge more that their contract amount for a specific code. But she said she doesn't have access to those codes. I asked her if she could look up what their $$cap is for E0601 and she said she can't....

I'm VERY frustrated! I feel like I'm dealing in a black market! For people in Portland area, are there any suggestions for an honest and easy to work with DME?

Any tips how to get pricing info from cpap DMEs?

Thanks.

[Pugsy]

If you are going to be using your insurance to fund the purchase of your new equipment you will be figuring your cost based on the insurance allowable amounts for the product HCPCS code.

I asked her if she could look up what their $$cap is for E0601 and she said she can't...

She could have if she would have but she didn't want to. Those fees are available on the insurance end but she either was too lazy to find them or uneducated on the process.
The allowed amounts can vary widely between insurance companies and even within various plans within one company.
DMEs can't possibly keep up with the allowable amounts for all the various insurance companies and plans out there.

Any DME that has a contract with your insurance company will be bound by that contract price...finding out the contract price is the hard part though. For some reason insurance company reps don't want to do just a little work and find the contract price.
So whatever your portion of whatever the allowed amount is....is going to be the same with any DME you might use because they all have to use the insurance allowed amount IF they have a contract with your insurance company.

You will have to find out the contracted fees from your insurance company. The DME can tell you what they normally charge but that doesn't really matter because the end result is they have to write off the difference between their pie in the sky amount billed and what the insurance contract says they have to be happy with.
Your portion of the bill that you have to pay is based off the allowed amount ...not the pie in the sky billed amount.

Now you do have the option of not having insurance pay for anything and buying totally out of pocket...which sometimes works out better especially if someone has a high deductible to meet and they don't often meet the deductible. Sometimes the out of pocket amount paid is less when insurance isn't in the picture.

[Blue Waters]

Thank you very much for your reply.

She could have if she would have but she didn't want to. Those fees are available on the insurance end but she either was too lazy to find them or uneducated on the process.

That's what I thought too.. But she seemed nice and we chat for about 15 mins, so maybe she was uneducated on the process.

So whatever your portion of whatever the allowed amount is....is going to be the same with any DME you might use because they all have to use the insurance allowed amount IF they have a contract with your insurance company.

Are you saying that an insurance company will have the same contract price with various DMEs for an "E0601" equipment?

You will have to find out the contracted fees from your insurance company. The DME can tell you what they normally charge but that doesn't really matter because the end result is they have to write off the difference between their pie in the sky amount billed and what the insurance contract says they have to be happy with.
Your portion of the bill that you have to pay is based off the allowed amount ...not the pie in the sky billed amount.

This is what I'm trying to figure out... Can the DME transfer that write off to me... That Resmed APAP I mentioned is under $900 here at cpap.com. I'm sure the "DME" will charge at least around 2x to my insurance company. What I'm trying to avoid is if they charge ~3x and then I'd be responsible for ~$1,000 + the usual copay...

Now you do have the option of not having insurance pay for anything and buying totally out of pocket...which sometimes works out better especially if someone has a high deductible to meet and they don't often meet the deductible. Sometimes the out of pocket amount paid is less when insurance isn't in the picture.

Exactly! In the past when my I didn't use my insurance at all, I bought my mask and other cpap supplies from here just to avoid the hassles.

Also, sometimes these companies do 13 month "leases", so the second year's deductible kicks in. Long story short, even with my insurance and best case scenario, most likely the CPAP and the masks will end up costing me ~$700-$800. So not too far from buying directly from cpap.com. But with this insurance purchase, I'll "consume" my deductible so I might as get some tests and checks up done for my ageing body

[Blue Waters]

By the way, after my first post, I sent this e-mail to my insurance customer service:

-------------------

Hi,
Here's my info:
Subscriber ID: xxxx
Insurance type: Preferred Provider Organization
Group number: xxxx
Group name: xxxxx

I'm trying to figure out what my out of pocket expenses will be for CPAP equipment for sleep apnea. I have a tight budget and I need to shop around several DMEs. But the DMEs are making it impossible for me to access pricing information. And they tell me to get the information from Moda Health! Can you please help me with the following?

From what I understand the CPAP devices fall under the hcpcs code E0601...

1) What is the payment schedule for these (E0601) are -- Can we buy outright or do we need to rent it? If we rent it, what is the rental period, 6 months, 13 months etc?

2) Is there a set maximum price Moda Health will pay for the equipment code E0601? What is that maximum price and does it depend on the vendor?

3) Can an in network DME charge more than the Moda set maximum price, and ask for the patient pay for the difference?

Thank you very much for your help.

[Blue Waters]

So I exchanged couple of e-mails with my insurance company. They haven't given me any numbers. But they said in network DMEs are in contract with them so they can't charge "the excess" to me. She said technically they'll take a "loss" if the amount is over. And she said it's OK for multiple DMEs to contact them at the same time to check my benefits and get back to me with pricing. We'll see how that'll work out....