Why Do DME's Charge So Much?

jrfoster · Post by **jrfoster** » Mon Oct 30, 2006 5:21 pm

I just received a FP Medium Cushion for my mask, which I could have bought myself on CPAP.com for $47 plus SH. They tell me I am allowed one replacement a month for the cusion. The bill my DME sent me that is being charged to Tricare is $100! Is it any wonder that insurance is going up? This is ridiculous. I can't wait to see what they charge in December for my normal mask replacement. If it is $100 just for the cushion, what is the entire FP 431 mask? Wow!

Jeff

snoregirl · Post by **snoregirl** » Mon Oct 30, 2006 5:27 pm

Watch out for your annual deductable and copay which may reset in January. If it is high, you may want to forgo the insurance for the cheaper online cash purchase. If you have great insurance (low deductable and low copay), feel lucky and there is nothing to do but be amazed at the prices they charge insurance, because they can

Get your stuff where the out of pocket for you is the cheapest.

You can always see if your insurance would work with you on reimbursement for online cash purchases and save everyone some money. But don't be surprised if like me, you are crushed at every phone call and letter by people who love to waste your money and let premiums skyrocket.

Guest · Post by **Guest** » Mon Oct 30, 2006 5:57 pm

It can seem really bizarre and insane, I agree.

There are a few things that go into it. The most important thing to remember though is that the insurance companies set the price - NOT the DME provider.

To be quite honest a large part of the added cost is the crazy insane hoops that a DME provider has to go through to get a claim paid by the average insurance company. Insurance companies love to deny claims; often doing things like requiring insane levels of documentation to pay a claim and denying because say 1 of the 12 signatures required is in the wrong spot.

Another is the length of time for an insurance company to pay a claim. Oftentimes a claim can take 6 months or more to be paid. Think about that! Imagine if your current employer told you it was going to be another 6 months before you got a paycheck! Sadly, the vendors whom we purchase supplies from don't take that as an excuse to delay payment. We currently have some claims that we've been fighting for over 2 years. And one insurance company is running at over 50% denial rates.

There are additional accredidation and liscence requirements that significantly increase the costs for many DME providers. A great example is the requirement of tracking serial numbers. Every CPAP that comes in has to have a complete file kept for it. This includes everything from the purchase order when it was bought, all pressure checks and calibrations, any service provided on it, all manufacturer updates, what patient it was given to, what doctor ordered it, what pressures it was used at, hours of use, etc etc etc. That's for every single piece of equipment to.

To be blunt there is also the fact that for right now, CPAP equipment and supplies is profitable. Not to the extent it appears when comparing prices to on line providers - but profitable all the same. This helps offset the loss leader items that a traditional DME is required by market forces to carry - Bedside Commodes, walkers, nebulizers, oxygen etc etc etc. Those items lose horrific amounts of money for a business.

Medicare is currently looking to significantly downgrade payments for CPAP supplies and insurance companies base thier prices on Medicare. So sooner or later the prices will come way down and these items will start being loss items for the providers as well. Some will stop carrying them, others will go find the next item that can make a profit and start focusing on that.

Then we get to start the process all over again.

mattman

curtcurt46 · Post by **curtcurt46** » Mon Oct 30, 2006 6:17 pm

jrfoster,
I to am a Tricare person. I have noticed that the DME may bill a large amount, but by prior agreement the price is already set. Check out your explanation of benefits. My masks have been costing $100 on the EOB, but the billed amount from the DME may be twice that.

jrfoster · Post by **jrfoster** » Mon Oct 30, 2006 6:21 pm

curtcurt46 wrote:jrfoster,
I to am a Tricare person. I have noticed that the DME may bill a large amount, but by prior agreement the price is already set. Check out your explanation of benefits. My masks have been costing $100 on the EOB, but the billed amount from the DME may be twice that.

Since going on Tricare Prime in September, I have not seen any listings on my EOB from my DME! I know they have to be going somewhere, but why they are not appearing on my EOB is beyond me. I will have to check it out.

Thanks!

curtcurt46 · Post by **curtcurt46** » Mon Oct 30, 2006 6:27 pm

With tricare prime you can register on line and see claim status at any time. Also, the eob's may not clearly state mask or cushion, but by knowing what I have received and the date, I know then how to match up claims.
Good Luck!
P.S. My DME told me Tricare would pay for a mask every 3 months.

Offerocker · Post by **Offerocker** » Mon Oct 30, 2006 6:27 pm

I would 'guess' that another reason DMEs charge so much is so that they can claim the difference as a business loss - or somehting like that, for tax purposes?

jrfoster · Post by **jrfoster** » Mon Oct 30, 2006 9:35 pm

curtcurt46 wrote:With tricare prime you can register on line and see claim status at any time. Also, the eob's may not clearly state mask or cushion, but by knowing what I have received and the date, I know then how to match up claims.
Good Luck!
P.S. My DME told me Tricare would pay for a mask every 3 months.

Yes they told me a new mask every three months and a new cushion every month! What a deal!

Also, do you have a copay with your Tricare? So far I have not had to pay one dime for any CPAP mask, hose, etc.

Jeff

CSA0890 · Post by **CSA0890** » Mon Oct 30, 2006 10:02 pm

I found out today just how expensive brick and mortar DMEs can be. I got set up for the first time. The guy that was setting me up with the mask and all and mentioned that the Ultra Mirage FF cost $300!!! Heck on cpap.com theyre something like 150. and the S8 compact was 2000. That was just crazy theyre screwing the insurance companies six ways from Sunday. At the DME all they carried were Resmed products so the only FF was the Ultra Mirage. Needless to say im stuck with it even though it leaks like a sieve, im just hoping that i can adjust most of them out tonight. One thing for sure is if the insurance company will reimburse im going online. At least even with masks I can get what brand and style I want.

jrfoster · Post by **jrfoster** » Mon Oct 30, 2006 10:07 pm

CSA0890 wrote:I found out today just how expensive brick and mortar DMEs can be. I got set up for the first time. The guy that was setting me up with the mask and all and mentioned that the Ultra Mirage FF cost $300!!! Heck on cpap.com theyre something like 150. and the S8 compact was 2000. That was just crazy theyre screwing the insurance companies six ways from Sunday. At the DME all they carried were Resmed products so the only FF was the Ultra Mirage. Needless to say im stuck with it even though it leaks like a sieve, im just hoping that i can adjust most of them out tonight. One thing for sure is if the insurance company will reimburse im going online. At least even with masks I can get what brand and style I want.

The mask is the KEY. It took me about 5 different masks before I found one that is comfortable and I can sleep with it for 8 hours a night! Who thought I would find a full face mask comfortable....go figure.

Hope you can find one you like as it makes all the difference in the world!

Good luck and happy hunting!

Jeff

Offerocker · Post by **Offerocker** » Tue Oct 31, 2006 7:18 am

jrfoster: you said: "six ways from Sunday"

Wow, I haven't heard that in a MONTH of Sundays!

snoregirl · Post by **snoregirl** » Tue Oct 31, 2006 7:25 am

CSA, I am assuming from you post that you walked out with a machine and mask and have signed billing papers. By doing this you may have limited your choices on going elsewhere (online or otherwise).

On the upside, the prices the DME quoted are typical Brick and Mortar DME prices. With your insurance you may find that you actually pay less out of pocket than by buying cash with no reimbursement. But also maybe not due to time of year you are starting. Read other thread on Deductables that is going on now.

I don't know what your copay is or the status of your deductable etc. But you should do the calculations for yourself since you are starting at the end of the year calendar year (some insurance years follow the calendar some do not).

Also, there are very few B and M Dmes that can't order other brands of products. If you want something else insist and see where it goes.

Good luck.

Offerocker · Post by **Offerocker** » Tue Oct 31, 2006 8:14 am

csa0890: Since you're 'early in the game', it's still possible for you to switch DME's, to one that offers what you want.

If you are renting, you don't want to wait too long to switch, because the second one may not accept, because he'd be losing the rental fees already paid to the first DME. Just a thought...

OwlCreekObserver · Post by **OwlCreekObserver** » Tue Oct 31, 2006 8:30 am

jrfoster wrote:
curtcurt46 wrote:With tricare prime you can register on line and see claim status at any time...P.S. My DME told me Tricare would pay for a mask every 3 months.

Yes they told me a new mask every three months and a new cushion every month! What a deal!

Also, do you have a copay with your Tricare? So far I have not had to pay one dime for any CPAP mask, hose, etc.

Jeff

Here's part of what they gave me in response to my question on mask replacements:

A new prescription is needed for a replacement mask.

I don't know if that applies to replacement parts, but I just went through the process of securing a script so that my DME could get reimbursed for ordering another mask. I was also told earlier by Tricare Prime that they would not, under any circumstances, pay for more than one mask per month. That's not a problem, obviously, but it doesn't exactly match with what your DME told you. I'd assume that your DME has had dealings with Tricare previously and knows pretty well what they actually will and won't approve.

OCO

CSA0890 · Post by **CSA0890** » Tue Oct 31, 2006 4:39 pm

Last night was my first night on CPAP it wasn't too bad I got my mask pretty much sorted out. I got almost all the leaks out of the mask, but I have to pull it pretty tight it wasn't bad last night but I'll see after a week or so about pressure sores.