Forget the DME

Sleepless_in_LM · Post by **Sleepless_in_LM** » Thu Dec 21, 2006 2:06 pm

Just before surgery, my doc ordered an APAP. Insurance of course dragged their feet and I found out if I bought it from the DME it would cost $1,230. If I bought it from cpap.com it would cost $599. I figured if insurance would only pay half of the DME's price I would still be money and headaches ahead to order online, plus I would have it in time for surgery. Then I checked and the insurance said I could purchase on my own and submit the bill. I would have never guessed, but that's a win/win and they normally don't like that kinda situation

Well today the insurance called and said I was approved for an immediate purchase of an APAP, covered at 100% YIPPEE! (after 4 faxes from the docs office, 20 phone calls by me, and 2 weeks after surgery). I explained that I already purchased the machine online and she wanted to make sure I understood they only paid up to a certain amount. When I told her I paid $600, she sounded shocked and said "that is certainly well below our normal amount."

Then I decided I needed another mask before this year's insurance ran out. Since my DME had been pretty good and actually got a hybrid as a sales sample, gave it to me and let me keep it, I felt somewhat obligated to allow them to make some money in this process. I called and asked them to order me a hybrid under my insurance. They informed me they do not carry the hybrid and probably would not in the near future. So I ordered my mask at cpap.com and will get reimbursed by my insurance.

All this has left me wondering what I will ever need the DME for again. I think I am finished with them. I save the insurance company and myself money by buying online. I get quicker service. I have less headaches.

Seriously folks, check and see if you can purchase online and be reimbursed. It is so much cheaper and easier than dealing with the DME. I suppose they have their place, especially in the early part of the process, but I don't think I will ever set foot in their building again.

lvwildcat · Post by **lvwildcat** » Thu Dec 21, 2006 2:30 pm

I have not dealt with my DME from he@% since April. Yes I do all of my ordering on-line. I actually haven't even tried to get reimbursed because my out of pocket expense ends up being a lot cheaper than my 20% copay with the DME mark-up. cpap.com has been nothing less than awesome. Their customer service dept. has always been helpful and I can track my order very easily. I'll never deal with my uncaring;incompetent DME again!

dataq1 · Post by **dataq1** » Thu Dec 21, 2006 2:55 pm

I called my insurance (BlueCross/BlueShield PPO) about an hour ago and was told that unless I purchased from a participating provider, I would not be reimbursed anything. I don't know if cpap.com is a participating provider or not, but I thought that the point of a PPO was so that you could go to a non-particpating provider.
Currently my DME charges BCBS $ 2,950 for a Bipap machine I can buy for 1250. I will continue to press for a rational reason.

Sleepless_in_LM · Post by **Sleepless_in_LM** » Thu Dec 21, 2006 3:00 pm

Interesting, since our insurance is a self-funded "veba" program, but we use Blue Cross/Blue Shieled for claims management and their PPO network. It is the BCBS people that told me I could purchase on my own and be reimbursed.

DME Daddy · Post by **DME Daddy** » Thu Dec 21, 2006 3:07 pm

BCBS has a zillion plans. A few are very restrictive, most are not. Call and ask the number on your card..

dataq1 · Post by **dataq1** » Thu Dec 21, 2006 3:10 pm

I'm in exactly the same situation, that is a BCBS managed, self-insured program.
As I said, I'm not giving up. I'm sure that the next rep I talk to, will probably give me a different answer.
It is unreasonable to expect the "insured " companies to pay above retail. Likewise, I'm irritated that my coinsurance is higher than it should be (even though it less than ten dollars difference).

neverbetter · Post by **neverbetter** » Thu Dec 21, 2006 3:58 pm

If my DME was too LAZY to order my Hybrids, I would never go back.

That's why we buy here!

Wulfman · Post by **Wulfman** » Thu Dec 21, 2006 4:04 pm

Sleepless_in_LM wrote:.....check and see if you can purchase online and be reimbursed. It is so much cheaper and easier than dealing with the DME. I suppose they have their place, especially in the early part of the process, but I don't think I will ever set foot in their building again.

This is exactly what I've been recommending since I joined this forum. I have a hard time believing that they can turn you down for out-of-pocket reimbursements......whether it be for medications/drugs or Durable Medical Equipment. I think if a person is willing to go high enough and challenge the system, it would work. But then.....some don't care about saving themselves money.

Den

snoregirl · Post by **snoregirl** » Thu Dec 21, 2006 4:59 pm

I have to disagree. I went as high as I could (Insurance company and 3 levels of corporate personel management at the company -- self insured company managed by a insurance company), and still lost on the online purchase and reimbursement. They just didn't care about the cost savings or anything else. Very rigid. Sad but true. I even asked them to consider it further even if they won't give it to me, they could save loads in the future on others, and for replacement machines. Again, they didn't seem to care.

I do agree that if you can make it work by being persistant, go for it.

Rabid1 · Post by **Rabid1** » Thu Dec 21, 2006 5:30 pm

What's the ONE thing DME's have to offer over an online store? That would be their time and sample inventory (I guess that's TWO things).

If DME's do a good job, and spend the time with patients to ensure they are getting the best treatment possible, then they deserve to make the markup.

However, human nature being what it is, the temptation to make the easy/fast buck, and provide minimal service, is going to win out most of the time.

I've yet to make my first purchase, but I'm fully prepared to get what I want from the local DME, or (most likely) do my own thing with CPAP.com

snorestats · Post by **snorestats** » Thu Dec 21, 2006 5:46 pm

My insurance pays 80% regardless if out-of-network plan or not. Unfortunately, there is a $300 deductible for out of network and only a $100 for in-network. I've already payed my in-network, but my out-of-network deductible is a different animal (so they say).... so I'd have to pay that.

My DME seems ok. I told them to make sure to send me the machine I requested. Today when I spoke the the tech who will be coming out with my first machine, he said I didn't need the auto because my prescription did not call for it.

I told him either get me the REMstar Auto C-Flex CPAP Machine or I'll find a DME who will. And if that does not work, I'll have my prescription specify the model and then go to another DME.

Guess who won?

Bearded_One · Post by **Bearded_One** » Thu Dec 21, 2006 6:43 pm

Insurance companies loath to make exceptions and they have their set procedures. Insurance companies have contracts with DMEs and it is very likely that the insurance company is not paying anything close to what you believe that they are paying.

snoregirl · Post by **snoregirl** » Thu Dec 21, 2006 7:07 pm

I don't know about you bearded one but I know exactly what my insurance paid it is on the advice I get when they pay. It is a lot.

mattman · Post by **mattman** » Thu Dec 21, 2006 7:17 pm

snorestats wrote:My DME seems ok. I told them to make sure to send me the machine I requested. Today when I spoke the the tech who will be coming out with my first machine, he said I didn't need the auto because my prescription did not call for it.

I told him either get me the REMstar Auto C-Flex CPAP Machine or I'll find a DME who will. And if that does not work, I'll have my prescription specify the model and then go to another DME.

Guess who won?

I'm not getting involved in this one again but I do have to make a quick comment here.

Please don't be so hell-bent on the DME company trying to rip you off that you get blinded to anything else.

If the prescription doesn't specify an Auto unit, they CAN'T give you an auto unit. It's not that they are trying to be difficult, or that they suck or that they are trying to screw you over. They just simply can't.

It's not a matter of just saying 'Screw you I'm going somewhere else'. They just can't. It's like going into your pharmacy and demanding oxycodone even though your prescription says darvocet. Yes they are both pain killers but you just can't give one over the other.

There are circumstances in which you can (What would actually happen is the DME would just call your doc and get a new Rx for an auto unit with a range and just never mention it to you) so technically you still aren't getting a CPAP without a script for an auto.

Just had to point that out.

mattman

dataq1 · Post by **dataq1** » Thu Dec 21, 2006 7:23 pm

Example:
Hybrid mask with headgear and all three sizes of cushions and nasal pillows

Available at retail for 175.00 (manufacturer's suggested retail is 209.00)

DME claimed 389.00
BCBS paid 269.56
I pay 29.96
total to DME is 299.52

I hope that no is suggesting that the Insurance Companies EOBs are false.

Mask

Additional Comments: Machine:Resmed S7 Elite; Oracle Mask(YES! My DREAM mask!!)