More DME antics

sleepyWI · Post by **sleepyWI** » Fri Dec 29, 2006 5:05 pm

I just got the bill and the accounting from the insurance company for my first mask. They gave me a Mirage Activa, which lists on here for $135 dollars. The DME billed my insurance $486 (!!!!!!) which they payed without batting an eyelid. I have a 20% coinsurance so I was out $80. Had I bought the mask here and got reimbursed my out of pocket would have been $27.

This is the same insurance company that sent me a very serious letter about how they needed to cut health insurance costs so therefore I need to cut my pills in half.

What a screwed up system!

Then I look through my paperwork and see that the machine listed on my paperwork (which I signed) is a REMSTAR PLUS w/C-flex. What they actually gave me was a RESMED S8 Escape...no c-flex.

Gonna spend alot of time on the phone tomorrow...sheesh

neversleeps · Post by **neversleeps** » Fri Dec 29, 2006 6:10 pm

$486.00 just for the mask?????????????

mattman · Post by **mattman** » Fri Dec 29, 2006 6:13 pm

Holy cow!

What freaking insurance decided to charge that much for a single mask?!

That's the allowed and not just the submitted??

Cripes remind me not to get that insurance huh?

mattman

sleepyWI · Post by **sleepyWI** » Fri Dec 29, 2006 6:41 pm

My figure was very slightly off. It was $430 for the mask, minus a $21.50 provider discount. My insurance ended up paying $326.80 and I had to pay $81.70 (the 20%).

They also billed the insurance $33 for a flimsy chinstrap

It gets worse ... the insurance was billed $1315.24 for the cpap and humidifier (about $900 on here) and $86.70 FOR THE HOSE! (They actually paid $65).

All this has my head spinning

neversleeps · Post by **neversleeps** » Fri Dec 29, 2006 7:08 pm

$408.50 just for the mask???????????

Who decided how much to charge for the mask? The DME or the insurance company?

mattman · Post by **mattman** » Fri Dec 29, 2006 8:06 pm

neversleeps wrote:Who decided how much to charge for the mask? The DME or the insurance company?

The insurance company does. They always set the prices.

mattman

Slinky · Post by **Slinky** » Fri Dec 29, 2006 8:54 pm

Okay, my primary insurance is Medicare.

My DME billed $48 for the hose
$325 for the Humidaire 3i humidifier
$ 70 for a heated breathing circuit (A4604) BACK TO THIS IN A MOMENT
$ 45 for the FlexFit Headgear
$130 for the FlexFit Mask
for a total of $618.00

They then crossed off the heated breathing circuit (whatever that is or was) BUT did NOT subtract that $70 from the bill.

Furthermore, I did NOT, nor did I EVER get a FlexFit mask from them. I got the Swift. They did write the Swift in but didn't cross off the FlexFit. I later switched to the ComfortLite 2 w/nasal pillow & nasal cushion. I did have to sign for the CL2 but was never given a copy so I don't know for sure whether they billed for the CL2 or not. However, in their records they STILL have me listed as their having provided the FlexFit, the Swift and the CL2.

The Resmed S8 Elite is a capped rental (they told me 15 months, according to Medicare the capped rental is 13 months) billed at $135 a month. I'm fortunate to have secondary insurance that picks up my 20% Medicare copay.

Because my titration study was so "insufficient" (42 minutes sleep out of a full night and 98 minutes sleep out of a 2nd full night) and some problems w/the pressure scripted my sleep lab scripted a loaner Respironics Auto w/C-Flex to better ascertain the pressure I need. The DME is billing Medicare $135 a month for this Auto. And no humidifier for it, much less a heated humidifier. Sleep lab managed to come up w/a passover humidifier which didn't help a whole lot but was better than no humidifier. God bless a fellow PAPper, he has loaned me an extra F&P HC 100 heated humidifier and since using that I've done great w/the Auto and am going to hate to return it!

So Medicare has initially been billed $618 plus they'll be billed $135 a month for at least 13 months, possibly 15 months, which = $1755 to $2025 for me to eventually own my Resmed S8 Elite. Plus the $618 purchases of the accessory equipment.

W/in 3 months Medicare "could" be billed an additional $48 a month for a new hose each month. At 3 month intervals Medicare "could" be billed $130 for a new mask (A7034) and at 6 month intervals $45 for new headgear (A7035) [the DME tried to tell me I was only eligible for a new mask every 6 months. They "say" they don't provide separate masks and headgear, TS for them Medicare says I'm eligible for the mask every 3 months and the headgear every 6 months]. Furthermore, Medicare allows for 2 replacment nasal cushions a month (A7032) or 2 pairs of nasal pillows a month (A7033). My DME tried to wiggle out of that one but has agreed they "can" provide them. If it turns out I need a new cushion or pair of pillows I'll ask for and expect to get them. So far I haven't need them.

In addition, I dropped my CL2 and the plastic elbow broke ($8.50 at cpap.com). When I went to my DME for a replacement elbow they gave me static that they didn't carry replacment parts. It took me an hour but the third person I talked to did "miraculously" (spelling?) manage to come up w/one in their "miscellaneous box". In the process, tho, the first person made the mistake of "reminding" me I had been thru 3 masks in less than 3 months. It didn't take me long to clarify they had only provided me w/TWO masks and had NEVER provided me w/a FlexFit mask!! I have the PROOF of that and PROOF of where I did get a FlexFit mask.

neversleeps · Post by **neversleeps** » Fri Dec 29, 2006 9:08 pm

mattman wrote:
neversleeps wrote:Who decided how much to charge for the mask? The DME or the insurance company?
The insurance company does. They always set the prices.

mattman

I thought the DME submitted an amount to the insurance company and then the insurance company would decide how much of that amount they would allow to be paid.

sharlan · Post by **sharlan** » Fri Dec 29, 2006 10:08 pm

For some reason, I decided to check my paperwork a little bit ago. My booklet is for a REMstar Plus M Series, model 200. My paperwork states model 100. Funny thing, none of the serial numbers on my equipment matches the serial numbers on my paperwork from the DME.

I am going to call Respironics on Tues and find out what the serial numbers match, whether it goes with what I got or if somebody switched out the machines.

ColoradoDreamer · Post by **ColoradoDreamer** » Fri Dec 29, 2006 11:18 pm

Welcome to the medical/insurance world. It has been a shock to me too. That is very excessive for a mask. And your insurance company will pay most of it! Below is a summary of what my DME charged and what my insurance was willing to accept. It is incredible that the DME charges so much. My ins. allowance is higher than what is listed on CPAP.com (except for the mask) but not too bad.

Info below is based on what was given to me by the two on 20 Dec 06
cpap humidifier Mask tube headgear
DME charges $1,800 $500 $206 $67 $61
Insurance allowance $783 $240 $94 $32 $29

I spent a day talking to my insurance and DME and they freely gave me the above information. It helped me in determining what my out of pocket expenses were going to be. Recommend that you may want to do the same for your other equipment. Looks like it will be quite an eye-opener!

neversleeps · Post by **neversleeps** » Sat Dec 30, 2006 12:06 am

ColoradoDreamer wrote:It is incredible that the DME charges so much.

Info below is based on what was given to me by the two on 20 Dec 06

................................cpap.........humidifier...Mask.....tube...headgear
DME charges..............$1,800..... $500..........$206.....$67....$61
Insurance allowance....$783....... $240..........$94.......$32....$29

So why does the DME set the price so high?

blarg · Post by **blarg** » Sat Dec 30, 2006 12:17 am

Because their customer (the insurance company) will pay that much. Something's worth what someone will pay for it. If the insurance company refused that high of a charge, I'm sure the DME would lower it. So, everyone who works for DMEs says, "It's the insurance company's fault for letting us get away with it. They set the prices." and everyone that works for insurance companies says, "It's the DME's fault for charging so much. They set the prices."

SuxBeingU · Post by **SuxBeingU** » Sat Dec 30, 2006 12:29 am

just my bill from the DME that started in April. they are bill my insurance 1200 for the cpap( Goodnight 420) and bill me 600 for it. Like everyone above this doesn't include the hose the chin strap the filter or other misc charges. Then they had nerve to call me after NOT sending a bill for 8 months and ask for immediate payment.
When I asked why I and the insurance was being charged 1800 for a machine that retails for 290.00 I was not given an answer, just I don't know I am in the billing Dept. I told her to kiss my ass adn she can come pick up the machine before I pay 600 after the insurance has already paid 1200 for a 295.0 machine. Haven't heard from them in a few weeks, we'll see what happens BUT this is highway robbery. the clinic my HMO is at has an exclusive contract with this DME so I can't buy a machine on my own w/o switching Drs.

Good Luck guys

Snoredog · Post by **Snoredog** » Sat Dec 30, 2006 12:52 am

neversleeps wrote:
ColoradoDreamer wrote:It is incredible that the DME charges so much.

Info below is based on what was given to me by the two on 20 Dec 06

................................cpap.........humidifier...Mask.....tube...headgear
DME charges..............$1,800..... $500..........$206.....$67....$61
Insurance allowance....$783....... $240..........$94.......$32....$29

So why does the DME set the price so high?

The reason they jack up the price is when you have any kind of a deductible, that deductible comes off the price charged by the DME, the $1800 figure for the machine not the $783 the DME would like you to believe.

For example, if you have a 50% deductible for DME equipment, for that $1800 machine, that means you pay $900 copay, the insurance pays the $783 to the DME which is what they have negotiated behind your back (the part where they screw you).

So who do you pay the deductible to? Yep, you guessed it, the DME, you pay them $900 and they collect $783 from your insurance, so they get $1683 for that $295 machine.

and don't forget this part, the hose comes with the Machine for FREE, so does the Headgear, it comes with the mask for FREE and parts removed like extra pillows or cushions that may come with the mask and you are then charged seperately for each item that may come free with the machine or mask.

You have to be an idiot to purchase from a local DME if you have any kind of deductible, you would be better off dropping DME coverage to lower your insurance premiums then just buying the equipment outright from an on-line supplier.

A legal license to steal. We can only hope that every politician in Washington comes down with OSA and government DME coverage drops to 50% only then will you see it change.

sleepyWI · Post by **sleepyWI** » Sat Dec 30, 2006 7:38 am

mattman wrote:
neversleeps wrote:Who decided how much to charge for the mask? The DME or the insurance company?
The insurance company does. They always set the prices.

mattman

The numbers I quoted are what the DME submitted as charges to the insurance company. The insurance company willingly paid those excessive charges. Then they have the gall to tell me to cut my pills in half to save money.

Good news is (maybe) I have a new insurance provider starting January 1. I'm calling them today to find out what my DME options are.