DME's ripping off the insurance companies..

jvoisin · Post by **jvoisin** » Sun May 13, 2007 1:02 am

My insurance is through Sunlife (Canada) and they state that they will allow a new mask every 12 months (not twice a year).

I bought the Mirage Switf and am having issues with my nares being extremely sore. I went to my DME to pick up a standard nasal mask as I saw them on cpap.com for 49 - 89 USD.. Imagine my surprise when I realized that they are charging 289.99 for the same mask at the DME.. I am surprised the insurance companies don't get annoyed at that.. that's more than 200 dollars more..

Needless to say since I have another 6 months before I can get another mask, I will be looking elsewhere since this is out of pocket.. Are there any Canadian online retail sites like cpap.com where I don't have to deal with customs and excessive shipping delays?

Joe

2007WOLF · Post by **2007WOLF** » Sun May 13, 2007 2:56 am

DMEs have quite a racket going - and I don't understand why insurance companies put up with it. My DME charged $2400 for a Remstar M Series Pro. Insurance paid 80% ($1920) and I paid the rest ($480). The same set-up is available at CPAP.COM for $595!!! The DME claims that their mark-up is needed because "It pays for a level of personal attention that internet providers do not give."

So - lets see: $2400 (cost of CPAP from DME) minus $595 (cost of CPAP from CPAP.COM equals $1805. This $1805 has paid for 20 minutes of "personal attention." Since there are 60 minutes in an hour (20 minutes times 3) $1805 x3 equals $5415. So the DME is charging $5415 an hour for "personal attention."

sleepyWI · Post by **sleepyWI** » Sun May 13, 2007 5:30 am

Here is a story to the contrary. I just got a new Comfort Lite II from my DME. That mask retails for about $89. My DME only billed the insurance company $70, the insurance company paid about 4$9, and my cost $9.62 ... needless to say I am a very happy camper with this arrangement.

fidget · Post by **fidget** » Sun May 13, 2007 5:42 am

*sigh*

Once again, it's called an insurance ALLOWABLE for a reason. It's the price the INSURANCE companies tell the DME they'll pay, and it's the price the DME by contract HAS to charge.

Sometimes that's less than retail, sometimes it's a great deal more.

Insurance companies don't "put up" with it, they control it.

Slinky · Post by **Slinky** » Sun May 13, 2007 7:36 am

Medicare pretty much "sets" the prices for DME equipment. Of course, that is done thru lobbyists and quasi-government "employees" (sub-contractors). A "billable" amount is established for each item.

Insurance companies then negotiate w/the brick & mortar DME companies and contract w/those they can establish a working relationship with on the reimbursement amount. Any brick & mortar DME who accepts Medicare (which is the bulk of their paying business) cannot "bill" insurances or individuals less than the agreed upon billable amount except in a few special circumstances or they lose their reimbursements rights from Medicare.

Since the online DME suppliers do not bill Medicare or insurances they are free to bill amounts closer to the actual cost plus reasonable profit prices.

Thus we see "Billed" amounts, "Allowed" amounts and the actual "Paid" amounts.

sleepyWI · Post by **sleepyWI** » Sun May 13, 2007 7:38 am

* sigh* those poor poor DME's having to "settle" for $289 for a mask.

Slinky · Post by **Slinky** » Sun May 13, 2007 7:54 am

Yeah, breaks your heart, doesn't it, SleepyWI? So little reimbursement for all the quality time and care they give us in fitting and finding just the right mask for us. Really touches the heart (wallet).

jvoisin · Post by **jvoisin** » Sun May 13, 2007 10:13 am

sleepyWI wrote:* sigh* those poor poor DME's having to "settle" for $289 for a mask.

And if we don't have additional insurance, do they charge us the real price? Nope.. We get to pay 289 for a 59 dollar mask.. nice.. Needless to say it's worth ording from cpap.com or somewhere online even if it takes 2-3 weeks to get here and we get tagged with brokerage and duty...

If that works for the insurance company, them telling the DME what to charge, why can't we tell them what to charge for stuff we buy out of pocket?

fidget · Post by **fidget** » Sun May 13, 2007 10:37 am

You can! Pay your lawyers to negotiate with the DME company's lawyers, to write up a contract agreeing that you will pay that price if they agree to accept your payments, and it's done!

Wulfman · Post by **Wulfman** » Sun May 13, 2007 11:11 am

jvoisin wrote:
sleepyWI wrote:* sigh* those poor poor DME's having to "settle" for $289 for a mask.
And if we don't have additional insurance, do they charge us the real price? Nope.. We get to pay 289 for a 59 dollar mask.. nice.. Needless to say it's worth ording from cpap.com or somewhere online even if it takes 2-3 weeks to get here and we get tagged with brokerage and duty...

If that works for the insurance company, them telling the DME what to charge, why can't we tell them what to charge for stuff we buy out of pocket?

I'm thinking that CPAP.COM labels the shipments as "medical" (or something like that) and it isn't subject to extra charges.

It's a conspiracy on both sides of the border.....and they're playing the games with OUR money (insurance premiums, co-pays and/or tax dollars).

This is precisely why I didn't use a local DME at all.....just CPAP.COM.
One of the questions by the "locals" was "What will you do if your machine needs servicing?" My answer: "For what you're charging, I can afford to buy two or three of these machines and have back-ups." (which is what I did)

Den

BarbarainCT · Post by **BarbarainCT** » Sun May 13, 2007 12:06 pm

I have run into a different situation. My DME (Apria) and insurance provider (CIGNA) act together to see that you get the cheapest piece of equipment possible. Any machine, but the cheapest, seems to be on backorder and unavailable for months. They recommend that the sleep doctor prescribe what they have in stock. Fortunately it is working well for me.

I was unable to find another DME who was willing to accept my prescription because of having to deal with Cigna.

RichCMH · Post by **RichCMH** » Sun May 13, 2007 12:45 pm

DMEs and Insurance companies rip off consumers! My cpap set up would cost $950 on cpap.com. My DME charged $1503.92, which they told insurance was 10% off my cost, so since that 10% is what the insurance would have paid, I am responsible for the $1503.92. My insurance deductable is $5000/yr OV, ER and Other, no thanks to my employer! I only have another $3496.08 to go to get 100% paid!

Severeena · Post by **Severeena** » Sun May 13, 2007 4:31 pm

I have HUMANA and CHAMPVA, I found out that since MEDICARE is Government funded and CHAMPVA is also government and since MEDICARE is accepted, CHAMPVA is suppose to be accepted wherever MEDICARE is. I am finding out online this is not so. I should be able to get suppliers to lose the MEDICARE funding over this particular issue.

Elle · Post by **Elle** » Sun May 13, 2007 4:36 pm

To OP, I ordered from cpap.com and although S&H was high ($17.) and it took a long time to arrive there was no customs or duty charged.

lvwildcat · Post by **lvwildcat** » Mon May 14, 2007 12:38 am

My very first mask was a F/P flexifit 431 and the DME charged Cigna $320!!!! That was the first and last time I ever ordered through the DME. I use cpap.com for my masks and filters. Actually I have to go to DME tomorrow to return their loaner machine. I think I'll ask how much an Oracle would cost since I pay $85 for mine-I'll let you know what their "markup" is.

Mask

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